Tropical diseases

Tropical diseases :Psychiatric
disorders,Infections :
toxoplasmosis , rubella , RTI,
STI, vaginal infections

Psychiatric disorders
INTRODUCTION

Meaning
Any disturbance of emtional equlibrium , as
manifested in maladptive behaviour and impaired
functioning caused by genetic , physical,
chemical,biological, psychological or social or
cultural factors . Also called as emotinal illness,
mental illness , or mental disorders . Disorder can
occur any where during the period of pregnancy
Mosby medical dictionary

Common psychiatric challenges in pregnant
women
1. MATERNAL STRESS
Animal research shows that stress produce both long
term and short term effects on the foetus
Human studies showed – 6 month dutch famine of
1944- 1945 , showed the pregnancy outcome for
women who experienced severe food shortage
 Data showed , affected pregnancy had shorter
gestation and higher risks for still births , with
impact more pronounced if exposed in the first
trimester

Babies exposed in third tirmester had large drop in
birth weights
Chance for neonatal deaths if exposed in the first
and third trimesters
Other research studies show- increased riskfor
preterm death

2. Mood disorders
DEFINTION
Defined as the disorders that have as their dominant
features a disturbance in the prevailing emotional
state
Incidences
In review of 21 research studies , prevalence of
depression during pregnancy as 7.4% during first
trimester , 12.8%during second trimester ,
12%during third trimester

CRITERIA FOR DIAGNOSIS
For diagnosis major depression should have the
following signs and symptoms
1. depressed mood , often with spontaneous crying
Markedly diminished interest in activities
Insomnia or hypersomnia
Weight changes ( increased or decreased )
Pschomotor retardation or agitation
Fatigue
Feeling of worthlessness or inappropriate guilt
Suicidal ideation
Dimished ability to concentrate
APA 2000

TREATMENT
Avoid giving antidepressants during the first
trimester
Symptoms are severe ( mood lability ,
disorganization, inability to care for self , cognitive
deficit ), then medication is considered
Fluoxetine ( prozac in small doses)
Other options include , tricyclic and tetracyclic
antidepressants , but excessive doses known to
maternal toxicity like urinary retention , irritability ,
with fetal complications

3. ANXIETY DISORDERS
Most common mental disorder
Includes phobias ( irrational fears , that leads to
avoid objects, persons or situation ) panic disorders ,
generalized anxiety disorders (constant worry ,
untreated to any event ), obsessive compulsive
disorders and post traumatic stress disorder

TYPES
A. PANIC DISORDER
Definition
Repeated unprovoked episodes of intense fear which
develop without warning and are not related to any
specific event
Incidences
In a estimated systemic review showed an 1-2% in
pregnancy, with women having no change or
improvement of symptoms

Study of 38,000 mothers in hungarian , reported
0.5% of mothers carried a diagnostic panic disorders
and high rate of preterm labour

3. Obsessive Compulsive Disorders (OCD)
Meaning
Includes reccurrent , persistent and intrusive thoughts
that cause anxiety , which a person tries to control by
performing repetitive behaviours or compulsions
(APA 2000)
PREVALANCE
0.2- 1.2% ocds in pregnancy

TREATMENT
Includes antidepressants medications ( SSRI),
Cognitive behavioural therapy and education on
management of symptoms

POST TRAUMATIC STRESS DISORDER
PTSD can occur because of any trauma manily
traumas eg : rape

SYMPTOMS
RExperiencing the traumatic event
Persistent avoidance of stimuli
Numbing
Difficulty sleeping
Hyper vigilance
Exaggerated startle response

Pregnancy because of rape- women becomes
extremely ambivalent about baby
Women might avoid examination like pv, if prenatal
examination triggers memories of original trauma
( triggered by bodily touch)
Pregnant women with PTSD have associated
psychiatric problems such as substance abuse , panic
disorders , eating disorders and depressions which
play a vital role in determining fetal outcome

D. GENERALIZED ANXIETY DISORDERS
INCIDENCES
8.5% of pregnant women develop generalized
anxiety disorder

Level of anxieties
MILD
Experience and manage tension related to activities
of daily living
She sees, hears and is aware of environmental
stimuli
Anxiety acts as motivator , helping women establish
tasks

MODERATE
Attention focus on immediately concerns , what she
hears , sees and perceives is compromised
SEVERE
Clients perceptual field is restricted significantly,
narrowing her awareness
Intent to relieve or reduce anxiety to a more reasonable
or comfortable level

PANIC
Experience awe, dread , and terror
Unable to follow commands
Increased motor activity
Loses capacity to think and reason, can dangers self
or others

OTHER PSYCHIATRIC DISORDERS
4a. SCHIZOPHRENIA
 a debilitating psychiatric disorders affecting 1% of
population
Etiology
No theory explains accurately

Clinical manifestations
Five subtypes of schizophrenia
1. paranoid – per occupation with one or more
delusion, frequent hallucination usually auditory,
organized speech and behaviour with appropriate
effects
2.DISORGANIZED – Disorganized speech,
disorganized behaviour , flat and appropriate affect
3. CATATONIC- at least two of the following 1.
motor immobility with waxy flexilibility, or stupor 2.
puporseless but excessive motor activity not
influenced but external stimuli and demand

3.Negativism
4. Maintenance
5. Mutisms
4. UNDIFFERENTAITED – delusions , hallucination
and disorganized speech , but no symptoms that
meet the predetermined criteria for paranoid
disorganized or catatonic
5. RESIDUAL – no prominent delusions,
hallucinations , disorganized speech , or disorganized
or catatonic behaviour, negative thoughts , contents ,
form usual perceptual experience

MOOD CHANGES
Signs and Symptoms
Experience anxiety , depression, tension, irritation
Isolates oneself from events and people
Anhedonia
COGNITIVE CHANGES
Disordered thoughts
Loses capacity to concentrate
Conversation shifts from one topic to another
irrerelvant
Disturbance in thought content – mainly through
delusion or false beliefs
Delusions

PERCEPTUAL CHANGES
Hallucination
Kinesthetic hallucination
Illusions
PHYSICAL CHANGES
Early stages , clients present with sweaty palms,
dilated pupils and mild tachycardia , psychomotor
activity ( restlenesses)

INTERPERSONAL DISTURBANCES
Inappropriate behaviours
Bizzare behaviours
Eg. Bangs her head , interrupt conversation, mutilate
body part with knifes , attempted suicide, introduce
inappropriate topic , laugh about that provoke
saddness

DISTURBANCES IN MOTOR FUNCTIONS
No interactions with others
With catatonic , the client becomes rigid and
unresponsive to crisis

Management
Primary assessment- interviewing and direct
observation
Interviewing focusing on signs and symptoms ,
degree of impaired thoughts processes , risks for
injury or violence towards self or others , availability
of support
Early stage of treatment- focus on improving the
clients sense of reality ( focus on real events during
hallucination and delusions ), nurse not to engage in
arguments , but rather gently introduce doubt ,
attempt to shift clients focus

Nurse should try to listen and try to clarify each
meaning
To watch for aggressive behaviours , risky behaviours
like social isolation
Nurse to model behaviour which help patient to built
social skills and learn ways to built rapport with others
Nurse to assess their knowledge , to provide teaching
about illness, its symptoms management , necessity of
following therpeutic regimen , signs of relapse and life
style accomdation

JOURNAL REVIEW ON PSYCHOTIC DISORDERS
Psychotic disorders and its affect on fetal outcome
with schizophrenia reported fewer total life time
pregnancies , a low rate of live births and a high rate
of losing the pregnancy
 Pts with schizophrenia and schizoaffective disorder
have higher number of chronic disease eg. HTN, DM
Meta analysis – found a doubling of risk of stillbirth
in pregnancy with psychotic disorder

Schizophrenia associated with more placental
abnormalities and cardiac defects
Another study shows- one third of women with
active psychiatric symptoms have no contact with
their psychiatric providers during pregnancy
Pts with schizophrenia – said to have worse health
behaviours like lack of exercise , smoking, poor diet
and substance abuse

Personality Disorders
 Definition
Personality disorders are a group of mental disturba
nces defined byDiagnostic andStatistical Manual of
Mental Disorders (DSM-IV)
as "enduring patterns] of inner experience and b
ehavior" that are sufficiently rigid and deep-seated
to bring a person into repeated conflicts with
his or her social and occupational environment.
Incidences
SWEDISH STUDY- of 625 primiparous mother ,
found a prevalence of personality disorders to be
6.4%during pregnancy

DSM-IV classifies personality disorders into three
clusters based on symptom similarities:
Cluster A (paranoid, schizoid, schizotypal): Patients
appear odd or eccentric to others.
Cluster B (antisocial, borderline, histrionic,
narcissistic): Patients appear overly emotional,
unstable, or self-dramatizing to others.
Cluster C (avoidant, dependent, obsessive-compulsive):
Patients appear tense and anxiety-ridden
to others.

4b. EATING DISORDER
INCIDENCE
Study with nearly 15,000 women in the uk assessed
women in their first trimester for active eating
disorder – found 1.4% women with anorexia
nervosa , 1.6% with bulima and 0.7% with both and
a total prevalence of 3.7%

Etiology
Several theories
Bielieve it arise , because of complex interactions
among biological , environmental and socio- cultural
factors .
Family functioning, lifestyle and stress

1. ANOREXIA NERVOSA
Characterized by disturbed body image , extreme
fear about being fat and emaciations.
CLINICAL FEATURES
Primary indicator- refusal to eat , weight below 85%
normal for their age and height
Women view their extreme thin bodies as fat
Dieting , defective obsession with cooking for others
and extreme exercises

Women with anorexia – tend to be compliant ,
obedient , perfectionists , achieving in school,
sports , employment
Physiological consequences of self starvation can be
life threating to mother and cause PTD of fetus
Can lead to hypotension, bradycardia , hypothermia ,
chronic constipation and electrolyte imbalance

2. BULLIMA NERVOSA
Characterized by consumption of extreme amount of
food (bingeging) with subsequent behaviours to
eliminate the excess calories (purging)
Women consume incredible calories in short period
(2000 to 3000) per episode called as bingeing
To prevent weight gain , induce vomiting , use
laxatives , exercise obsessively
Women will be high achievers
Physiological complications include changes HR,
RHYTHM, GASTRIC DILATION , ELECTROLYTE
IMBALANCE

JOURNAL REVEIWING
Women with active bulimia compared with women
with prior diagnosis of bulimia ( with no active
symptoms) showed twice rates of miscarriage , three
times like hood of PTD AND nearly 6 times the odds
gestational diabetes
Higher rate of hyper emesis gravidarum seen in
active bulima group
Women with anorexia , also have significant higher
risks of gestational diabetes and low birth weight
ifants

COLLABORARIVE MANAGEMENT
 treatment is hard because clients deny their
problems
Combination of therapy , cognitive behavioural
therapy , family therapy
 medication generally not primary treatment
measure , but can also be treated with anti
depressants , anti anxiety drugs . Lithium and anti
convulsants
Through physical examination, , weight , h/o of
previous high and low weight , chronology of recent
weight flucations

h/o of desirable food and fluid intake , any problems
related to elimination , questions on type of food ,
exercise , difficulty sleeping and energy levels
Laboratory and cardiac testing , electrolyte
imbalances
Main intervention focus on nutritional balance
Fetal health concerns to be addressed
Encourage realistic thinking process
Improving clients self esteem, bodyimage and
develop effective coping and problem solving
strategies
Extreme cases hospitalization is required

INTIMATE PARTNER VIOLENCE
Women who experinece IPV are at risk for
developing depression, anxiety , eating didorder ,
alcoholisms, post traumatic stress disorder and
numerous other maladise
( coker , 2005)

Substance abuse in pregnancy
Defintion
Refers to the continued use of substance despite
related problems in physical , social or interpersonal
areas
( APA/ 2000)
MAJOR depression and anxiety disorders are the
psychiatric disorders that commonly occur with
substance abuse

Risk factors
Women begin using during period of depression to
relax , feel more comfortable, to lose weight, to
decrease stress , or to help slepp at nightn
Peer pressure in teens
Lower educational attainment
Lower rates of employement
Psychological factors like : low self esteem, tendency
to seek pleasure , and to avoid pain
h./o family dysfuntion , psychiatric illness , or
physical or sexual abuse

BARRIERS TO TREATMENT
Less than 10% take treatment
Social stigma, labelling and gulit are social barriers
Dont seek help, due to fear of losing custody

CONCERNS RELATED TO PREGNANCY
Use of substance lead to premature labour, abruptio
placenta , still birth and numerous other
complications
Alcohol related , lead to fetal alcohol syndrome
,symptoms being microcephaly , mental retardation,
attention deficit , hyperactivity disorder
Use of cocaine –( fetus) IUGR , organ malformation,
preterm labour, abruptio placenta , withdrawal
symptoms to neonate for months

Heroine – withdrawal symptoms for mother and
infants or both , irritability , poor feeding ,
respiratory complication , and neurological
difficulties

COLLABORATIVE MANAGEMENT
Client deny their addictions or blame people or
circumstance
Client taught on coping with stressors, repair
realtionship
Abstinences , counselling and peer support

PSYCHOPHARMACOLOGIC THERAPY
DURING PREGNANCY
Use of psychiatric drugs pose a threat to manage
psychiatric problems – due to detrimental effects on
fetus or newborn development
Assumed that all psychotropic drugs cross the blood
placental barrier

1. DETREMINING RISK AND BENFITS
Health care providers to assess the risks and
benefits of maternal drug therapy
Concerns include – possibility of Lbw babies ,
sucidality, inability to engage in appropriate
obstetric care
Basic rule to avoid administering any medication
Consent made jointly by partner , the women and
health care worker
Aims – at maintaining the lowest level of
therapeutic dose

US FOOD AND DRUG ADMINISTRATION
Not approved psychotropic agents for treatment of
mental illness during pregnancy or lactation
Developed classification system for prescribing
drugs
CATEGORY
1. A - controlled studies shows no risk . Well controlled
studies have failed to demonstrate risk to fetus
2.B- no evidence of risk in humans : EITHER animal
findings show risk , but humans donot or adequate
human studies have been done

C- risk cannot be ruled out. Human studies are
lacking and animal studies are either positive for
fetal risks or lacking as well . Potential benfits amy
justify potential risks
D- postive evidence of risk . Investigation shows risk
to fetus . Potential benefits may outweigh risks
X- contraindicated in pregnancy . Studied in animal
and humans shows fetal risks , that clearly outweigh
any possible benefits to the patient

System and current research – developed creation of
three categories of somatic risks to fetus and
nweborns with use of psychotropic agents
1. teratogenicity and organ malformation
2. Neonatal toxicity
3. neurobehavioural and developmental teratogenic
effects

Medication for psychiatric disorders
A. ANTIDEPRESSANTS
A. Tricyclic anti depressants ( TCA’S )
API committee on drugs ( 2001) has suggested ,
clinician proceed with caution with use of such drugs
as support has not been established
Nullman and colleages ( 1997)- Reported that in
utero exposure to fluoxetine or TCA’S didnot affect
either neurodevelopemental or behaviour in
preschool childrens.
Other studies showed higher rates of perinatal
complications

TCA’S cause central nervous system and peripheral
nervous system side effects , overdose cause death
Side effects for mother – inlcude weight gain,
tremors , grand mal seizures , night mares , agitation
or mania and extra pyradimal side effects , anti
cholinergic effects

MONOAMINE OXIDASE INHIBITORS ( MAOI’S )
Fall in the category” C” of FDA’S
MAOI’S not to be used during pregnancy
USEof MAOI’S require dietary restriction associated
with preventing hypertensive crisis
Dangerous food include –beer, red wine, aged cheese
, smoked fish , brewers yeast , beef and chicken livers
, yoghurts, bananas, soy sauce , chocolates

SELECTIVE SEROTININ REUPTAKE INHIBITORS
Emerging as first line agent in treatment
Relatively safe and carry fewer side effects than
TCA’S
Not to be taken with DEXTROMETHORPHAN
(cough syrup ) combination trigger serotonin
syndrome
Frequent side effects in mother – gastro intestinal
disturbances , headache and insomnia
1/3 rd clients show reduced libido , arousal o
orgasmic functions

MOOD STABILIZERS
Used to treat mental illness- mainly bipolar disorder
Lithium carbonate is major mood stabilizers , but its
use is contraindicated in pregnancy
Alternative to lithium in pregnancy are
anticonvulsants ex. Carbmazepine , valproic acid ,
donazepam

ANXIOLYTICS
Benzodiazepines are most frequently preferred
This class drugs can aclumate in the fetus if given to
the mother for a longer period of time
These drugs should be withdrawal abruptly amd
must be tapered significantly before birth to prevent
infant withdrawal
Benzodiazepines produce infant withdrawal
syndrome that last longer than 3 months

ANTIPSYCHOTICS
Used to manage schizophrenia and other though
disorders in women
Msot fall in the “c” category of FDA category ,
indicating they are associated with rare anomalies ,
such as fetal jaundice and anticholingenric effect at
birth
Said that all psychotics drugs cross the placental
barrier, predisposing infants to numerous problems

 studies have shown so far that 3 antipsychotic i.e
haloperidol, perphenazine , and chloropromazine ,
have shown no direct link to congenital
malformation
Other drugs cause in women- extrapyramidal side
effects , neuroleptic malignant syndrome

Nursing management
Nurse to see that , the clients have adequate
knowledge about their health status
A. DISCUSSING INFORMED CONSENT
Nursing responsibility to make client is whole
knowledge about the risk of psychotropic mediation
during pregnancy .
Through discussion on risk verus benefits need to be
done

B.DOCUMENTING RISK VERSUS BENFITS
Document potential risk for any illness if untreated
,including risks to the women and fetus and infants
Critical decison based on scientific knowledge , the
clients clinical history , cultural consideration and
personal preferences

C. Promoting community and psychosocial
interventions
To Maintain these women in the community
Community focused interventions- case
management, rehabilitation , self help groups and
day hospitalization

D. TEACHING STRESS MANAGEMENT
Being pregnant , can produce stress
Body reaction to stress is flight and fight techniques
Common physical reaction to stress – increased bp,
palpation, tense muscle , poor or excessive appetite
and disturbed sleep
Common symptoms – short tempered , feeling tired
frequently, eating toomuch or too little , sleeping too
much or too little , changes in menstrual cycle ,
forgetfullness, frustration, irritability , diffculty to
concentrate and sleep distubances

Diseases can also occur- heart diseases, DM, irritable
bowel syndrome , depression ,UTI, asthma
Management- behavioural change
Specific strategies – prioritizing responsibilities ,
taking time to relax , exercising , become involved in
social support systems , healthy perspectives ,
powerful strategies to improve quality of life
Regular sleep routines

E.ASSISTING WITH ACESS TO HEALTH
CARE
F.PROMOTING HEALTH LITERACY

INFECTIONS :
TOXOPLASMOSIS, RUBELLA ,
RTI’S , STD’S ,VAGINAL
INFECTIONS

DEFINTIONS
SEXUALLY TRANSMITTED DISEASES
A group of communicable diseases that are
transmitted predominantly by sexual contact and
caused by a wide range of bacterial , viral , protozoal ,
fungal and ectoparasitites
REPRODUCTIVE TRACT INFECTIONS
Infections that occur in the reproductive tract and it
encompasses both sexually transmitted and other
common genital tract infections

PREVALANCE
True incidence of STD’S unknown – because of
inadequate reporting and secrecy that surround
them
1. gonorrhea – 6.2 million
2. genital chylamyidial infections – 89 million
3. syphyillis – 12 million
4. chancroid – 2 million

Viral STD’S
genital herpes – 20 million
human papilloma virus infection- 30 million
trichomoniasis – 170 million
( who health situvation 1994)

Prevalance of disease in india
SYPHILLIS – a prevalence of 2.4
GONORRHEA – most cases are unreported
80% INFECTED women are asymptomatic
carriers
CHLAMYDIA – mostly prevalent in the
southern states
DONOVANOSIS- Greater prevalence in the
coastal region , endemic in T.N, A.P, ORISSA

Epidemi0logy
A. HOST FACTORS
AGE – 20- 24 years old,followed by 25- 29 yrs and
15- 19 yrs
SEX- morbidity is higher for men then for women,
but morbidity caused by infection is generally much
more severe in women
MARITAL STATUS – the frequency of STD’S is
higher among single , divorced and separated
womens than among married couples
SOCIO ECONOMIC STATUS – individual from low
socio economic have higher morbidity

B. SOCIAL FACTORS
PROSTITUTION- prostitutes act as reservoir of
infections
major incidences in asia is accounted to prostitution
BROKEN HOMES – promiscuous women are drawn
from broken homes eg. Homes that are broken due to
death of parents , or their separations , reared in
unhappy homes
SEXUAL DISHARMONY – married people with
strained relations, divorced and separated persons are
often victims of STD’S

EASY MONEY – prostitution provides way for
occupation and for earning easy money , fostered
with lack of female employement
EMOTIONAL IMMATURITY
URBANIZATION AND INDUSTRIALIZATION- type
of life styles contribute to infections
SOCIAL DISRUPTION- caused by disasters , wars ,
civil unrest
INTERNATIONAL TRAVEL – travellers can import
and export infections

CHANGING BEHAVIOURS PATTERNS – Moral
and cultural value , tendency to break from
traditional ways of life to newer ways of living
SOCIAL STIGMA – Leads to non detecting of cases ,
not disclosing the case nor the source and hence it
leads to infection
ALCOHOLISM- effect boast prostitution

CLASSIFICATION OF SEXUALLY
TRANSMITTED DISEASES
A. BACTERIAL INFECTIONS
1. gonnorrhea- Neisseria Gonorrhea
2 chlamydia
3. syphilis -Treponema pallidium
4. chancroid -Hemophilus ducreyi
5. Lymphogranuloma venerum- Donavanis
granulomatis
6. genital mycoplasmas- Mycoplasma vaginalis
7. group B streptococcus

B.VIRAL INFECTIONS
AIDS - HIV
GENITAL HERPES – Herpes simplex virus (HSV)
CONDYLOMA ACCUMINATA- HPV
MOLLUSCUM CONTAGIOSUM- HPV -16,18,31
VIRAL HEPATITIS – Pox virus
C. PROTOZOAL
TRICHOMONAS VAGINITIS- trichomonas vaginalis

d. Fungal
Monilia vaginitis - candida albicans
e. Parasites
Scabies – sarcoptes scabies
Pediculosis pubis

Effects of sexually transmitted diseases
1. EFFECT IN THE REPRODUCTIVE TRACT
Females- Infections , development of ectopic
pregnancy, infertilty , pelvi inflammatory diseases, ,
chronic pelvic pain
Males- inflammation of the epididymus , infertility,
urethral stricutre
Infants- eye infection, blindness

2.ULCERATION OF URO GENTIAL TRACT, mouth,
rectum , cardiovascular complications , peripheral
nervous inflammatory disease ,
3. TRICHOMONIASIS- parasitic infection causing
vaginitis , arthritis, adverse effect of pregnancy – low
birth weight babies , premature rupture of
membrane

4. Inflammation of the lymph node , ulcerative
genitalia and elephantiasis – effects of chancroid
and lymphogranulona
5. Genital herpes –Papular lesions and ulceration
Carcinomas- hepatocellular carcinomas , caused by
hepatitis B, kaposis sarcoma , bcell lymphomas

Types of infections
A. Protozoal infection
TRICHOMONAS VAGINALIS(VAGINAL
INFECTION)
A unicellular protozoan flagellate
Transmitted through sexual intercourse
Women usually infects vagina and skene’s duct in men
Can be present in the lower

SYMPT OMS
Vaginal discharge – yellow green , frothy or bubbly
and copious with a strong foul odour
Cervix and upper vagina often tiny petechiae , due to
inflammation
With severe inflammation-vaginal wall, cervix and
vulva may be oedematous and erythematous
Moderate to severe itching
Women- dysuria and dyspareunia secondary to
inflammation

Contd symptoms
Symptoms vary form mild to severe
MILD SYMPTOMS can be- discharge that is thin,
slight , whitish yellow , without typical foul odour
Often cervix and vagina demonstrate “ strawberry
spot”

DIAGNOSIS
DURING PELVIC EXAMINATION-
Discharge samples placed on a saline mount and
examined microscopically
Motile trichomonades are seen
Under high power seen as 2 to 3 times the size of
WBC and their flagella may be seen moving
Lactobacilli are usually absent, many WBC are
present, array of vaginal intermediate and parabasal
epithelial cells are present
Routine pap smear indicates presence of
trichomonades

TREATMENT
Treated with metronidazole (flagyl) 2 gm orally in a
single dose or 250mg tid for 5 to 7
days( contraindicate during the first trimester of
pregnancy )
Womens sexual partner also to be treated with 2 gm
single dose
When taking to avoid alcohol , because it produces
abdominal cramps , nausea, vomiting , headache and
flushing

Lactating women to be treated with 2 grams
metronidazole , but not to breast feed for 24 hours
after the therapy
Metronidazole is contraindicated during pregnancy ,
especially during the first trimester . Clotrimazole
vaginal cream or tablets at bedtime for 7days can
provide symptomatic relief

Local vulvar inflammation and dysuria - to be
treated with Sitz bath or steriod creams
 For Dyspareunia – avoided for 2 to 3 days to allow
for healing

Fungal infections
CANDIDA VAGINITIS ( vaginal infection)/ VULVO
VAGINAL or yeast infection
Caused by fungus Candida albicans widely
distributed in nature , found in skin and mucous
membrane
Causes : occurs frequently in women with DM ,
Women taking systematic antibiotics are more
susceptible to candidas due to suppression of normal
vaginal flora and changes in PH and enzymes
Stress – decreases resistances to candida vaginitis
and hygiene practices such as douching , using
perfumed oils

SYMPTOMS
Common symptom is – vulvar and possible vaginal
pruritis
Itching may be mild or intense , interfere with rest
and activities , occur during or after intercourse
Women c/o of period of dryness
Others- have painful urination , usually results
because of excoriation , resulting from scratching

Discharge is thick, white , lampy and cottage cheese
like
Discharge may found on vaginal walls , cervix and
labia
Commonly vulva is red ,&swollen labial folds , vagina
and cervix may also be swollen
Rarely a yeast or musty smell occurs

Screening and diagnosis
Complete history acts as the valuable screening tool
Physical examination – including complete
examination of the vulva and vagina
Speculum examination – always essential
Saline and potassium hydrooxide (KOH) mounts –
Prepared from vaginal or labial secretion, vaginal ph
is normal in yeast infection
Microscopic examination- Shows hypae and spores
of candida albicans
On saline mounts the vaginal epithelium cells appear
normal , there are numerous lactobacilli ( normal
flora and few white blood cells )

TREATMENT
Vaginal tablets or creams such as mycostatin ,
miconazole , clotrimazole, terconazole and
triconozole are prescribed for insertion once daily for
7 to 14 days
Shorter regimen : terazol and
butaconazole( femstat) in a 3 day regimen...
&
mycelex G-500 AND vagistat ( 0.5%in
a single treatment)

Persistent or chronic candida vaginitis treated with
oral anti fungal medications , such as mycostatin ,
ketoconazole or fluconazole
Single oral dose of fluconozole is as effective as 3days
of intravaginal clotrimazole
Prophylactic oral fluconozole once a month can
control recurrent infections( can cause liver toxicity ,
hence liver test to be done)

Teaching points
Minipad can be advised during the day to absorb the
drainage
Women should not use tampoons during treatment ,
as it absorbs the medication
Douching to be avoided , and intercourse to
preferably stopped or a condom used during the
intercourse
Vulvar inflammations and itching are severe –
antifungal or steroidal creams can be applied for
several days

If candida vagnitis is recurrent , male partner should
be examined and skin scraping to be done

BACTERIAL INFECTIONS
BACTERIAL VAGINOSIS ( VAGINAL INFECTIONS)
Caused by gardnerella vaginalis or haemophilus
vaginitis , a short gram negative rod ( cocco bacillus)
often seen in combination with mobiluncus species ,
mycoplasma hominis and anaerobic bacteria , such
as non- fragile bacteroides species
Common in vaginal flora , but cause symptoms when
crowded out the lactobacillus species

Etiology
Exact etiology is unknown
PATHOPHYSIOLOGY
Normal h202 lactobacilli are replaced with high
concentration of anaerobic bacteria ( gardnerella and
mobilluncus)
With more proliferation of anaerobic , the level of
vaginal amines is increased and normal acidic ph of
vagina is altered
Epithelial cell slough and numerous bacteria attach to
their surface
Amines are volatilized , then the characteristic odour
of BV occurs

Symptoms
Fishy odour in the vaginal area
B.V discharge is usually profuse , thin, vulvar and
vaginal inflammation are commonly seen
Serious consequences can arise if infection is severe
–cellulitis , PID , intra-amniotic infections , post
partum endometriosis , preterm labour , recurrent
urinary tract infection

Careful history – to help distinguish from other
vaginal infections
Microscopic examination of vaginal secretion
Normal saline and 10% potassium hydroxide smear
to be made
Presence of clue cells by wet smear is highly
diagnostic – is specific to BV
Clue cells appearances is due to vaginal epithelial
cells appear stippled due to growth of gardenerellla
and other organisms

Management
Oral metronidazole 5oomg orally twice a day for 7
days 0r 2gms in a single dose
Clindamycin 300 mg orally tid for 7day s is an
alternative
Clindamycin phosphate vaginal cream 2%at bed time
for 7days or metronidazole vaginal gel at bedtime for
5 days
When administering metronidazole advice to be
given for avoiding alcohol

Side effects of metronidazole – sharp , unpleasant
metallic taste in mouth , furry tongue , central
nervous system reaction, urinary tract disturbances
Metronidazole contraindicated in pregnancy and
lactating mother , coz high concentration seen in
infants . If necessary to follow pump and dumb
method

BV AND PREGNANCY COMPLICATIONS
Includes
Postpartal infections
Preterm labour and delivery
Preterm rupture of membrane
Fever during labour
Postpartal endometriosis
Intra amniotic infections
Post caesarean endometriosis

Case detection
Clinical criteria and through vaginal examination
B.V is diagnosed when atleast three of the follwoing
criteria are present
A. Vaginal ph is above 4.5
B.Thin, homogenous , white or gray vaginal
discharge
C.Clue cells present on saline prep of vaginal
discharge
D.presence of fishy amine odour with additional of
10%potassium hydroxide to vaginal fluid

GROUP B STREPTOCOCCUS
VAGINAL INFECTIONS
Group b streptococcus considered as a part of the
normal vaginal flora in women and is present in 9 to
23% of the healthy pregnant women
Incidences
Associated with poor pregnancy outcomes

RISK FACTORS
Positive culture for Group b STREPTOCOCCUS
Preterm of less than 37 weeks of gestation
Premature rupture of membrane for a duration of 18
hours or more
Intrapartum maternal fever higher than 38 c

Diagnosis
Prenatal screening done by vaginal or cervical
cultures at 26 to 32 weeks gestation
GBS culture is recommended for pregnant women
admitted for premature or prolonged rupture of
membrane , premature labour, fever during labour
and multiple births
EIA TEST for GBS antigen provides for rapid
detection but sensitivity may be low , leading to false
negative

GROUP B STREPTOCOCCAL DISEASES IN
NEONATES
Occurs in 2 to 4% of 1000 live births
Rates of infections are 1 to 2 per 1000 births , and
mortality rate of 30%
Sepsis apparent birth or may not appear until after 1
week
Infection lead to puenmonia, bacteremia , meningitis
with residual neurologic development deficits or
deaths

Late onset of disease – occurs after 7days and may
cause meningitis , bacteremia and bone and joint
infection

TREATMENT
PRENATAL
Ampicillin 500mg orally QID for 7days given in the
third trimester ( rdeuce colonization prior to
delivery)
Erythromycin used in case for penicillin sensitive
client
Sexual partners treated with ampicillin to prevent
recolonization
Use of condoms

INTRAPARTUM
Ampicillin 2g iv intially followed by 1 t0 2 g iv q6h
during labour
Erthromycin or clindamycin is used with penicillin
allergy
NEOANATE WITH EVIDENCE OF INFECTION
Parental ampicillin 75 mg /kg q12h plus gentamycin
2.5 mg/ kg q12h starting within 2 hours after birth
continuing for 10 days

EFFECTS OF GROUP B STREPTOCCCOUS
INFECTIONS
Pregnancy effects fetal
effects
Preterm labour preterm birth
Premature rupture of membrane
Chorioamniotis
Postpartum sepsis
Urinary tract infection

CHLAMYDIA TRACHOMATIS INFECTION
EPIDEMIOLOGY
Caused by chylamydia trachomatis
High prevalence among adolescents and young
adults
More than 4 million cases annually
Is a intracellular organism that infects the lower
genital tract of women and men causing urethritis

RISK FACTORS
age of 24 or younger
multiple sexual partner
New sexual partner
friable cervix
non barrier method of contraception or no
contraception

SYMPTOMS
Two third of the cases are asymptomatic
Symptom consists a complex of pelvic pain , fever ,
tenderness and muco-purulent cervical discharge
indicating PID OR salphingitis
ANTEPARTUM
Reviews of various studies show that ante partum
trachomatis causes amniotis and postpartum
endometroisis
Chylamydia cerviticis occurs in 30% pregnant
women

NEWBORN
Newborn infections – upto 60 to 70% i.e during
passage via the birth cannael
Inclusion conjuntivitis of newborn – most common
infection occuring in upto 50% of exposed newborns
Chlamydia neonatal ophthalmia is also seen
Infected neonate many also develop pneumonia

DIAGNOSIS
Direct immunoflurescent monoclonal antibody stain
and enzyme linked immunosorbent assay ( ELISA)
and polymerase chain reaction – provide rapid and
accurate diagnosis
Elisa and PCR developed that can be used in urine
and genital swab specimens

Treatment
Acc to CDC recommendes – treating women and
partner
Treatment regimen includes :
Doxy cycline hyclate 100 mg orally BD for 7days
Azithromycin 1 gram orally single dose
Erthromycin 500mr orally QID for 7days
Ofloxacin 300mg orally bid for 7days
Sulfisoxozole 500 mg orally qid for 10 days

TREAMENT DURING PREGNANCY......
Doxycycline, erythromycin, estolate and ofloxacin
are contraindicated
Erthromycin or sulfisoxazole may be used , but
sulfisoxazole is less effective
Amoxicillin or clindamycin is also effective
treatment

Prevention
Prevention of neonatal trachomatis infections:
Newborns routinely treated prophylactically aganist
ocular chylamdial infection
Topical erythromycin or tetracycline ointments are
used
Chlymadial pneumonia and conjunctivits in
neonates – treated with systemic erthromycin

GONORRHEA
One the oldest communicable sexuaaly transmitted
disease
caused by gram negative Coccus Nesserei gonorrhea
– commonly infects the mucosa of the lower genital
tract
Other sites of infections include endocervical glands ,
urethra, anus and oropharynx
Also spread by oral to genital and anal to genital
Evidence show infection spread from vagina to
rectum
Also transmitted to neonate in the form of opthalmia
neonatorum

Risk factors
Sexually active individuals
Young adults
African – amercian
Multiple sexual partners

SYMPTOMS
Women are asymptomatic : one third of infections
seen in adolescents, symptoms are unnoticed
Purulent endocervical dischanrge , dicharge minimal
or absent
 complaints of Pain Chronic or acute severe pelvic or
lower abdominal pain or longer , painful menses
Infrequent dysuria, vague abdominal pain or lower
back pain
Gonococcal rectal infection – Ocuur in women after
anal intercourse with 10 % to 30 % urogential
infections

Contd...
Individual with rectal gonnorhea – may be
completely asymptomatic or conversely have severe
symptoms with profuse purulent anal discharge ,
rectal pain and blood in stool .
Rectal itching , fullness , pressure are commen
symptoms

Gonorrhoea infection in pregnancy...
Gonococcal infection in pregnancy affects mother
and fetus – so routine gonorrhea testing is
recommended in early pregnancy and repeated at 28
weeks
Women with cervical gonorhinginits may develop in
first trimester
Perinatal infection with gonorhaea can lead to
premature rupture of membranes , preterm births ,
chorioamniotics , sepsis , intrauterine growth
restrictions and maternal postpartum sepsis

GONORHEA IN NEWBORNS CAUSES –
 OPTHALMIC NEONATORIUM is the common
manifestaion – highly contagious , if untreated can
lead to blindness
INFECTIONS OF the nasopharygeal passage , vagina
, anus , earcannals and scalp abscesses

SCREENING ND DIAGNOSIS
CDC recommends screening of all women
All pregnant women routinely screened at the first
prenatal visit and infected those identified with risky
behaviours are rescreened
For diagnosis cultures are obtained from –
endocervix, the rectum and the pharynx
Diagnosis is confirmed if it shows intracellular gram
negative diplococci .i.e culture done on a gram stain

Management
CDC recommendation for uncomplicated urethral ,
endocervical or rectal infections are dual therapy
with one of the following
 ceftriaxone sodium 125mg IM single dose
Cefixime (suprax) 400mg oral single dose
Ciprofloxacin HCL 500MG orally single dose
Ofloxacin (fluxacin) 400mg orally single dose
Spectinomycin hcl ( TROBIN) 2GM im single dose
combined with doxycycline 100 mg orally bd for
7days

Fluroquinolone – not to be used in pregnant and
younger than 18 years
Gonorrhoea with co-existing Chlamydi- 7days of
doxycycline ( not used for prg women)or single dose
of azithromycin is added

Gonorrhoea during pregnancy ...
Treated with ceftrixone 125 mg IM or other
cephalosporins ( spectinomycin 2 gm IM if allergic)
plus erythromycin base 500 mg orally QID for 7days
In neonates prophylatically against gonococcal
opthalmia - topical application of 1% silver nitrate
- also erythomycin , tetracycline ointment
NEWBORNS INFECTED PERINATALLY – treatment
with parental antibiotics

SYPHILLIS
CAUSED by spirochete treponema pallidum
one of the earliest described diseases STI’S
Transmitted through exposure to infected exudate
during sexual contact, by contact with open wound
or infected blood or congenitally
Rate of acquisition from that of a infected person is
30%
Disease also transmitted by kissing, biting, hugging.

INCIDENCES
More than 30,000 new cases of primary and
secondary occur anually
Incidences increased during the 1985 to 1990 ,
presently still continue to increase in incidences

SYMPTOMS
Infection manifest itself in stages with different
symptoms
Primary syphilis is characterized by primary lesion .
Ie the CHANCRE , appears 5 to 90 days after
infection
Lesion begins as painless papule then erodes to form
a non tender , shallow , indurated , clean ulcer with
several millimeters to centimeters to size

Secondary syphiilis – occurs 6 weeks to 6 months
after apperance of chancre
Characterized widespread , symmetric
maculopapular rash on the palms and soles with
generalized lymphanopathy
May also develop fever , headache and malaise
Condylomata (broad, painless, pink grey wart like
infection ) develop on vulva , the perineum or anus
If untreated , some women enter latent phase others
develop teritary syphilis – 1/3 rd of women

Contd......
Neurological , cardiovascular musculoskeletal or
multiorgan complications can develop in third stage

Syphilis during pregnancy
Can be transmitted to fetus through placental
circulation as early as 6th week
Clinical manifestation of disease in foetus usually do
not occur unless infection is present in women after
16 week of gestation
Risk of prematurity , perinatal death and congential
syphilis is greater during primary or secondary
syhilis
Congenital syphilis – is systemic
infections,newborns affected heptosplenomegaly ,
hemolytic anemia , osteochondritis , bullous skin
eruptions containing spirochetes

Screening and Diagnosis
All women diagnosed with another STI’ S OR WITH
HIV infections TO BE screened for syphillis
All pregnant women to be screened for syphillis at
first prenatal visit
Two types of serologic tests are used : NON
TREPONEMAL and TREPONOMAL

CONTD..
Non- treponemal tests- SUCH AS VDRL , rapid
plasma reagin are used as screening tests
False postive test results are seen for acute
infections, autoimmune , malignancy .
The TREPONEMAL tests – FLURORESCENT
TREPONEMAL antibody absorbed and micro
hemagglution assays for antibody to T.pallidium, are
used to confirm POSTIVE TESTS
Tests results for early or incubating syphillis may be
negative

MANAGEMENT
Penicillin is drug of choice
Proven therapy used even during pregnancy
Parental penicillin – drug of choice treatment for all
stages of syphillis

DOSAGE
Less than 1 year duration single dose of 2.4 million U
benzathine penicillin G IM
More than 1 year duration , three doses of 2.4 million
U BENZATHINE penicillinG im WEEKLY for 3
weeks
Neuro syphilis 10 to 14 days of iv penicillin or
procaine penicillin IM plus oral probenecid
Penicillin allergy in non pregnant client
-Erthromycin

CHANCROID
Diseases caused by H.ducreyi

INCIDENCES
Prevalent in India
Incidence now found to have decline
Different states present with different status, highest
amoung them been recorded in the northeast with
retropective data showing highest incidences of
about 25.7%
Diseases is less common in the developed and more
prevalent in the developing countries
Found in minority ethincity , multiple sexual
partners, prostitution, and drug users

Diagnosis
Made by presences of a powerful genital ulcer ,a
negative test for syphilis and herpes and bilateral
inguinal lymphdenopathy
Ulcer – usually deeper , softer at edges and more
irregular than syphilitic chancre
More painfull and one or more lesions will be
present

TREATMENT
AZITHROMYCIN 1GM orally single dose
OR
CEFTRIAXONE 250 MG IM single dose
OR
CIPROFLOXACIN 500 MG orally , twice daily for
3days
OR
ERTHROMYCIN BASE 500MG ORALLY , 3times
daily for7day
Erthromycin contraindicated during preg,
Following treatment women to be reexamined

MOLLUSCUM CONTAGIOSUM
Member of the pox virus
Frequently seen in chlidren as skin infections
Found commonly in the tropical areas , disturbution
is world wide

Risk factors
Among adults through sexual transmission – more
common spread
 poverty
Inadequate resource for good hygiene
Overcrowding
Transmission occurs through contact with infected
skin.
Apart from sexual route also transmitted through
from personal objects , that has been contact with
lesions by skin to skin contact
Infection also transmitted by touching infected areas
and then touching other body parts

Signs and symptoms
Cause a benign infection of skin
Firm raised flesh coloured nodules with a softly
indented centres from small papules
Average size less than 0.5 cm
Central area is filled a soft curd like materials , that
can be expressed
Nodule appear on the genitals , buttocks and thighs
and chest
Large lesion seen in immune suppressed pts

DIAGNOSIS
Presumptive diagnosis made – ON CLINICAL
PRESENTATION
STAINING OF the material expressed form the
nodules can identify typical molluscum bodies in the
cytoplasm

TREATMENT
A benign disease with limited course , it resolve
spontaneously after week or month
Cryotherapy , scraping the core material with a sharp
object , curetting the lesion , applications of
podophyllins in the office or podofilox at home

LYMPHANOGRANULOMA VENEREUM
LGV is caused by some subgroup of cotrachomatis
Genital ulcer may appear at site of initial infections ,
but resolves quickly
More prominetly seen as tender lymphedenopathy ,
most commonly in the inguinal areas/femoral areas

Diagnosis
By exclusion of other causes of lyphadenopathy or by
compliment fixation testing

Treatment
Doxy cycline – 100mg orally twice a day for 21days
Erythromycin base 500mg – orally four times a day
for 21 days
All partners to be tested

VIRAL SEXUALLY
TRANSMITTED DISEASES

HUMAN PAPILLOMA VIRUS
Hpv also known as condylomata accuminata or
genital warts
Most common viral STI’S in ambulatory health
setting
HPV a double stranded DNA virus , which has more
than 30 serotypes ,that can be sexually transmitted ,
five of which are known to cause genital warts
formation , eight of which causes oncogenic potential
About 70 tyoes of hpv virus , skin commonly infected
by 1,2 ,3 ,4 and mucuosa by hpv 6, 11, 16, 18

Incidences
Dramatic rise in hpv infections in last 20 years with
estimated incidences at about 17%
Younger women have higher rate of incidences
Cervical hpv rates 33% and combined cervix and
vuvla rates of 46%

Risk factors
Younger age
Failure to use condom

Signs and symptoms
Lesions large , cauliflower like clusters or condyloma
,usally multiple , although single lesions can be seen
on the vulva, vagina ,cervix and rectum
Lesions are small 2 to 3 mm in diameter and 10 to 15
mm in height
Papillary swelling occuring singly or in clusters on
the genital and anal rectal regions
Infection of longer duration look like cauliflower like
mass
In moist areas such as vaginal introtus , lesions look
like multiple fine finger projections

Complain of profuse , irritating vaginal discharge ,
itching , dyspareunia or post costal bleeding
Women may report of bumps on her vulva
Flat topped papules 1 to 4 mm in diameter are seen
in cervis
DURING PREGNANCY , the lesions become so large
during pregnancy that the affect urination ,
defecation , mobility and fetal descent
Hpv infection can also be acquired by neonate
during birth

Complete h/o OF signs and symptoms , pap tests
and physical examination
Hpv – DNA test can be used in women over the age
of 30 in combination with PAP test to screen for
types of HPV or in women with abnormal PAP test
Only definitive diagnosis is - for presences of
histological evaluation of a biopsy specimen

MANAGEMENT
Untreated warts may reslove on their own in young
women , because of strong immune system
No therapy eradicates HPV
GOAL of treatment is removal of warts and relief of
signs and symptoms , not eradication of HPV
For pregnant women – cryotherapy with liquid
nitrogen, TCA OR BCA 80 – 90%
Women with discomfort associated with genital
warts find bathing with oats meat solution and
drying the area with cool bar drier.

Keep the area clean and dry.
Cotton underwear and loose fitting clothes decrease
friction and irritation and decrease discomfort.
Women to be counseled regarding diet, rest and
exercises.
 also to be taught on virus transmission.
Sexually active women with multiple partener or
history of HPV to encourage to use latex condom.

To be instructed about medications and therapies
available.
Importance of concurrent treatment of vaginitis and
other STD’S to be emphasized.
Educate the importance of annual health
examination to screen disease reoccurrence.
Women should be counselled for regular pap
screening.

prevention
Prevention include abstinence from sexual activity.
Staying in longterm monogamous relationship.
Prophylactic vaccination(HPV) vaccine..

HERPES SIMPLEX VIRUS
Incidence or history :
Unknown until point of middle of 20th centuary, now
a wide spread problem especially in the united states.
Caused by two antigen subtypes, herpes simplex
virus 1(HSV1) and herpes simplex virus 2(HSV2)
HSV 2 is usually transmitted sexually and HSV1 non-sexually.
HSV1 /commonly associated with gingivostomatitis
and oral labio ulcers.
HSV2 with genital lesions.

HS V 1 mainly seen as cold sores of lips.
Risk factors:
Lower income and educational levels.
African americans or hispanic race.
Female gender

SYMPTOMS
Multiple painful lesions , fever ,chills, malaise and
severe dysuria and last upto 2 to 3 weeks
Incubation period for primary infections is 3 to 14
days
Following this incubation period the women with
HSV – 2 will develop painful vesicles in the vulva
and perineal areas
Women with primary genitla herpes progress
forming vesciles , pustules and ulcers that crust and
heal without scarring
Ulcers become tender

Women also have itching , inguinal tenderness and
lymphadenopathy
Severe vulvar edema may develop and have diffculty
sitting
Cervix may appear normal or be friable , reddened ,
ulcerated or necrotic
Heavy, watery to purulent vaginal discharge is also
seen
Extragental lesions may also be present
Urinary retention and dysuria may occur secondary

Women with recurrent episodes of HSV infection
commonly have only local symptoms , which are less
severe

DURING PREGNANCY
Have adverse effects both on mother and fetus
Primary infection during the first trimester have
been associated with increasing miscarriage rates
More severe complications of HSV infections is
neonatal herpes
Risk for neonatal infections is heightened among
women with primary herpes infection who are near
term

A thorough history and physical examination
History taking into account-any viral symptoms ,
malaise , headache, fever ,local symptoms like vulvar
pain , dysuria, itching or burning at site of infection.
A thorough physical examination – emphasis on
vulva, perineal, vaginal and cervical area to be
carefully inspected
Confirmed by viral cultures or antibody titres using
ELISA technique .
Multinucleated giant cells on a pap smear also
support diagnosis

MANAGEMENT
Genital herpes – CHRONIC recurrent disease , for
which there is no cure
Mx aimed at specific treatment during primary and
recurrent infections , preventions , self help measure
and psychological support
Systemic anti viral medication partially control
symptoms and signs of HSV infection

IN NON PREGNANCT WOMEN
Acyclovir 200mg orally five times daily or
400 mg threee times daily for 10 days
recurrent infections – acyclovir 200mg five times for
daily for 5 days
or
800 mg twice daily for 5days started
within 2 days after appearance of lesion
CHRONIC SUPPRESSIVE THERAPY – with 400 mg
acyclovir twice daily , helps reduce recurrences

IN PREGNANT WOMEN- Safety of acyclovir not
established
ACYCLOVIR can be used if benefits outweight the
potential harm to the fetes
Cleaning lesion twice a day with saline will help
prevent secondary infection

Measures that increase comfort – warm sitz bath
with baking soda
keeping lesions dry by blowing the area ,
pat dry the area with soft towel
Wearing cotton underwear and loose clothing
Using drying aids such as hydrogen peroxide ,
burrows solutions or oatmeal baths , applying cool ,
wet , black tea bag to lesions and applying compress
with infusion of cloves or pepper oil to lesions

Oral analgesics such as aspirin or ibubrofen is used
to reduce pain sensation
Non viral ointment , especially containing cortisol
are extremely sensitive and such agents should be
avoided
A thin layer of lidocaine ointment or antiseptic spray
may be applied to decrease discomfort
Diet rich in vitamin c , B-complex vitamins , zinc and
calicium – to help prevent recurrences

Contd....
Amino acid l-lysine has been used in doses of 750 –
1000 mg daily while lesions are active and 500 mg
during asymptomatic period
Counselling and education
Referral for stress reduction therapy , yoga ,
meditation
Avoiding exercise , heat and sun , hot baths and
using lubricant during sexual intercourse to reduce
friction , to use condoms during intercourse

Vaginal births is preferred if there is not visible
vaginal lesions
 A Cesearen birth within 4 hours after labour begins
or membranes rupture is recommened if visible
lesions are present
Infant delivered through infected vagina to be
carefully observed and cultured

VIRAL HEPATITIS
Five different viruses (hep A,hep B, C, D & E)
HEPATITIS A
Acquired primarily through feco- oral route by
ingestion of contaminated foods, particularly milk,
shell fish or polluted water or person to person
contact
Also transmitted through sexual contact

symptoms
Abrupt onset of flu like symptoms
Abdominal pain
Fever
Malaise , anorexia
Nausea, vomiting
Jaundice and puriritis
incubation period of 15 to 20 days
Transplacental transmission of HAV to fetus occurs
rapidly

DIAGNOSIS
 Detection of antiHAV antibodies in serum is
elevated
LFT –show elevated aspartate transaminase (AST) ,
Alanine aminotransferase (ALT), alkaline
phosphates , cholestrol, and bilirubin

TREATMENT
PREVENTION – vaccine ‘havrim” made from
inactivated hepatitis virus , FDA approved this
vaccine in 1995
One dose is 96% effective
Non immunized people who come in close contact
with infected person to be given serum
immunoglobulin within 14 days of exposure

HEPATITIS B
Common cause of acute and chronic hepatitis
Transmitted through sexual contact and blood fluids

Risk factors
Women of asian, pacific islands or alaskan eskimo
descent , women both in haitior , sub saharan africa
Women with history of acute or chronic ulcer disease
who work or receive treatment in dialysis unit
Women with histroy of multiple blood transfusions
Prison inmates
Homesexuals
Iv drug users
Frequent blood users

Transmission
Perinatal transmission occur in infants of mother
who have acute infection in the third trimester or
during postpartum or during intrapartum from
exposure to positive vaginal secretion , blood
amniotic fluid and breastmilk
Also transmitted through artificial insemination

Symptoms
Many are asymptomatic
Classic symptoms – fatigue , nausea , anorexia ,
abdominal pain, low grade fever , and in 25% of
cases jaundice
Later women develop clay coloured stools, dark
urine , increased abdominal pain and jaundice
Infection become chronic , ranging from
asymptomatic carriers to persistent hepatitis

Thorough history and physical examination
Serological testing for hepatitis B surface antigen
(HBsAG)

HEP B IN pregnancy
Newborns to receive prompt treatment and health
care worker to take appropriate precaution
HBV can be prevented in 85 – 95% OF NEWBORN
by administering hepatitis B immunoglobulins , as
soon as possible , within 12 to 48 hours after birth

TREATMENT
HBV vaccine is administered in 3 doses , first two
are given 1 month apart and third given in 6 months
Pregnant women with definite exposure to HBV to
be given hep b immunoglobins and to begin hep B
vaccine series with 14 days of most recent contact
Vaccine a series of three doses over 6 months
period , with the first two doses given at least 1
month apart , given in detoid muscle
Prevention – to decrease transmission , women with
positive HBV should maintain high level of
personnel hygiene

HEPATITIS C VIRUS
VIRUS rarely tranmitted through sexual route ,
mostly by blood or blood products , feco oral route
RISK FACTORS
h/o of injections , intravenous drugs
h/o of STI such as hep b , Hiv
h/o of blood transfusion

Symptoms
Clients are usally asymptomatic or have general flu
like symptoms
DIAGNOSIS
Confirmation of HCV is confirmed by presences of
anti- c antibody during laboratory testing
TREATMENT
Interferon alfa – 2b alone or with ribaviran for 6 to
12 months is the main therpay for HCV
INFECTIONS

HEPATITIS E VIRUS
Usually causes an acute , self limiting icteric illness
without chronic infections or liver diseases
DELTA HEPATITIS
OCCURS in inconjunction with HBV INFECTIONS
Found in people with multiple parental exposures ,
such as iv drug users , hemophilias and those having
repeated blood transfusions
No treatment , should be encouraged plenty of sleep,
eat nutritious food

HUMAN IMMUNODEFICIENCY VIRUS
Spread throug HIV 1 AND HIV 2 . HIV 1 causes
infections in europe and western hemisphere
HIV 2 – is a retrovirus ENDEMIC in west africa

Transmission
Primarily througH sexual contact , also through
blood and body fluids , transplacentally and through
breast milk

SYMPTOMS
INCLUDE fever
Headache
Night sweats
Malaise
Generalized lymphadenopathy
Myalgia
Nausea
Diarrhoea
Weight loss
Sore throat

Diagnosis
FROM 6 weeks to 1 year after exposure , hiv
antibodies appear in serum and detected by ELISA,
which is usally confirmed by western blot test
Antibody testing is done sensitive screening test
such enzyme immunoassay (eia)
Reactive screening test must be confirmed by
additional tests such as western blot or an
immunofluorescence test

INCIDENCE
About one million people are estimated by CDC IN
1991

HIV INFECTION IN PREGNANCY
Druing prenatal visit , women to be screened for HIV
RISK FACTORS
Early indication of possible HIV infection include
persistent candida infections , anogential condyloma
and herpes simplex
Hiv infection causes premature rupture of
membranes , foetal death and low birth weight
babies
Higher incidences of infectious diseases during
pregnancy – bacterial pneumonia ,

Perinatal transmission
Factors affecting
Preterm neonates are more like to be infected
Identical twins more likely to be infected
Vitamin A Deficiency
Newborns of symptomatic mothers
Mothers with lower CD4 – CD 8

NEWBORN born by C section are slightly less likely
to be infected
Invasive procedures such as episiotomy , internal
foetal monitoring, foetal scalp sampling , use of
forceps and vacuum extraction during labour

Management for perinatal transmission
Zidovudiene administered to a symptomatic
seropositive women during pregnancy and labour
and to newborn
According to the united states public health service ,
issued recommendation regarding use of
ZIDOVUDIENE
Asymptomatic women with CD4 lymphocyte count
above 200 , not yet taken zidovudiene- decrease the
risk for prenatal transmission
Pregnant women with HIV who have lower cd4
counts or more than 34 weeks gestation


Treatment
All pregnant women CD4 COUNT to be detremined
IF > 600 cells/ul , repeat count not needed
If 200 – 600 cells/ul repeat each trimester
If < 200 celles/ul repeat every 3 months to monitor
antiretroviral therapy
When CD4 COUNT is less than 500 cell/ul pregnant
women to be started with antiretroviral therapy

Pelvic inflammatory disease
Infectious process that commonly involve the uterus
( fallopian ) tubes , and rarely the ovaries and
peritoneal surfaces
Causes
Multiple organism
Common causitive organisms is n. Gonnorrhea and
chlamydia

Risk factors
Young age
Multiple partners
High risk of new partners
History of sti’s
Women who use IUD

SYMPTOMS
Acute , subacute and chronic
Pain is a common- dull , intermittent
ACUTE PID
I. intermentrual bleeding
II.Fever of 39 c or above , uretheral or cervical
discharge , often purulent
III.Peritonitis
IV.Pelvic tenderness, adnexal tenderness

WOMEN WITH SUBACUTE PID
Far less dramatic .with lesser severity and extent of
sypmtoms , that women ignores them
Symptoms – chronic lower abdominal pain ,
dyspareunia , menstrual irregularities , urinary
discomfort , low grade fever , low back pain
Abdominal examination shows no rebound
tenderness

Carefull h/o and vital signs
Complete physical examination
CRITERIA FOR DIAGNOSIS
Oral temp greater than 38.3
Abnormal cervical or vaginal discharge
Elevated erythrocyte sedimentation rate
Laboratory documentation with cervical infections
with n.gonorrhea or trachomatis

Management
Prevention counselling
Instructing women for safe sex guideline
Partner notification when STI’S is diagnosed
CDC’S recommendation for hospitilization
SURGICAL emergencies such as appendicitis
Women with tuboovarian abscess
Women is pregnant
Women unable to follow outpatient command
Failed to respond to out pt treatment

Treatment regimen vary depending on the infecting
organisms , a broad spectrum antibiotics are
generally given

TORCH INFECTIONS
TOXOPLASMOSIS, AND other infections ( eg .
Heptatitis)rubella virus , cytomeglovirus (cmv) and
herpes simplex virus , collectively called as TORCH
infections

Toxoplasmosis
A protozoal infection caused by toxoplasmagondi
Infection transmitted through encysted organisms
by eating infected raw or uncooked meat , through
contact with infected cat feaces
Fetal risk for infection with duration of pregnancy is
15% , 30%,60%in the first trimester, 2 nd 3 rd
trimester
Increased risk for abortion, still births , and IUGR
AFFECTED develop hydrocephalous ,
choroidentitis . Microcephaly and mental retardation

Is a self limited illness in an immuno-competent
adult and does not require any treatment
 DIAGNOSIS
Acute infection is diagnosed by detecting IgM
specific antibody

Current infection is confirmed then the following
test are carried out
1. aminocentesis and cordiocentesis for detection of I
g M antibodies
TREATMENT
Pyrimethamine 25 mg orally daily or oral sulphiazine
1 gm four times a day is effective
Luecovorin is added to minimize toxicity , fro 4- 6
weeks consecutively
Pyrimethamine not given in first trimester –
spiramycin has been used as alternatively

PREVENTION
Avoid uncooked meat, unpasturized milk , contact
with stray cat or

Rubella
Or german measles TRANSMITTED BY respiratory
droplet exposure
Fetal affect is through transplacental route
Risk for major anomalies when infection occurs int
the first , second, and 3rd trimester are 50%, 25% and
10% respectively

Signs
Multi sytem abnormalities, following cogenital
rubella
Cochlear , cardiac , haematologic and chromosomal
abnormalities
Virus predominant affect the fetus especially during
1 st trimester and ITS IS EXTREMELY
TETRATROGENIC
Increased chance for abortions , stillbirths and
congential malformed baby

DIAGNOSIS
Test for rubella psecific antibody to be done within
10 days of exposure , to know whther pateint is still
immuno or not

Treatment
Active immunity can be conferred in non immune
clients
Clients given live attenuated rubella virus vaccine
during 11 – 13 yrs
NOT RECOMMENDED in pregnant women, when
given during child bearing period , pregnancy to be
prevented within 3 months by contraceptive
measures

CONTROL OF STD’S
1.INTIAL PLANNING
Based on the prevalence of the area – to be obtained
Prioritisation to be based on multiple infected areas
Appropriate strategies to be layed down
2. INTERVENTION STRATEGIES
Cases under doubt- confirmed using screening and
contact tracking technique
In cluster testing – pt asked to name persons moving
in the same socio – sexual environment,

Need is stressed on contact treatment to control the
spread of STD’S
Consists – administering full therapeutic dose of
treatment to persons exposed to STD’S
Pts adviced to follow the appropriate contraceptive
during sexual activity
Through functional STD’S clinic operable at the
district level even at PRIMARY HEALTH CENTER
Suitable arrangement for treating female patients

The clinic / health centre / hospital ,to have
adequate laboratory facility to provide basis for
correct aetiological diagnosis, treatment, and follow
up care
Taking complete history , including the behavioural
risk management
Early diagnosis of RTI/STD an integral part of chain
of prevention of life threatening diseases
Management and counselling for safe sex pratices

SAFE SEX PRATICE
Reducing the numbers of partners and avoiding
partners who have had previous sexual practices
Discussing new partners previous sexual history and
exposure to STI will help reduce the risks
Women to be taught low risk sexual practice and
which sexual practice to avoid
Sexual fantasizes is safe , as are hugging , body
rubbing and massage

Women to be taught in the clinic , where to
purchase condoms, how to use them , motivating
them to use condoms
All clinics , gynaecological procedure to be carried
out in aseptic way , otherwise lead to RTI
SOCIAL WELFARE – to eradicate the existence of
RTI/STI include rehabilitation of prostitution ,
provision of descent living condition , marriage ,
counselling , prohibiting the sale of sexual
stimulating literature, pronographic books and
photographs

3. MOINTORING AND EVALUATION
Monitoring the disease trends and evaluation of the
program
Periodic evaluation direct method to judge
effectively

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