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1. Report on Sexually transmitted diseases & pregnancy

2. STD (epidemiology, most common std’s,diagnosis & management)

STD in pregnancy should be treated because it may lead to miscarriages or premature labor. Post partal
infection like endometritis , thrombophlebitis, sepsis. Amnionitis in pregnancy. Perinatal infection of the
newborn starting from perinatal mortality or leading to handicapped baby & congenital malformations.
Ante natal screening for STD in Latvia.- A. gonorrhoea-1st visit , then 30-34th week. B. syphilis – 1st visit &
then 30th week. C. trichomonas + gonorrhoea. D. bacterial vaginosis

Gonorrhea-
Etiology –Neisseria gonorrhea ,grm -,kidney shaped diplococci. Male:female-2:1. I.P-3-7 days.
Found mostly in places of columnar(glandular/cylindric) epithelium. In urethra, cervix, bartholini glands,
anus, pharynx. Not usually found in vagina because vagina has squamous epithelium but may be found in
vagina of children. Dominant age group 20-29 yrs.
Clinic- 50% asymptomatic. Early symptoms vaginal discharge, frequency, urgency, disuria, rectal
discomfort. In pregnancy discharge is not so specific b/c of physiological discharge in pregnancy. Vulva,
vagina, urethra & bartholinian glands may be inflamed with itching & burning. Infection can spread to uterus
but not in pregnancy b/c of product of conception. Urethra & bartholini glands should be squeezed out for
discharge . anal inflammation is due to spread of vaginal discharge. Acute tonsillitis, pharyngitis occurs if oral
sex. Spotting & post coital bloody discharge.
Dg- bacterioscopy, culture in Thayer Martin medium to confirm the dg. Dg in pregnancy- screening on 1st
visit & 34th week(30) . Smear taken from the cervix canal- cylindrical epithelium. If discharge then do culture.
Should be reevaluated after 1 week.
Risk factors- previous STD & clinical signs of STD.
Complications- premature labor↑ b/c of ↑ prostaglandins, septic puerperal infections , ophthalmia
neonatorum( gonoblenoria ) conjuctival infection in neonates. Sulphosilnatrium injection after birth or drops
into eyes used in some countries.
Treatment- at only time of pregnancy treated by venerologist. Gonococcal + must be checked for Chlamy.
trachomatis. Treat the partner & check sensitivity of microbes. During pregnancy- ofloxacin-0.4g orally
single dose. Ciprofloxacin 0.5g orally once, azithromycin 1g orally once ,if chlamidia +; if not pregnant
penicillin with probenecid 1g P/O, ceftrioxone 125mg IM once & doxicycline 100mg 2x /d for 7 d (follow up
culture should be made after 7 days of therapy, repeat culture made at monthly intervals following menses for
3 months if the reports are persistently – then the pt is declared cured.)

Urogenital chlamidiosis-
Etiology - chlamidia trachomatis. An obligatory intracellular gm- m.o like neisseria. In men non gonococcal
urethritis can also cause lymphogranuloma venerum.( rectal ulceration,rectal strictures, regional
lymphadenopathy) M:F-2:1.
Clinic-mostly no symptoms. Urethritis, painful voiding haematuria, mucopurulent cervicitis-yellowish
cervical discharge + polymorphoneutrophils, salphingitis can lead to infertility due to tubal obstruction or
extra uterine pregnancy.
Risk groups-sexual contact with infected partner, new partner within 2 months, pregnant women <25 yrs of
age, pregnant women has had STD or currently another STD. Common age group 20- 29 yrs. Dg- PCR, Elisa
, blood analysis is not helpful. No screening in LV.
Complications- 3-14 days after delivery late peuperial endometritis , extra uterine pregnancy, infertility if
salpingitis. Most common cause for adhesions in the tubes & with the hepar. Neonate-ophthalmia neonatorum
developing 7 d after delivery conjunctiva sticky, swollen, erythema, purulent discharge can lead to blindness.
Must use chlorotetracycline eye drops. Chlamidia pneumonia develops 3-4 weeks after delivery.
Treatment- pregnant- azithromycin 1g P/O once, erythromycin 0.5 g 3-4d –7d, amoxycillin 0.5g 3x/d –7d,
ofloxacin 0.5g once daily if connected with gonorrhea. If non pregnant woman- doxacycline 100mg P/O 2x/d-
7d. Treat the partner.
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Trichomonas vaginalis-
Etiology- Tr .v. A motile parasite which has 4 anterior flagella. Transmitted mainly by male partner who has
organism in his urethra & prostata. Also by toilet articles- from woman→w. Pathology- worst just after
menstruation or during pregnancy. There is vaginal inflammation & vaginal pH >5.(normal-3.5-4.5) Clinic-
thin foamy greenish, foul smelling discharge. Pruritis vulvae. Vaginal exam- painful inflamed vaginal walls
with punctuate hemorrhagic spots. “Strawberry spots” in cervix & vagina. Dg-discharge on slide →saline→
coverslip→microscopically can see motile trichomonas. Treatment- immediately upon dg metrinodozole
500mg 2x/d orally 7 d. for both partners. Treat other std’s & treat the partner. No risk factors in pregnancy.

Bacterial vaginosis- normally in vagina is lactobacillus which keeps vaginal pH at 3.5-4.5. in anaerobic
conditions lactobacillus ↓ & ↑ of gardnella,mycoplasma, bacteriodes mobilineus.
Clinic-pH: >4.5, fishy smell, creamy yellowish discharge w/o extensive evidence of inflammation. Clue
cells- vaginal epithelial cells surface stippled b/c of coccobacili m.o adherent that the borders are obscured.(
superficial epithelial cells).
Treatment- Metrinodozole-500mg 2xd for 7 d or 2g once, locally dalacin 2% cream vaginally 1xd-7d. in
pregnancy metrinodozole alone 200mg 8hrs P/O for 7 d. If recurrent treating the partner may be helpful.
There is an↑ risk of preterm labor, intraamniotic infection during pregnancy. [ Is bacterial vaginosis an std ?-
Yes→occurs after changing of partners, very rare if monogamist couple, Exam reveals different flora which
are not endogenous. Even after treatment pt comes w recurrent attacks. ; No→no bacteria in male genital
tract. 12% of b.v occur in women who are virgins. Similar m.o can be detected in rectum.(endogenous) ]

Syphilis- Etiology- Triponema pallidum. Transmitted by sexual contact, trans-placentally to the fetus and
blood transfusion?, Male:female- 1:1. Incubation- 10-90days. ~21days. Four main phases-
(1). Primary syphilis-T.P invade through damaged skin or intact mucosa →organism reaches subcutaneous
tissue where it multiplicates & in 10-90 d dev a papule→ulcerates→forms a shallow punched out ulcer with
well defined borders & a smooth shiny floor → chancre. Chancre is usually painless & found in cervix ,labia,
vulva, penis, lips, anus, nipple or finger. Usually only one chancre is found. About 1week after appearance of
chancre there is lymphadenopathy of regional lymph nodes. L.N are painless, mobile, rubbery in consistency.
Dark field microscopy can be used to see motile T.P in this stage. (scrapings from edge of ulcer is taken).
Serology – ve.

(2). Secondary syphilis – 4-10 weeks after primary lesion. constitutional symptoms- fever, sore throat,
anorexia, malaise, arthralgia & headache. Bilateral symmetrical copper colored macular popular rash in trunk
& limbs. ( palms & soles ). May also occur in face & scalp.( corona veneris) alopecia areata. Condyloma lata
in moist areas (vulva, anus) –pink or grayish-white raised plates. Mucus patches in lips tongue oral mucosa
palate pharynx. Painless generalized lymphadenopathy. Serological test + ve. (3). Latent syphilis.- history or
serological evidence of previous infection. Absence of lesions. A) Early latent phase- till 1 year after infection
symptoms of secondary syphilis may reoccur during this stage (clinical relapses). B) Late latent phase→1
year after infection. D) Tertiary syphilis→ 4-20 yrs after primary syphilis. •Formation of gumma ( necrotic
center surrounded by mononuclear, epithelial, giant, fibroblastic cells) in skin & bones. •Neurosyphilis-
asymptomatic neurosyphilis & symptomatic n.s . symptoms- meningeal ,meningovascular , tabes dorsalis &
generalized paralysis. •Cardiac syph- aneurisma of aorta & aortic regurgitation.

Congenital syphilis- A) Early- within 2 years of birth- begins as rhinitis (infectious). Followed by
osteochondritis, ostitis, mucocutaneous rash (bullous,macular papular desquamating rash). Signs of TORCH-
hepatospleenomegaly, jaundice, anaemia, ly.pathy.
B).Late- (noninfectious) symptoms occur 2 years after birth. Mainly interstitial keratitis- acute onset of
photophobia, pain , circumcorneal injection, bilateral knee effusions. Characteristic stigmata- hutchisons
teeth, frontal loosing, saddle nose, poorly developed maxilla, anterior tibial loosing, linear scars in angle of
mouth.
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Risk factors – Women < 25 years ( most common age 20-29), Unstable relationship, history of STD or PID,
new partner 20 d before delivery. Risk factors for new born- mother serologically +, mother did not receive
treatment or no record , M received tr during pregnancy, end of pregnancy, received optional medicine not
penicillin.
Diagnosis- 1. Screening- 1st visit VDRL + TPH , repeat at 34th ( 30th) week. , if intercourse with infected
person- VDRL +TPH +FTA-ABS( fluorescent T antibody absorption ). (Wassermann reaction done
sometimes, but due to false –ve results seldomly used.) Neonatal screening- VDRL, TPHA, Tri pallidum
immobilization reaction, FTA-ABS & IgM antibodies.
Treatment- Benzyl penicillin G 2.4 million units IM. Doxycycline 100 mg 2x-14d. Tetracycline( not in
pregnancy) 500mg 4x-14d. congenital syphilis tr- Tr of pregnant woman 16-18 week of gestation. Prevents
congenital syphilis. Tr after that arrest fetal infection. Benzathine penicillin G 50, 000 units/ kg IM as a single
injection for asymptomatic infants w/o neurosyphilis. Procaine penicillin G 50,000 units /kg IM 10-14 d.- for
symptomatic infants or those with n.s. Follow up 1,3,6,12 months after Tr of early syphilis & serological
tests.

Herpes simplex –genital infection-HSV type 2, HSV type1. Rarely in pregnancy.

Clinics- symptoms of the 1st attack usually appear <7d after sex contact. Initially red inflammatory area
appears commonly on the clitoris, labia, vestibuli, perineal skin, thighs, vaginal wall & cervix. Extremely
painful vesicles which breaks to form small ulcers→ scabs. Virus shed from the lesion until healing is
complete. Micturination is very painful, retention of urine may occur. Initial attack- fever, malaise, inguinal
ly.nodes. In some pt virus remains dormant but in others recurrent attacks occur.& may last for about 7-10
days. During pregnancy→a) primary attack of genital herpes during early pregnancy→ abortions ,IUD,
congenital malformations, microcephaly, microophthalmia. A 1ry attack during last weeks of pregnancy→
transplacental spread of V to fetus may cause damage to CNS. ( increase mortality of neonate). Babies who
survive→ neurological sequence. If evidence of recurrent active lesions in vagina, vulva in the last weeks of
pregnancy or at onset of labor→ wise to carry out C-section.
Diagnosis- clinics, viral cultures, in the smear-inclusion bodies, antibodies in serum.
Treatment- Saline bath may ↓local pain , Acyclovir 200mg P/O every 4 Hrs-5d. (does not prevent
recurrence). Neonates given acyclovir IV. Both partners should be treated. Woman should have anal cervical
smear.

HIV-It’s a retrovirus. Transmission-isolated from semen, plasma, tears, saliva, CSF, urine, breast milk,
cervical mucus, but only semen, blood & cervical secretions transmits. Modes- sexual intercourse- homo, bi,
hetreo, blood products, contaminated needles, breast feeding, vertical transmission- transplacental during
delivery or breast milk.
Clinics- following exposure to HIV infection pt develops antibodies to HIV in 8-12 weeks → stage of
seroconversion→ clinically flu like syndrome w fever, skin rash, arthralgia, diarrhea, for 2-3 weeks. After
initial exposure pt remains asymptomatic for yrs(7-10yrs). During this pt s immunity ↓. With ↑
immunodeficiency→ pt becomes susceptible for 2ry infections. Some may have ly.pathy during this period.
Commonly as 2ry infections→ atypical TBC, pneumocystic carini pneumonia, systemic candiditis,
meningitis, encephalitis, myolopathy. High grade lymphoid neoplasmas, karposhi sarcomas, non Hodgkin’s
lymphoma.
Diagnosis-an absolute CD4 cell count <200 / mm3 – cutoff point when 2ry infections can occur. ELISA test
confirmed by western blot method.
Treatment- transmission prevented – Zidovudine(ZDV) or Azidothymidine(AZT) admin after birth-1st
6weeks. ZDV- 150-500mg /d/ divided doses. AZT-100 mg-5 days P/O. Delivery- C-Section preferable. 36-38
weeks. IV AZT 2mg/kg. Vaginal delivery- staff should use gloves, apron, face protection. Artificial rupture of
memb – application electrodes on fetal scalp, scalp sampling. New born- early cord clamping & early bathing
may↓ the risk of transmission. Neonatologist should be present. W.H.O rules & regulations should be
followed. Virus culture & PCR method till 2 months of age. Antibody test cannot be done b/c it can be
females antibody. Baby of an infected female will carry the antibody for 6-9 months or a yr may be.
(congenital anomalies, IUGR, Preterm delivery)
1. Report on Sexually transmitted diseases & pregnancy
2. STD (epidemiology, most common std’s,diagnosis & management)

Report prepared by
1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom.
2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia.
3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania.

Contact: publications [at] infekcijas.eu