STIs in OBS/GYN under graduate medical school

STIs in women

1. SEXUALLY TRANSMITTED INFECTIONS NAGASHA DEBRAH SUPERVISED BY DR JOHN ZIMULA

2. These are infections that are primarily transmitted through sexual contact . They can be caused by bacteria ,viruses and parasites. The transmission can be; Horizontal-through intercourse Vertical-from mother to child during pregnancy, delivery or breastfeeding.

3. Common STIs Syphilis Gonorrhoea Chlamydia Herpes-simplex virus infection Human papilloma virus HIV Vaginitis

4. SYPHILIS Caused by a spirochaetal bacterium, Treponema pallidum. Horizontal transmission can be by small abrasions in the vaginal mucosa which provide entry during intercourse. Skin to skin contact with an infected person Vertical transmission – It can cross the placenta during pregnancy and infect the fetus causing congenital syphilis. The baby comes into contact with the spirochetes from lesions at delivery or across placenta membranes. Incubation period is 9-90 days

5. Manifestation These are classified according to the staging of the infection. Primary syphilis It is characterised by a chancre which develops at the inoculation site. The chancre resolves within 2-8 weeks with or without treatment. Multiple lesions are commonly found in women with HIV co-infection.

6. Secondary syphilis The spirochetes disseminate into multiple organs Manifestations appear 4-10 weeks after the chancre disappears. They include; a diffuse macular rash, plantar and palmar lesions, patchy alopecia and condylomata lata These manifestations resolve within 1-6months with or without treatment.

7. Latent Syphilis becomes latent when the clinical manifestations of primary and secondary syphilis have resolved but the infection persists. It can only be identified by serological testing Latent syphilis can be; Early latent.- The disease is acquired within 12 months of infection. Timing of infection is determined by laboratory results, symptoms consistent with primary or secondary syphilis within the prior 12 months, or exposure to a sexual partner in the previous 12 months with primary, secondary, or early latent syphilis. Late or unknown duration-The infection is of unknown duration or more than 12 months.

8. Congenital syphilis Due to maternal infection(vertical) When vertical transmission occurs, severe congenital syphilis progresses along a continuum. Hepatic abnormalities are followed by anemia , thrombocytopenia, and then ascites and hydrops. The newborn may have jaundice with petechiae or purpuric skin lesions, lymphadenopathy, rhinitis, pneumonia, myocarditis, nephrosis, or long-bone involvement.

9. Diagnosis Serological testing together with clinical findings is used to make a diagnosis. Physical examination of a mother Routine antenatal screening( VDRL,RPR,TPHA) Abdominal ultrasound scan can detect complications like hydrops

10. Following maternal diagnosis, sonographic evaluation is performed for foetuses >20 weeks’ gestation to search for signs of congenital syphilis. Abnormal sonographic findings include; Hepatomegaly Placental thickness Hydramnios Ascites Hydrops fetalis Elevated middle cerebral artery

11. Treatment Primary, secondary and early latent syphilis Benzathine penicillin 2.4 million IU IM stat, half in each buttock or Doxycycline 100 mg every 12 hours for 14 days Late latent or uncertain duration, or tertiary without neurosyphilis Benzathine penicillin 2.4 million IU IM weekly for 3 weeks Or Doxycycline 100 mg every 12 hours for 28 days Neurosyphilis Benzylpenicillin 4 million IU IV every 4 hours or Ceftriaxone 2 g IV or IM daily for 10-14 days Followed by Benzathine penicillin 2.4 million IU IM weekly for 3 weeks Treat partner(s), abstain from sex during treatment and 10 days after

12. P revention Avoiding contact with infected persons. Use of condoms. Regular syphilis testing before and during the pregnancy. Limiting sexual partners

13. GONORRHEA Second most common bacterial STI Caused by bacterium Neisseria gonorrhoeae, a gram negative coccus Gonococcal infection can have adverse effects in any trimester. It is associated with preterm delivery, preterm prelabor ruptured membranes (PPROM), low birthweight, and perinatal mortality. In most gravidas, infection is limited to cervix, urethra, and periurethral and greater vestibular (Bartholin's) glands Untreated gonococcal cervicitis ass. w/ septic abortion and uterine infection after surgical abortion

14. Risk factors Sex work Prior/current STI Partner with STI Multiple partners Inconsistent condom use

15. Transmission: vertical through fetal contact with cervical infection at birth. Signs and symptoms : thick discharge, burning urination, severe menstrual or abdominal cramps. C omplications : Gonococcal ophthalmia neonatorum which can lead to corneal scarring, ocular perforation and blindness.

16. INVESTIGATION Clinical diagnosis Culture Microscopy

17. Treatment Give cefixime 400 mg stat or ceftriaxone 250 mg IM stat Plus doxycycline 100 mg 12 hourly for 7 days Plus metronidazole 2 g stat However if client is pregnant Replace doxycycline with erythromycin 500 mg 6 hourly for 7 days or Azithromycin 1 g stat Treat the partner

18. CHLAMYDIA Caused by an obligate intracellular bacteria called Chlamydia trachomatis Most infected pregnant are asymptomatic However one third of pregnant women have urethral syndrome, urethritis or greater vestibular (Bartholin's) gland infection Most common STI Females outnumber males Cervix is the site of infection Most cases remain asymptomatic until pain and fever from pelvic inflammatory disease set in. Symptomatic women present with Vaginal discharge ;

19. SIGNS AND SYMPTOMS Painful urination Lower abdominal pain Bleeding Fever Nausea Vaginal discharge

20. COMPLICATIONS Complications include; Cervicitis Chronic Pain Infertility Salpingitis Ectopic Pregnancy Still Birth Reactive Arthritis Otitis Media In Babies Etc.

21. diagnosis and treatment. Diagnosis is made clinically. Treatment Give cefixime 400 mg stat or ceftriaxone 250 mg IM stat Plus doxycycline 100 mg 12 hourly for 7 days Plus metronidazole 2 g stat However if client is pregnant Replace doxycycline with erythromycin 500 mg 6 hourly for 7 days or Azithromycin 1 g stat Treat the partner

22. Expedited partner therapy This is to prevent transmission. With EPT, treatment is provided to persons who were sexual contacts of the patient within the prior 60 days.

23. HERPES SIMPLEX VIRUS INFECTION Caused by herpes simplex virus Is contagious viral infection from direct skin to skin contact particularly in oral and genital areas Recurrent incurable diseases, 80% of which asymptomatic HSV1- responsible for nongenital infections Acquired in childhood. Presents with cold sores, fever, and blisters primarily around the mouth

24. HSV2-genital herpes (usually transmitted sexually) More than half of the new cases of genital herpes in adolescents and young adults are now caused by HSV-1 infection due to rise increase in rates of oral-genital sexual practices.

25. Manifestations A papular eruption with itching or tingling Multiple vulvar and perineal lesions Many women do not present with typical lesions, and abraded or knife-cut lesions instead may be found. Transient systemic influenza-like symptoms or isolated high fevers with or without painful lesions are frequent and attributed to viremia

26. Vertical transmission Peripartum transmission is the most frequent route of infection, and the fetus is exposed to virus shed from the lower genital tract. HSV-1 or -2 invades the uterus following membrane rupture or is transmitted by contact at delivery. Of neonatal manifestations, infection may localize to the skin, eye, or mouth. Postpartum transmission is uncommon and passed to the newborn by contact with an infected mother, family member, or health-care worker. In-utero transmission of HSV-1 or HSV-2 is rare and is part of the TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes virus) group of infections.

27. diagnosis Serological assays to detect antibodies produced against the specific HSV glycoproteins. PCR Culture Swab: for microscopy Blood: for VDRL/TPR Samples are gotten from mucocutaneous lesions, amniocentesis.

28. Treatment Multiple painful blisters or vesicles: likely herpes Acyclovir 400 mg every 5 hours for 7 days If RPR positive add Benzathine penicillin 2.4 MU IM single dose (half in each buttock) If lesions persist, repeat acyclovir for 7 days All other cases Ciprofloxacin 500 mg every 12 hours for 3 days plus Benzathine penicillin 2.4 MU IM single dose (half into each buttock) In penicillin allergy, give Erythromycin 500 mg every 6 hours for 14 days If ulcer persists >10 days and partner was treated Add Erythromicin 500 mg every 6 hours for 7 days

29. HUMAN PAPILLOMA VIRUS A common STI infecting the lower genital tract. Infection with in few years of sexual activity onset. Most infections are asymptomatic and transient. Few develop genital warts(condyloma) Of >70 types, 30 types can infect genital tract. High risk type are those w/ oncogenic potential (16,18,31&45)

30. Warts can be small to large, raised to flat, or single to clustered There is no cure for HPV although lesions can be removed Methods include: cryotherapy, chemicals, and laser therapy HPV is associated with cervical cancer or cervical dysplasia Early detection reduces mortality Also linked to cancers of the oral cavity.

31. GOAL OF TREATMENT Symptomatic Decrease the bulk of the lesion Without treatment, warts may resolve on their own, remain unchanged or increase in size and/or number Often treatment is worse than lesion

32. TREATMENT Patient applied Podofilox 0.5% solution or gel Provider applied Cryotherapy Podophyllin resin 10-25% Surgery, intralesional interferon, laser

33. External warts: Patient may apply podofilox 0.5% solution or gel 2 times a day for 3 days, followed by 4 days of no therapy, for a total of up to 4 cycles, or imiquimod 5% cream at bedtime 3 times a week for up to 16 weeks. Treatment area should be washed with mild soap and water 6- 10 hours after application or podophyllin resin 10-25% in compound tincture of benzoin in small amounts to each wart, repeat weekly if necessary; or surgical removal. Vaginal warts: cryotherapy with liquid nitrogen, or Trichloroacetic acid 80-90%, or podophyllin 10-25%

34. VAGINITIS Characterized by increased vaginal discharge. Classified into; Bacterial vaginosis Candidiasis Trichomoniasis

35. Trichomoniasis One celled parasite Found in both men and women Remains dormant in asymptomatic women It presents with vaginal irritation, itching, diffuse malodorous discharge, and colpitis macularis (strawberry cervix) in symptomatic women Women may see red spots on the vaginal walls(vulvovaginal erythema) Most men are a symptomatic Both partners must be treated with antibiotics.

36. diagnosis Microscopy of vaginal secretions Culture NAAT of vaginal/cervical sample

37. Treatment Metronidazole 2 g stat HC2 Cefixime 400 mg stat or ceftriaxone 250 mg IM stat Plus doxycycline 100 mg 12 hourly for 7 days Plus metronidazole 2 g stat However if client is pregnant Replace doxycycline with erythromycin 500 mg 6 hourly for 7 days or Azithromycin 1 g stat Treat the partner

38. Bacterial vaginosis Bacterial vaginosis (BV) is a maldistribution of normal vaginal flora. With BV, numbers of lactobacilli are decreased, and anaerobic bacterial species are overrepresented. Clinical features Most women are asymptomatic. A foul, thin vaginal discharge is a typical complaint

39. Risk factors Douching multiple partners Smoking altered host immunity

40. Treatment

41. Candidiasis( yeast infections) Fungal infection due to overgrowth of Candida albicans Symptoms include itching, discharge, burning, or irritation Pregnant women commonly experience yeast infections Factors most often associated with repeat infections include diabetes, obesity, suppressed immunity, antibiotics, corticosteroids, or birth control pills.

42. Treatment Give clotrimazole pessaries 100 mg; insert high in vagina once daily before bedtime for 6 days or twice daily for 3 days Or fluconazole 200 mg tablets single dose, orally± Metronidazole 2 g stat dose

43. HIV AND AIDS Acquired Immunodeficiency Syndrome (AIDS) is a condition of reduced immunity as a result of infection with the Human Immunodeficiency Virus (HIV ) It is caused by Human Immunodeficiency Virus. It can be transmitted through; Sexual intercourse with an HIV-infected person Transfusion with HIV-infected blood Mother-To-Child Transmission during pregnancy, delivery, or through breastfeeding HIV-contaminated sharp instruments, e.g., dental and surgical equipment, needles, scalpels, razors, hair shaving equipment, nail cutters, and other sharp objects Exposure to HIV-infected materials through an open wound or cut

44. Clinical features These are grouped according to the WHO staging as follow; Stage 1 Asymptomatic Persistent generalised lymphadenopathy Stage 2 Moderate unexplained weight loss (< 10% of presumed or measured body weight) Minor mucocutaneous manifestations (seborrheic dermatitis, popular pruritic eruptions, fungal nail infections, recurrent oral ulcerations, angular cheilitis ) Herpes zoster Recurrent upper respiratory tract infections (e.g., bacterial sinusitis, tonsillitis, otitis media, pharyngitis

45. Stage 3 Unexplained severe weight loss (more than 10% of presumed or measured body weight) Unexplained chronic diarrhoea for longer than one month Unexplained persistent fever (intermittent or constant for longer than one month) Persistent oral candidiasis Oral hairy leukoplakia Pulmonary tuberculosis Severe bacterial infections (such as pneumonia, pyomyositis , empyema, bone or joint infection, bacteraemia , meningitis) Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis Unexplained anaemia (below 8 g/dl), neutropenia (below 0.5×109per litre ), or chronic thrombocytopenia (below 50× 109 per litre )

46. Stage 4 HIV wasting syndrome Pneumocystis jirovecii pneumonia (PCP) Recurrent severe bacterial pneumonia (> 2 episodes within 1 year) Toxoplasmosis of the brain Cryptosporidiosis with diarrhoea for longer than 1 month Chronic isosporiasis Extrapulmonary cryptococcosis including meningitis Cytomegalovirus infection (retinitis or infection of other organs other than liver, spleen or lymph nodes) Chronic oro -labial, genital or ano -rectal herpes simplex virus (HSV) infection for >1 month Progressive multifocal leukoencephalopathy (PML)

47. Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis Candidiasis of the oesophagus , trachea, bronchi, or lungs Disseminated non-tuberculous mycobacterial infection Recurrent septicaemia (including non-typhoid salmonella) Extrapulmonary tuberculosis Lymphoma (cerebral or B-cell non-Hodgkin) Invasive cancer of the cervix . Kaposi sarcoma HIV encephalopathy Atypical disseminated leishmaniasis Symptomatic HIV-associated nephropathy or symptomatic HIV associated cardiomyopathy

48. Diagnosis

49. Management 1 st line – Tenofovir , Lamivudine, dolutegravir If tenofovir is contraindicated, replace with efavirenz Manage opportunistic infections

50. Prevention Use of condoms Encouraging partner testing Abstinence Adherence to treatment

51. Conclusion Most STIs (e.g., gonorrhea, syphilis) can be treated. All STIs can be prevented. If not prevented, early diagnosis and treatment can decrease the possibility of serious complications such as infertility in both women and men.

52. References William’s textbook of obstetrics,26 th edition. Chapter 68 pages 3139-3181 UCG 2023