OBSTETRICS 2

F06. STD and INFECTIONS IN PREGNANCY (Part 1)

Dr. Jandoc | May 03, 2019

OUTLINE
I. INFECTIONS/STI in PREGNANCY
II. PREGNANCY SAFETY INDEX
III. CERVICAL INFECTIONS
IV. VAGINAL INFECTIONS
V. GENITAL ULCER INFECTIONS
VI. CONSIDERATION IN THE MANAGEMENT OF GENITAL ULCERS
I. INFECTIONS/STI in PREGNANCY
 Pregnant women CAN become infected with the STI same as non-pregnant women
 Pregnancy DOES NOT provide women or their babies any protection against STI
 Consequences may be more serious, even life threatening, for a woman and her baby

II. PREGNANCY SAFETY INDEX

 (US FDA pregnancy categories)
Category A Proven safe because of controlled studies in women failed to demonstrate a risk to the fetus in the first trimester (and no evidence of a risk in later trimesters) and the
possibility of fetal harm remains remote
Studies in humans and animals
Ex. Pre-natal vitamins, multivitamins
Category B Either animal reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women or animal reproduction studies have shown an adverse
effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the 1st trimester (and there is no evidence of a risk in later trimesters).
Studies on animals not on humans, no abnormalities seen in pregnant women, where most medications belong)
Ex. antibiotics, acid-related disorders medications, analgesic
Category C Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and no adequate and well-controlled studies in humans. Drugs should be
given only if the potential benefit justifies the potential risk to the fetus
No controlled studies both in animals and humans, but no congenital abnormalities in women who use these drugs
Category D There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e,g if the drug is needed in a life threatening
situation or for a serious disease for which safer drugs cannot be used or are ineffective)
Proven abnormality seen when medication is administered but benefit for use in pregnant women outweighs the risk
Category X Studies in animals or humans have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in
pregnant women clearly outweighs any possible benefits. The drug is contraindicated in women who are or may become pregnant.
Proven fetal risk and risks outweigh benefits
Ex. anti-convulsant drugs, Tretinoin

*Both categories D and X show fetal risks but the use of category X outweighs the benefits

ETIOLOGIC CLINICAL CHARACTERISTICS DIAGNOSIS IMPLICATIONS DURING MANAGEMENT

AGENT PREGNANCY
III. CERVICAL INFECTIONS
A. GONORRHEA Neisseria  Gonococcal Cervicitis  G/S of endocervical swab Gonococcal infection can have  Cefixime 400 mg. orally single dose OR
Gonorrhea  Symptoms: yellowish, mucoid cervical (result: Smear shows deleterious effects in any trimester.  Ceftriaxone 250 mg IM single dose (1
discharge positive for intracellular In pregnancy is associated with: vial is 500 mg) + 1g oral azithromycin
 Hyperemic, edematous gram-negative  Low birth weight  3rd-5th generations: Category B
diplococci with few pus  Premature delivery safe to give to pregnant
 For men who have this condition, they present cells)  Preterm rupture of membrane  4th and 5th gen cephalosporins are
more acutely than those women who have  Culture  Chorioamnionitis for those resistant to earlier
gonorrhoea: Pus on urinalysis (purulent  nucleic acid amplification  Postpartum sepsis generations
urethral discharge) tests (NAATs) – have  Secondary infertility – those PLUS
replaced cultures in most who suffer from PID then tries  Treatment for non-gonococcal urethritis
laboratories to get pregnant for the second or cervicitis
time

 Conjunctivitis (ophthalmia neonatorum) “sticky  Diagnosis may also use

eye” gram staining/culture of

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 Purulent conjunctival discharge 2-5 days after conjunctival swab also show
birth intracellular gram-negative
 Disseminated neonatal infection diplococci

Extra-genital Gonorrhea:
 Arthritis – often affects the knee, may cause
joint destruction
 Rash – septicemia/Blood infection
 Eye infection: get a thorough history
o By swimming and diving ;P

You have to have suspicion. Try to look at the more

common etiologies rather than the least common
ones. Then check also the partner.

B. NON- Chlamydia  If patient has Gonorrhea, most likely she has  Culture In pregnancy is associated with:  DOC (non-pregnant): Doxcycycline:
GONOCOCCAL Trachomatis Chlamydia  NAATs  Low birth weight Tetracycline (Category C/D: not safe)
CERVICITIS  Gram stain: polymorphonuclear but absence of  Premature delivery  Choose other meds that are safer which
IP = 1-12 days to 3 Gram (-) diplococci  Preterm rupture of membrane could be:
mos.  Cervical erosions compared to gonorrhea,  Chorioamnionitis  Azithromycin: Macrolide (Category B:
chlamydia causes more destruction leading to  Postpartum sepsis safe)
pelvic inflammatory disease causing infertility  Erythromycin: Macrolide (Category B:
 IP = 1-12 days to 3 mos. safe) – avoided because of drug-related
When treating gonorrhea, also treat for chlamydia hepatotoxicity
 Both are gastric irritants so advise to
take with full meals but Doxycycline is
the most gastric irritant
IV. VAGINAL INFECTIONS
A. Trichomonas  Profuse, frothy, greenish-yellow, vaginal  Wet mount: pear-shaped Some studies have linked  Metronidazole 2 grams PO single
TRICHOMONIASI vaginalis discharge, “fishy-odor” trichomonads with WBCs trichomonal infection with preterm dose OR
S  “Strawberry cervix” because of petechiae birth. A few other studies implicate o also DOC for Ameobiasis TID;
IP: 3-28 days  Severe vaginal pruritus leading to this infection with preterm premature Category B: safe
(average 5-10 thickened/reddened vulva rupture of membranes and small-for-  Metronidazole 500 mg. BID for 7
days)  Dysuria due to vulvar inflammation gestational age newborns days
 Dyspareunia
B. BACTERIAL  Gardnerella  May or may not be sexually transmitted but  Gram staining of vaginal  Important to treat them  Metronidazole 500 mg. PO BID x 7 days
VAGINOSIS vaginalis you have to treat swab because to them, it may be  Metronidazole 2 grams. PO SD
 Mycoplasma  Tell-tale sign is CLUE nothing but it may lead to Metronidazole – category B
 Anaerobes Clinical Features: CELLS (indistinct premature rupture of
 Homogenous discharge gravid margin and a membranes, preterm labor,
 Thin white to greyish homogenous discharge, refractile granular prematurity
coating the walls of the vagina appearance due to a
 Asymptomatic in 50% large number of
adherent bacteria)

Clinical Diagnosis:
three of the four following criteria
are present:
1. vaginal pH >4.5;
2. a thin, milky, noninflammatory
vaginal discharge;
3. >20 percent clue cells seen
microscopically; and
4. a fishy odor after addition of
10-percent potassium hydroxide
to vaginal secretion samples (+
whiff test)

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C. VAGINAL  Candia  Thick, curd-like cheesy vaginal discharge with - Direct visualization of The link between candidiasis and  Clotrimazole 100 mg Vaginal
CANDIDIASIS albicans whitish plaques pseudohyphae preterm birth is not robust Suppository OD X 7 days (Category B
 Severe pruritus in the vulva/anal region vaginal preparation – safe)
 Dysuria / painful urination  Clotrimazole 500 mg per vagina SD
 Painful sexual intercourse  Miconazole 400 mg per vagina each
 50% asymptomatic night for 3 days (Broader effect
 Not a sexually transmitted infection because however it is under Category C)
there is a certain number of normal flora in the  Good personal hygiene
vagina that would show candida but in a small
percentage; may be due to alteration of
immune system in pregnancy - immune system
is down, there is overgrowth of anaerobes 
symptomatic
 Becomes STI if a woman has contact with a
man with candidiasis
V. GENITAL ULCER INFECTIONS
A. SYPHILIS Treponema a. Primary Lesion (chancre)  Dark field microscopic of  Fetal infection through several A. Early Syphilis (Primary, Secondary,
Pallidum b. Secondary Lesion – eruption involving skin and specimens obtained from routes (transplacental, Early Latent <2 yrs.)
mucous membranes, long periods of latency the chancre and secondary perinatal)  Benzathine Penicillin G 2.4 M Units
c. Late/Tertiary Lesions – of skin, bone, viscera, syphilitic lesions IM SD (Category B:safe)
CNS, cardiovascular system  Serologic test for syphilis:
RPR If allergic to
If allergic to
1. EARLY infectious Penicillin and
Penicillin
a. Primary: IP 9-90 days Pregnant
b. Secondary: 6 wks. – 6 mos. (4-8 wks. after  Doxycycline 200  Ceftriaxone 250
primary lesion) mg orally BID x mg. IM every
c. Latent (early): <2 years 14D other day for 10
 Tetracycline doses (Category
2. LATE (non-infectious) 500 mg. orally B)
QID x 14D
-20 years
-40 yrs. B. Late Syphilis (Late Latent >2 years)
 Gummatous syphilis 3-12 yrs. after primary  Benzathine Penicillin G 2.4 M units
infection IM weekly for 3 doses for a total of
7.2 M units
If allergic to
If allergic to
Penicillin and
Penicillin
Pregnant
 Doxycycline 200  Ceftriaxone 250
mg orally BID x mg. IM every
4 weeks other day for 10
 Tetracycline doses
500 mg. orally
QID x 4 weeks
1. Primary  Solitary and painless lesions
syphilis  Red macule that progresses to a papule and finally ulcerates
 Inguinal lymph nodes moderately enlarge, painless
 Primary lesions will heal w/in 3-10 week, may go unnoticed
 Lesions on the cervix, rectum, and anal canal may be asymptomatic
2. Secondary  Skin lesions
syphilis  Mucous membrane lesions
 Generalized lymphadenopathy
 Arthritis, arthralgia, and periostitis
 Alopecia and neurologic disease
Rare Features:
 Hepatitis
 Glomerulonephritis, nephritic syndrome
 Iridocyclitis and choroidoretinitis

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 Neurological disease (meningitis, cranial nerve palsies)
 Alopecia

Classic rash - red macules & papules over palms of hand & soles of feet, larger than
herpetic ulcers, & not tender unless secondarily infected.
Papular lesions can become large and coalesce to form large, fleshy masses (condyloma
lata) - seen in anus and labia (genitals)
3. Tertiary  Granulomatous, painless lesions 3-12 years after the primary infection
syphilis  May occur on the skin, mucous membrane, bone or viscera
a. Neurosyphilis  10-20 years after primary infection
 General paralysis of the insane
 Irritability, delusions, seizures, etc
 Tabes dorsalis (dorsal column impairment)
o Increasing ataxia
o Falling vison, sphincter disturbances, attacks of severe pain
o absent ankle and knee reflexes
b. Cardiovascular  Aortic regurgitation, angina, and aortic aneurysm
syphilis  10 – 40yrs after primary infection
B. GENITAL Herpes Simplex Clinical features:  Virological: PCR or culture Maternal primary HSV infection Management:
HERPES type ll  Painful genital lesions  type-specific serological during pregnancy is associated Primary
 May start with a prodrome of irritation or tests. with: 1. Acyclovir 400 mg PO TID for 7-10
IP: 2 -14 days after paresthesia at the site of the future lesions  Spontaneous abortion <20 days or 200 mg 5x a day for 7-10 days
exposure  Lymphadenopathy wks AOG (Category B)
 Other systemic manifestations: fever,  Low birth weight 2. Famciclovir – 250 mg TID for 7 -10
headache, myalgia  Premature delivery >20 wks days (Category B)
Herpes Simplex  Recurrent lesions may occur after 1-4 months AOG 3. Valacicclovir – 1gm PO BID for 7-
Type I – stomatitis  Genital herpes is lifelong chronic condition  Stillbirth 10 days (Category B)
(unable to eat, left  The virus becomes latent in a local sensory
with semi-solid ganglion Genital Herpes in Pregnancy Secondary
foods because  Suspected primary genital  Acyclovir 400 mg. orally 3x a day for
lesions are very Main Symptoms: herpes acquired during the 5 days OR
painful) FIRST EPISODE/PRIMARY EPISODE third trimester of pregnancy  Valacyclovir 500 mg. orally 2x a day
 Multiple painful genital ulcers starting as  Offered acyclovir antiviral for 5 days
vesicles (parang singaw sa oral cavity) treatment
 Constitutional symptoms: fever, malaise,  Delivered by elective LSCS if
headache, photophobia, and occasional labor occurs within six weeks
retention of urine after diagnosis

RECURRENT EPISODES/SECONDARY EPISODE

 Less severe ulceration, sometimes preceded by
prodromal symptoms, ie. tingling sensation
C. GRANULOMA Klebsiella Characteristics: Laboratory Diagnosis Oral broad-spectrum Antibiotics
INGUINALE granulomatis Primary lesion: asymptomatic (painless) papule with  Giemsa stain: macrophage  TMT sulfamethoxazole 800 mg
(formerly elevated & irregular edges which ulcerates giving rise with vacuoles containing BID for 3 days (Category D) OR
calymmatobacteriu to a beefy red ulcer with fresh granulation tissue bipolar- staining bacilli  Doxycycline 100 mg BID for
m) (Donovan bodies) – Board minimum of 3 weeks (Category D)
Exam question Alternative:
IP: 1-4 wks. (up to  Ciprofloxacin 750mg BID for
6 months) minimum of 3 weeks
 Erythromycin base 500 mg
QID for minimum of 3 weeks
(Category B) – more preferred
*Fluoroquinolones – DOC for UTI but not
safe, change to Ceftriaxone
 Repeat urinalysis
D. Chlamydia Characteristics: Treatment: Similar for chlamydia
LYMPHOGRANUL trachomatis  Chronic infection of lymphatic tissue 1. Doxcycycline 100 mg BID for 21 days
OMA VENEREUM  Vulva – most frequent site of infection 2. Erythromycin base 500 mg QID for 21
IP: 3 days – 6  Subclinical infection is common days

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weeks 3 Distinct Phases: 3. I & D of infected nodes
1. Primary infection Extensive surgical reconstruction for the
 Shallow and painless papule, pustule or destructive tertiary phase so you have to
vesicles, heals without treatmen clean your wounds
2. Secondary phase
 Painful inguinal & perirectal adenopathy
 1-4 weeks after primary infection
 If untreated, infected nodes become
tender & enlarged forming bubos
3. Tertiary phase
 “Groove sign”/double genitocrucal folds
 Bubos rupture producing multiple sinuses
& fistulas in 7-15 days
L. CHANCROID Haemophilus Characteristics: Appropriate media are not widely 1. Azithromycin - 1gm single dose
ducreyi  Distinct feature: kissing lesion accessible, and no Food and Drug 2. Ceftriaxone - 250 mg IM single dose
 Soft, painful, anogenital ulcers Administration (FDA)-cleared PCR 3. Ciprofloxacin - 500 mg BID for 3 days
 Ulcers single or multiple test is yet available. Instead, for non-pregnant
 Purulent base painful genital ulcer(s) and 4. Erythromycin base - 500 mg QID x 7
 Contact bleeding negative screening for syphilis or days
 Tender inguinal lymphadenopathy HSV leads to a presumptive
diagnosis.

VI. CONSIDERATION IN THE MANAGEMENT OF GENITAL ULCERS

Patient must be informed about the natural history of the disease:
 Potential for recurrent episodes
 Asymptomatic viral shedding and sexual transmission
 Use of condoms during all sexual exposures with new uninfected partners must be encouraged because it can prevent reinfection
 The risk of neonatal infection should be explained
 Giving antiviral therapy during recurrent episodes might shorten the duration of lesions
 Suppressive antiviral therapy can ameliorate or prevent recurrent outbreaks

CHECKPOINT
a. Syphilis
b. Gonorrhea
c. Candidiasis
d. Bacterial Vaginosis
e. Trichomoniasis
f. Chlamydia
g. Granuloma Inguinale
h. Genital Herpes
i. Chancroid

1. Strawberry Cervix
2. Clue Cells
3. Classic Rash
4. Donovan Bodies 1. E
5. Causes Ophthalmia Neonatorum 2. D
3. A
6. Kissing lesions 4. G
7. Chancre 5. B
8. Pseudohyphae in KOH 6. I
7. A
8. C

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