Transcript High Parity Pregnancy (The Grande Multipara)

S EXUALLY T RANSMITTED
D ISEASES
(STD’ S )
75% of the world’s STD’s occur in
developing countries because...

They have a greater proportion of young adults

Urban migration

Practices such as..



Polygamy

High bride prices

Use of traditional remedies
Health resources are limited

Self treatment and incomplete treatment →

Drug resistance
War and civil disturbances
Burden of Illness

WHO worldwide estimates for 1995...

Syphilis


Gonorrhoea


62,000 cases
Chlamydia


12,000 cases
88,000 cases
There are marked regional variations especially for the
less common STD’s

Chancroid, Lymphomagranuloma venereum & Donovanosis
Symptoms of STD

Vaginal discharge or irritation

Dysuria and Dyspareunia

Genital ulceration or other lesions

Lower abdominal or testicular pain

HOWEVER

May be asymptomatic in carriers

And early symptoms ignored in others
Diagnosis of STD

Requires a high index of suspicion

And a knowledge of common local presentations

When ONE sexually transmitted disease is
diagnosed...

Always consider the possibility of others

In this context pregnancy and abnormal cervical
cytology should be regarded as STD’s

Lack of diagnostic resources may require an empiric
approach to treatment
Principals of Management

Best dealt with by a network of detection, treatment
and follow up facilities coordinated by Specialist Clinics

Should operate in conjunction with resources for HIV

Such centres should provide...


Patient friendly resources

Confidentiality
Single dose treatment regimens ...

Optimises compliance

Reduces the risk of emerging drug resistance

Offers the best prophylaxis against long term complications
There is a potentially long list of
STD’s

Syphilis

Gonorrhoea

Chlamydia

Lymphogranuloma venereum

Chancroid

Donovanosis

Genital Herpes

Genital warts

Bacterial vaginosis
S YPHILIS

A sexually transmitted infection caused by the
spirochetal bacterium Treponema pallidum

Incubation period usually 14 – 28 days

Recognised in 3 stages in adults…

Primary = typically a painless genital ulcer with non
tender rubbery lymphadenopathy. Will be tender if 20
infection occurs. May go unrecognised

Secondary = Fever, rash, anorexia, aches & pains, and
condyloma lata Occurs 2 – 8 weeks in only 1:3
individuals after primary infection and resolves
spontaneously

Tertiary = can affect any body organ including heart,
bones and brain
D IAGNOSIS OF S YPHILIS

Diagnosed by a serological test for reagin – a lipid
released from cells that are attacked by T. pallidum

This test is sensitive and should revert to negative after
treatment but…



It is not positive until up to 12w after infection

It is non-specific and there is a large number of
conditions that cause a false positive test
Tests that detect antibodies to Treponema are more
specific, appear before reagin but…

Usually negative with the primary chancre

They are present for life even after successful treatment

Yaws (and Pinta) will also be positive to these tests

Rapid test used at PMGH is an antibody test
Dark field microscopy of the organism possible
S YPHILIS IN P REGNANCY

Typically does not cross the placenta until >20 weeks

Fetal effects include…


Stillbirth

Intrauterine growth restriction

Prematurity
Neonatal effects include…

Hepatosplenomegaly

Pneumonia

Anaemia & Jaundice

Skin lesions

Osteochondritis
T REATMENT OF S YPHILIS


In the mother with a positive STS = serological test for
syphilis

Give 3 doses of Benzathine penicillin 2.4 mU weekly

Erythromycin 500 mg 4 x daily for 15 – 30 days for true
penicillin allergy
For a neonate

Adequate treatment >28 days before delivery should
prevent neonatal syphilis

But “safety net” treatment commonly practised

25,000 IU/Kg Penicillin twice daily for 10 days

If the baby is clinically affected at birth the prognosis is
poor – see paediatric texts diagnosis & treatment

Ideally all babies born to STS-positive mothers should be
followed with reagin tests until negative
F OLLOW - UP AND C ONTACT T RACING


For a patient with a positive STS…

Contact and test/treat all partners for previous 12m

Other children may require testing
Follow up by a specialist clinic by reagin testing is
desirable to ensure that this test returns to negative
(or titre stabilises) after appropriate therapy is confirmed

It is desirable to document this and give this to the
patient to present at future health encounters
Gonorrhoea and Chlamydial
Infections

Share a number of features in common

Gonorrhoea is caused by...


Neisseria gonorrhoea
Whereas Chlamydia trachomatis...

Subtypes D – K

Preferentially infect columnar and transitional
epithelium of the male and female genital and urinary
tracts

Both may spread within the peritoneal cavity

But only N. gonorrhoea is blood-borne spread to joints
whereas C. trachomatis can cause neonatal pneumonia
Gonorrhoea and Chlamydial
Symptoms

50% of females are asymptomatic

So it is an important cause of chronic PID and infertility

Acute symptoms include...

Vaginal discharge

Dysuria (males and females)

RUQ in women

Can cause proctitis, pharyngitis, arthritis & dermatitis

Tends to flare in the post menstrual week in ♀ or after
abortion/D&C etc.
Diagnosis of Gonorrhoea and
Chlamydia


Requires gram stain for N. gonorrhoea

Look for gram negative diploccoci

Ideally also culture and test for antibiotic sensitivity
The best test for Chlamydia is PCR (Polymerase Chain
Reaction)

Can be performed on the first passed urine from both
females and males

Where it has high sensitivity for genital tract infection

And high specificity
Follow up for Gonorrhoea and
Chlamydia

Retesting not required after adequate single
dose testing

But trace and test or treat all sexual contacts of
the last two months after the diagnosis of
acute infection
Neisseria and Chlamydia in the
Neonate

N. gonorrhoea causes an acute conjunctivitis within 5
days

Whereas C. trachomatis causes conjunctivitis at 5 – 14
days

And can cause a pneumonia and otitis

Untreated the conjunctivitis causes keratitis and blindness

Treatment is by a single dose of IM antibiotics


Check local protocols
Or use universal prophylaxis with AgNO3 drops (need to
be made up fresh), Tetracycline or Erythromycin ointment
Lymphogranuloma venereum
Caused by Chlamydia trachomatis Subtypes L1-3

Incubation period 7 – 28 days

Causes a genital vesicle or papule → shallow ulcer with
inguinal lymhadenopathy

Can cause lower abdominal pain and PID

Untreated results in fistula, stricture and lymphatic
obstruction → elephantoid change in the genitals

Consult your local laboratory for possible tests

DD includes...

Chancroid, Syphilis and Herpes when acute

Donovanosis, TB, Filiarisis, Actinomycosis, Crohns and
neoplasm
Lymphogranuloma
venereum
Lymphogranuloma venereum
Treatment

Doxycycline or Erythromycin for not less than 21 days

May require reconstructive surgery

And Caesarean delivery in a few
Donovanosis
Caused by Calymmatobacterium granulomatis

Incubation period 8 – 90 days

Causes chronic slowly-growing granulomatous ulceration
of the anogenital region and groin

Begins as a painless indurated ulcer that grows into a beefy
granuloma with a rolled edge with moderate
lymphadenopathy

Secondary infection and surface bleeding common

It then becomes painful, foul and locally erosive or
sometimes neoplastic

May also cause fibrosis, stenosis and elephantoid change
Donovanosis
Donovanosis (cont’d)

Diagnose by Leishman stain of crushed material from the
lesion


Look for Donovan bodies in cytoplasmic vacuoles of
enlarged mononuclear cells
Treat with...

Trimethoprim/Sulfamethaxozale

Doxycycline or Erythromycin for 3 weeks or until healed

Combination therapy with Gentamicin, Chloramphenicol or
Streptomycin may be required
Donovanosis Diagnosis
Chancroid
Caused by Haemophilus ducreyi (Gram neg Bacterium)

Incubation period 1 – 8 days

Causes a painful genital ulcer with inguinal buboes



Tender papules → Pustule → Ulcer with ragged red margin
& granulomatous slough in the base

Main DD is syphilis – negative to dark field illumination
Mostly diagnosed in men

Women are presumably carriers

Contact and treat partners of the preceding 10 days
Treatment

Considerable regional variation in antibiotic sensitivity so
check local protocols
Chancroid
Genital Herpes
66% is due to Type 2 Herpes simplex and 33% is due to Type 1
of this virus



More or less reversed for oral Herpes
Affects ≈ 5% of the population

Spread by direct contact (genital, oral or other)

The virus established latency in neurones from where
recurrences occur
The Primary Attack

Incubation period 2 – 10 days

Erythema, itching & burning then vesicles

Severe generalised vulvovaginitis is common with the 1st
attack
Genital Herpes
Genital Herpes (cont’d)



Primary Attack (cont’d)

Urinary retention common

May be systemic features with fever, arthralgia etc.
Secondary Attacks

Occur in 50% of individuals

Troublesome “cold sores” at varying intervals

Causes great psychological distress
Diagnosis

Usually clinical aided by PCR and viral culture
Genital Herpes
Treatment of Genital Herpes


Primary Attack

Good hygiene, Sitz bathes etc

Analgesia

Bladder catheterisation

Responds to Acyclovir (and similar antiviral agents)
Secondary Attacks

Counselling and maintaining good health

Topical Acyclovir

There is a role for oral Acyclovir in prophylaxis
Genital Herpes during
Pregnancy

Genital herpes at the time of vaginal delivery carries a risk
of neonatal Herpes – Mother to Child Transmission

This is a very serious generalised infection with high
mortality and risk of long term morbidity

(See Herpes in Pregnancy)

Risk from primary infection is 25 – 56%

Risk from secondary infection is only 1 – 3%

Caesarean section (provided that membranes have not
ruptured >4 hrs) reduces the risk of MTC of Herpes
A Word About HIV

The most important STD of our time

It is the Syphilis of the 21st century

All STD’s (with the possible exception of gonorrhoea and
Chlamydia) but particularly those with genital ulceration
will greatly increase the risk of HIV transmission

And concurrent HIV makes many of the STD’s much
worse, especially the viral ones due to Human Papilloma
virus and Herpes simplex
A NY Q UESTIONS OR C OMMENTS ?