Presented By: Patrick E.

Dycoco

Objectives:
Definition of STIs: What are they?
Transmission: How are they spread?
Types of infection:
Bacterial (Chlamydia, LGV, Gonorrhea, Syphilis)
Viral (HSV, HIV, HPV)
Parasitic (trichomoniasis)

STI vs STD
STI Infections acquired through sexual
intercourse (may be symptomatic or
asymptomatic)
STD Symptomatic disease acquired
through sexual intercourse
STI is most commonly used because it
applies to both symptomatic and
asymptomatic infections

Sexually Transmitted Infections

Infections that are most commonly
passed through sexual contact:
Oral
Vaginal
Anal
Skin-to-skin

Syphilis
Treponema Pallidum
Incubation period: 3-90 days

Syphilis: Clinical
6
Primary Phase
Presentation
Primary chancre
Begins as papule and erodes into
painless ulcer with a hard edge
and clean base
Usually in the genital area
Appears 9-90 days after
exposure
Can be solitary or multiple (eg.
kissing lesions)
Heals with scarring in 3-6 weeks
and 75% of patients show no
further symptoms

Syphilis: Clinical Presentation

(continued)
Primary / Infectious / Early Syphilis Stage:
Secondary Phase
Occurs 4 to 10 weeks after chancre
Lasts several weeks
Accompanied with fever, malaise, generalized
lymphadenopathy, and patchy alopecia
Maculo-papular rash usually on palms and soles
Condyloma lata on perianal or vulval areas
Possible mild hepatosplenomegaly
7

Syphilitic Rash

Credit: Dr. Gavin Hart and CDC

Credit: Connie Celum and Walter Stamn

and Seattle STD/HIV Prevention Training Center

Condyloma lata

Condyloma
lata

Credit: CDC

Syphilis: Clinical Presentation (continued)

Secondary / Latent Stage:

Positive serology
Rapid Plasma Reagin (RPR)
Venereal Disease Research Lab (VDRL)

Patients are asymptomatic and not

infectious after first year, but may relapse
One-third will convert to sero-negative status
One-third will stay sero-positive but
asymptomatic
One-third will develop tertiary syphilis

10

11

Syphilis: Clinical
Presentation (continued)

Tertiary Stage:
Cardiovascular: Aortic valve
disease, aneurysms
Neurological: Meningitis,
encephalitis, tabes dorsalis,
dementia
Gumma formation: Deep
cutaneous granulomatous
pockets
Orthopedic: Charcots joints,
osteomyelitis
Renal: Membranous
Glomerulonephritis

Maternal Syphilis

May cause:
Fetal death
Fetal growth restriction
Neonatal infection

Syphilis: Diagnosis
Non-Specific Treponemal Tests:
1. Venereal Disease Research
Laboratory
(VDRL)
2. Rapid Plasma Reagin (RPR)

13

Syphilis: Diagnosis (continued)

Positive serology on blood or CSF
Specific Treponemal Test:
1. Fluorescent Treponemal Antibody Absorption
(FTA-ABS)
2. Microhemagglutination-Treponema pallidum
(MHA-TP)

Organism may not be cultured but diagnosis

cannot be determined by clinical findings only
15

Syphilis: Treatment Considerations

16

 Gonorrhe
a

17

N. gonorrhoeae-gram negative
diplococci

18

Credit: Negusse Ocbamichael and Seattle STD/HIV Prevention Training Center

Risk factors

Age <25
Prior gonococcal infection
Multiple sexual partners
Drug use

Gonorrhea: Clinical Presentation

Signs and Symptoms
Frequently asymptomatic

Areas of Infection

Urethra
Endocervix

Vaginal discharge
Abnormal uterine
bleeding
Dysuria

Upper genital
tract
Pharynx
Rectum

Mucopurulent cervicitis
Lower abdominal pain
20

Effects on pregnancy

Pre term delivery

Premature rupture of membranes
Chorioamnionitis
Postpartum infection

Gonorrhea: Diagnosis
Clinical exam
Cervical culture
Polymerase chain reaction (PCR) or ligase chain
reaction (LCR)
Gram stainpolymorphonucleocytes with gram
negative intracellular diplococci

22

Gonorrhea: Treatment Considerations

Intramuscular Ceftriaxone 125 mg
For pregnant women only:
Ceftriaxone single dose but substitute Quinolones with
Erythromycin

Evaluate and treat all sexual partners

23

 Chlamydia
Chlamydia trachomatis

24

Risk factors
<25 years old
Multiple sexual partners
New sexual partner within 3 months
Presence or history of other STD(s)

Chlamydia: Clinical Presentation

Mucopurulent cervicitis/vaginal discharge
Dysuria
Lower abdominal pain
Urethritis, salpingitis, and proctitis
Post coital bleeding friable cervix

Key Considerations:
50% of females are asymptomatic
Sterile pyuria with urinary tract symptoms should
trigger you to think chlamydia

26

Effects on Pregnancy
Preterm Labor
PROM
Amnionitis
Fever
SGA
Neonatal septicemia

Fetal effects
Inclusion conjunctivitis
Neonatal pneumonia

Cervicitis

29

Credit: University of Washington and

Seattle STD/HIV Prevention Training Center

Chlamydia: Diagnosis
Chlamydia culture
New tests include:

Direct immunofluorescence assays (DFA)

Enzyme immunoassay (EIA)

Nucleic Acid Amplification Testing (NAAT)
30

Lymphogranuloma Venereum
Caused by Chlamydia trachomatis.
Develops inguinal adenitis and leads to
suppuration
Treatment
Erythromycin 500mg orally 4x daily for
21 days.

 Herpes Simplex Virus

(HSV)

33

HSV: Clinical Presentation

Primary Infection

Prodrome phase:
Tingling/itching of skin

Appearance of painful
vesicles in clusters on an
erythematous base

Vesicles ulcerate then crust

over and heal within 7-14
days

Viral shedding continues for

up to 2-3 weeks

Recurrent Disease

After primary infection,

virus migrates to sacral
ganglion and lies
dormant
Reactivation occurs due
to various triggers
Reoccurrence is usually
milder and shorter in
duration
34

Herpes Simplex in Women with AIDS

36

Credit: Jean R. Anderson, MD

Neonatal routes
Intrauterine(5%)
Peripartum (85%)
Postnatal (10%)

HSV: Diagnosis
Clinical presentation
Viral culture
Tzanck smear/Giemsa smear
Skin biopsy

38

Human Papillomavirus
One of the most common sexually transmitted
infections.
Oncogenic HPV types 16 and 18 are associated with
dysplasia
External Genital Warts Condyloma Acuminata
-increase in number and size during pregnancy
Treatment: Trichloroacetic or bichloracetic, 80-90%
solution applied topically once a week.

Bacterial Vaginosis
Maldistribution of normal vaginal flora
Decreased lactobacilli and overrepresented species
are anaerobic bacteria that include Gardnerella
Vaginalis, Mobiluncus, and some Bacteroides species.
Treatment: Metronidazole 500mg twice daily for 7
days.

 Trichomoniasis
Trichomonas vaginalis

43

Trichomoniasis: Clinical Presentation

Signs and symptoms:
Vulvar irritation
Dysuria
Dyspareunia
Pale yellow, malodorous - gray/green
frothy discharge
Strawberry cervix, inflamed and friable
44

Strawberry Cervix

45

Credit: Claire E. Stevens and Seattle STD/HIV Prevention Training Center

Trichomoniasis: Diagnosis
Flagellated, motile trichomonads on wet
mount
Vaginal pH > 4.5
Diagnosis confirmed by microscopy

46

Trichomoniasis: Treatment Considerations

For HIV-infected women: same treatment

as non-HIV infected women
Metronidazole or Tinidazole
Sex partners have to be treated
47

HIV

49

What Is HIV/AIDS?
Acquired immunodeficiency syndrome (AIDS)
is caused by the human immunodeficiency
virus (HIV).
HIV attacks and destroys white blood cells,
causing a defect in the bodys immune
system.

Etiopathogenesis
Causative agents of AIDS are RNA
retroviruses
Most cases worldwide are caused by
HIV-1 infection.

Clinical manifestations
Incubation: 3-6 weeks
Common symptoms
Fever, rash, headache, lymphadenopathy,
pharyngitis, myalgias, arthralgias, nausea,
vomiting and diarrhea.

HIV Transmission from Mother to Infant

52

Antenatal
In utero by transplacental passage

Intranatal
Exposure to maternal blood and vaginal
secretions during labor and delivery

Postnatal
Postpartum through breastfeeding

HIV and Pregnancy

Pregnancy does not
accelerate the
progression of HIV
disease to AIDS
Patients with AIDS
are more likely to
suffer from
pregnancy-related
complications
53

Effect of Advanced HIV on

Pregnancy
Decreased fertility
Spontaneous abortion
Infections (opportunistic, GU, postpartum,
post-surgical)
Preterm labor
Premature rupture of membranes
Low birth weight babies
Stillbirths

54

Factors Influencing MTCT

Viral Load
The higher the viral load, the higher the risk of
MTCT

Lower risk through:

Use of ART during pregnancy and postpartum to
mother and newborn
Adequate nutrition, particularly vitamin A

55

Factors Influencing MTCT (2)

Maternal factors increasing risk:
Viral or parasitic placental infection
(especially malaria)
Becoming infected with HIV during
pregnancy
Severe immune deficiency
Advanced clinical and immunological state
Maternal malnutrition

56

Factors Influencing MTCT (3)

Labor and delivery factors increasing risk:
Prolonged rupture of membranes (>4 hours)
Injury to birth canal during child birth
Antepartum procedures
Acute chorioamnionitis
Invasive fetal monitoring
Instrumental delivery
Mixing of maternal and fetal body fluids
Delayed infant cleaning and eye care
Routine infant airway suctioning

57

Factors Influencing MTCT (4)

Fetal Conditions increasing risk:
Premature delivery
Low birth weight
Immature immune status
First infant in a multiple birth
Oral diseases
58

Antenatal Care
Primary prevention during pregnancy
Education about safer sex with use of
condoms for mother and father
Early treatment of STIs
Safer sex during pregnancy and
lactation
59

Initial Examination
All pregnant women
Syphilis test
Hgb
HIV counseling and consent
HIV test (rapid, if available)
Rule out active TB

If HIV positive:
Baseline TLC
CD4 and CD8 counts
CD4/CD8 ratio and all other baseline tests (CBC, LFT, etc.)
Viral load screening
60

Labor and Delivery Care

Labor and Delivery Care

Offer HIV testing for women in labor

If a woman accepts an HIV test, provide
counseling and rapid test

62

Cesarean Section (CS)

Reduces the risk of MTCT
Not available and safe in many settings
Not routinely performed for women with HIV
infection in developing countries
Risks of morbidity associated with CS needs to
be carefully balanced with risk of MTCT

64

Postnatal Care of Mother

Routine postnatal care
Infant follow-up
Close monitoring for secondary postpartum hemorrhage
Early recognition and treatment of infections
Continue on HAART if patient is eligible (if on HAART while
pregnant)
Commence on HAART if patient is eligible (if HAART was not
started while pregnant)
65

Postnatal Care of Mother (2)

Extra nutrition and micronutrient support
Counseling about safe disposal of infectious
soiled pads or other garments
Family planning counseling
Infant feeding counseling
Social support

66

Family Planning
Discuss family planning BEFORE discharge
Assess risk behaviors and counsel on suitable
and effective methods
Review birth control and infection control
Dual protection to prevent and reduce further HIV
infection, STIs and pregnancy

Access to emergency contraception

68

END
Thank you