Sexually Transmitted Infections in O&G

Most common cause of PID

Etiology

• Chlamydia trachomatis (D-K serotypes), an obligate intracellular parasite

Sites affected

• Endocervix
• Urethra
• Bartholin’s gland

Symptoms

• Usually asymptomatic in 80% of cases
• Clear mucoid, non-offensive discharge
• Dysuria, urinary frequency

Diagnosis

• Urine MCS- bacteriuria,
• Culture in McCoy medium
• Polymerase chain reaction
• Specimen to be taken from the endocervix

Treatment

• Oral Azithromycin 1g STAT or doxycycline 100mg twice a day for 7 days
• In pregnancy- oral Azithromycin 1g STAT or amoxicillin 500 mg TDS for 7 days or erythromycin 500 mg four times a day for 7 days

Most common cause of genital ulcers, chronic relapsing condition

Etiology

• 90% are caused by HSV-2, 10% HSV-1
• HSV 1 causes oral lesions, HSV-2 causes genital lesions

Symptoms

• Initial erythematous plaques which later form vesicles and then small ulcers with an erythematous halo and yellow base
• Ulcers are extremely tender and inguinal lymph nodes are enlarged
• After initial infection, virus remain dormant and can be activated at anytime
• In addition to ulcers- constitutional symptoms of fever, headache, malaise

Diagnosis

• Electron microscopy
• Tissue culture
• Polymerase chain reaction
• Failure to detect HSV by PCR or culture-does not indicate absence

Complications

• Urinary retention
• Pneumonitis
• Hepatitis
• Meningoencephalitis

Treatment

• Acyclovir 200mg 5 times a day for 7 days or 400mg 3 times a day for 7 days
• Other drugs- famciclovir, valacyclovir

Genital Herpes and Pregnancy

• Most mothers of affected infants do not have evidence of clinically evident genital herpes
• Risk for transmission depends on gestational age the infection is acquired, when acquired near delivery transmission is high (30-50%) compared with first half of pregnancy (<1%)
• Acyclovir can be used in severe HSV during pregnancy
• Women with recurrent genital herpetic lesion at onset of labor- offer C/S to prevent neonatal HSV infection (although does not totally eliminate the risk)

Second most common cause of PID

Etiology

• Neisseria gonorrhea, a gram negative diplococcus

Common sites affected

• Endocervix
• Urethra
• Bartholin’s gland

Symptoms

• Purulent vaginal discharge
• Dysuria
• Urinary frequency
• Cervicitis
• Adnexal tenderness

Diagnosis

• Nucleic acid amplification testing
• Culture in Thayer Martin Media
• Urine or endocervical swab

Treatment

• IM ceftriaxone 250mg STAT + oral azithromycin 1g or
• Oral cefixime 400mg + azithromycin or
• Doxycycline 100mg orally twice a day for 7 days
• In pregnancy- IM ceftriaxone 250mg or azithromycin 1g STAT
• Treat sexual partners

Etiology

• Hepatitis B and Hepatitis C virus respectively
• Concentration of HBV is highest in blood, lower in other body fluids like wound exudates, semen, vaginal secretions and saliva
• HBV more stable in the environment and more infectious than HBV and HIV

Clinical features

• Asymptomatic (50%)
• Jaundice
• Constitutional symptoms
• Anorexia
• Nausea
• Right upper quadrant discomfort
• Fatigue

Diagnosis

• HBsAg (hepatitis B surface antigen). A positive test result means the person is infected with hepatitis B virus.
• IgM anti HBc (IgM antibody against hepatitis B core antigen). A positive result indicates a past or current hepatitis B infection.
• Anti-HBs or HBsAb (hepatitis B surface antigen). A positive test result indicate a person is protected against the hepatitis B virus and cannot be infected. This protection can be from the result of receiving hepatitis B vaccine or successfully recovering from past hepatitis B infection.
• Anti-HCV test for hepatitis C

Complication

• Acute liver failure

Treatment-

• Acute HBV infection
• Supportive care
• Chronic HBV infection
• Specialist care
• Interferon, lamivudine, adefovir, dipivoxil, telbivudine and entecavir.
• Treatment HCV- interferon, ribavirin, pegylated interferon

Prevention of perinatal infection

• Routine screening of all pregnant women for HBsAg
• Immunoprophylaxis (both hepatitis B immunoglobulin and hepatitis B vaccine)
• No vaccine for HCV and prophylaxis with immune globin is not effective in preventing HCV infection after exposure

Etiology

• Human immunodeficiency virus, a retro virus

Clinical features

• HIV may be asymptomatic
• AIDS -similar to other illnesses but may take longer to resolve or be recurrent
• Weight loss
• Diarrhea
• Night sweats
• Oral thrush

Diagnosis

• ELISA (enzyme linked immunosorbent assay) high sensitivity
• Western blot test; highly specific

HIV and Pregnancy

• Maternal transmission can occur transplacentally before birth, peripartum by exposure to blood and bodily fluids at delivery or postpartum through breastfeeding
• All pregnant women should be offered HIV testing
• In the absence of interventions, 30% of mothers will transmit the infection during pregnancy and delivery, 15-20% through breastmilk
• Vertical transmission occurs mostly (50-70%) in the intrapartum period, 15-30% antepartum
• Mode of delivery of women on HAART at term is the same as women without HIV
• CS- before onset of labor and membrane rupture when viral load >1000copies/ ml
• During labor- avoid repeated vaginal examinations, invasive procedures

Etiology

• Hemophilus ducreyi, a gram negative rod

Clinical features

• Lesion begins as an erythematous papule that evolves into a pustule and degenerates into a saucer shaped ragged ulcer circumscribed by an inflammatory wheal
• Lesion is very tender and produces a heavy foul discharge that is contagious
• Painful inguinal adenitis in about 50% of cases

Diagnosis

• Identification of H.ducreyi in culture media

Treatment

• Personal hygiene
• Antibiotics
• Azithromycin 1g STAT
• IM ceftriaxone 250mg STAT
• Ciprofluoxacin 200mg twice daily for 3 days (in non-pregnant women)
• Erythromycin 500mg orally thrice daily for 7 days
• Usually responds quick to antibiotics

Chronic ulcerative granulomatous disease that usually develops in the vulva, perineum and inguinal region

Etiology

• Klebsiella granulomatosis (formerly known as Calymmatobacterium granulomatosis)

Clinical features

• Painless slowly progressive ulcerative lesions on the genitals without regional lymphadenopathy
• Lesion begins as a papule which ulcerates with the development of a beefy red granular zone with sharp edges
• Lesions are vascular and bleed easily, associated malodorous discharge
• May mimic Ca cervix

Diagnosis

• Organism difficult to culture
• Diagnosis is by visualization of dark staining Donovan bodies revealed by Wright or Giemsa stain

Treatment

• Antibiotics
• Azithromycin 1g orally once per week or
• Azithromycin 500mg orally daily for at least 3 weeks until lesions have completely healed

Etiology

• L serotypes (L1, L2 or L3) of Chlamydia trachomatis
• Men are more affected than women
• Presence of infection strongly associated with HIV infection in men who have sex with men

Clinical features

• Tender, usually unilateral inguinal and/or femoral lymphadenopathy
• Genital ulcer is often not evident

Treatment

• Doxycycline 100mg twice daily for 21 days
• Erythromycin 500mg orally 4 times a day for 21 days

Etiology

• Human papilloma virus, most common sexually transmitted infection
• More than 200 subtypes- type 6 and 11 – anogenital warts

Sites affected

• Cervix
• Vulva
• Vagina
• Anus

Clinical features

• Soft multiple warts on any dermal or mucosa surface mostly seen on the posterior introitus, labia majora and minora

Diagnosis

• Gross inspection
• Colposcopy to rule out other cervical or vaginal lesions

Treatment

• Podofilox 0.5% solution
• Imiquimod 5% cream
• Cryotherapy
• Trichloroacetic acid
• Surgical removal
• Laser

Prevention

• HPV vaccination
• Note- condoms do not prevent HPV

Vertical transmission in pregnancy

• Can cause juvenile laryngeal papillomatosis in the neonate

Etiology

• Treponema pallidum

Clinical features

• Presents as a single hard painless solitary chancre on the vulva, vagina, anus, lips, nipples or cervix, non-tender inguinal lymphadenopathy, primary chancre resolves within 3-6 weeks.
• Secondary syphilis— rash on the palms, soles with flu like symptoms
• Tertiary syphilis— organ destruction (gummas), meningitis

Diagnosis

• VDRL (screening)
• Fluorescent treponemal antibody test (confirmatory)
• Dark field microscopy

Treatment

• Benzathine penicillin

Syphilis and Pregnancy

• All pregnant women should be screened at the first antenatal visit and repeated 28-32 weeks in high risks
• Course of syphilis is unaltered by pregnancy but effect of syphilis on pregnancy can be profound
• Risk for fetal infection depends on degree of maternal spirotchemia (> in secondary than primary stage) and gestational age
• The earlier in pregnancy the fetus is exposed, the more severe the infection as well as risk of preterm delivery and stillbirth

Congenital Syphilis

• Results in placenta infection with resultant endarteritis, hydropic placenta
• Frequently associated with polyhydramnios
• Clinical spectrum is analogous to adult secondary disease as the disease is systemic from onset due to transplacental hematogenous inoculation

Etiology

• Trichomonas vaginalis, a flagellated protozoan

Clinical features

• Profuse frothy greenish yellow discharge
• Dysuria
• Dyspareunia
• Strawberry cervix

Diagnosis

• Saline microscopy— typical motile flagellated trichomonas
• Culture on Feinberg Whittington or Diamond media

Treatment

• Oral metronidazole 2g STAT or 500mg BD for 7days
• In pregnancy- oral metronidazole 250mg TDS for 7 days
• Treat sexual partners

• Vertical transmission
• Eye infections
• Blindness
• Pneumonia (chlamydia, genital herpes and gonorrhea)
• Central nervous system damage (syphilis, herpes)
• Otitis media (chlamydia)
• Preterm delivery
• Low birth weight

• Infertility in both males and females
• Ectopic pregnancy
• Increased risk of cervical malignancy
• Chronic pelvic pain
• Increased risk of HIV/ AIDS transmission