OBSTETRICS & GYNECOLOGY DEPARTMENT, ZMH

ECUSTA Higher Learning Institute

CLINICAL YEAR-I

STI/HIV, PMTCT, Abnormal vaginal

discharge and genital ulcers

Presented by: Meklit Kibkab

Presented to: Dr Haimanot
objective
Provide in-depth understanding and practical skills on sexually
transmitted infections (STIs) focusing on HIV/AIDS, prevention of
mother-to-child transmission (PMTCT), abnormal vaginal discharge, and
genital ulcers.
Key Topics Covered
Topic 1: STI and HIV/AIDS
➢ Definition, common examples, and risk factors of STIs
➢ Signs, symptoms, and diagnostic approaches
➢ General management and prevention strategies
Topic 2: PMTCT
➢ Understanding PMTCT and transmission routes
➢ Risk factors, diagnostic tests, and strategies for reducing perinatal HIV
transmission
Topic 3 and 4: Abnormal Vaginal Discharge and Genital Ulcers:
➢ Discussion on normal vaginal secretions
➢ Causes of abnormal vaginal discharge and ulcers, clinical evaluation, and
laboratory tests
➢ Treatment options and complications of untreated genital discharges and
ulcers.
TOPIC 1: Sexually Transmitted Infections (STIs) ( focusing on
HIV/AIDS)
Sexually transmitted infections (STIs) are infectious diseases that spread
mostly through unprotected sexual contact with an infected individual. These
medical conditions can be caused by bacteria, viruses, parasites, protozoans
or fungus.

Even though the majority of STIs are transmitted through sexual contact,
some STIs can be transmitted non-sexually through

● Blood transfusion
● Needle sharing, or
● From mother to child during childbirth or breastfeeding.
STI vs STD
STI and STD (Sexually Transmitted Disease) are often used interchangeably,
but they do have slight differences. An STI refers to any infection that can be
transmitted through sexual contact, including those that are asymptomatic or
in the early stages of infection. On the other hand, an STD refers to a
recognizable disease state that has developed from an infection. where signs
and symptoms of the infection are present.
The term "STI" is now more commonly used by healthcare professionals
because many infections can be present without noticeable symptoms.
Common Examples of STIs
According to 2011 EDHS (Ethiopia Demographic and Health Survey), 1%, of
each Ethiopian women and men reported having had an STI in the past 12
months before the survey. Three percent of women and 2% of men reported
having had an abnormal genital discharge. Also 1% of each women and men
reported having had a genital sore or ulcer in the 12 months preceding the
survey.Among the STIs mentioned, HIV, Hepatitis B (HBV), syphilis, and herpes
simplex 2 (HSV-2) are the most prevalent in Ethiopia.
Reasons for Rising Incidence of STIs
● Rising prevalence of viral infections like HIV, hepatitis B and C.
● Increased use of ‘pill’ and intrauterine contraceptive device (IUCD)
● Lack of sex education and inadequate practice of safer sex.
● Increased rate of overseas travel.
● Increased detection due to heightened awareness.
Risk factors
Having unprotected sex

Having multiple sex partners

Alcohol and Substance use

Sharing needles or injection drug use

low socioeconomic status

Having a history of previous STIs

Common Sign and Symptoms of STI
unusual discharge from the vagina, penis or anus
Pain when peeing
Lumps or skin growths around the genitals or anus
Rash
Unusual vaginal bleeding
Itchy genitals or anus
Blisters or sores around the genitals or anus
Warts in the mouth or throat, but this is very rare
STI diagnostic approaches
Syndromic (Comprehensive) approach
Syndromic approach is called “Comprehensive approach” because in addition to the
provision of treatment it includes:
● Education of the patient
● Condom supply
● Counseling
● Partner notification and management
● And HIV testing and counseling (HTC).
Disadvantages of symptomatic approach
Clients may not be satisfied
Risk of developing drug resistance
General management of STI
flow chart(algorithm): is a decision and action tree which is used to manage an
STI patient. Each flow-chart is made up of a series of three steps. These are:

1. The clinical problem

2. The decision that needs to be taken
3. The action that needs to be carried out

The diagnosis of STIs is based on a thorough history and physical examination.

Syndromic diagnosis is based on the identification of symptoms and signs,
thus the health worker should elaborate on the patient's chief complaints in
order to define the syndrome.
History Taking
● The patient's demographic information, such as age, gender, and marital
status
● Onset of symptom
● History of unprotected casual sex, history of STI in the partner, multiple
sexual partners and change in sexual partner
● If there is Vaginal discharge: change of color, amount and odor of vaginal
discharge
● If there is Lower abdominal pain in women: The onset, type of pain,
radiation, severity, presence of vaginal discharge, last menstrual period,
and systemic symptoms like fever, nausea and vomiting.
● Past medical and sexual history
Physical Examination
General examination: on inspection any rash, sores, warts and discoloration are noted. then palpation is
carried out to determine the presence of enlargement of lymph nodes.

Examination of the oral cavity: the oral cavity should be carefully visualized with a torch for ulcers,
candidiasis, leukoplakia, gingivitis.

Examination of the abdomen: The abdomen is inspected and any obvious lumps are noted. The abdomen is
then palpated and the size of the liver and spleen and the presence of any masses, tenderness, guarding and
rebound tenderness are noted.

Examination of the inguinal and femoral triangle lymph nodes: The inguinal areas and the femoral triangles
should be palpated to check for lymphadenopathy or lymphadenitis.

Examination of the penis: first the foreskin should be retracted to look for redness, rash, discharge, warts
and ulcers on the glans penis, and then the urethra should be milked for discharge if an obvious urethral
discharge is not seen.
Examination of the scrotum and testes for swelling and/or pain: Both the scrotum and testes should be
carefully palpated with the aim of ruling out any swelling and pain.

Examination of the vulva: The labia should be separated, the vulva should be visually inspected for any
lesions and the Bartholin's glands should be milked for discharge.

Examination of the anus and perineum: The anal area should be visually inspected for any lesions.

Speculum examination: The speculum should be inserted fully and gently opened in order to visualize the
cervix; then gently withdrawn to visualize vaginal mucosa as it falls into place.

Digital bimanual examination: Physical examination in women is not complete without a digital bimanual
examination which will help to enlist cervical tenderness/excitation or adnexal masses.
Management
General STI Management
• Educate and counsel on risk reduction

• Promote/provide condoms

• Notify and manage partner

• Offer HIV testing and conseling (HTC)

• Advice to return 7days

• Recording and reporting

PREVENTION
Prevention and control of STIs are based on the following five major strategies
1. Accurate risk assessment and education and counseling of persons at risk
regarding ways to avoid STIs through changes in sexual behaviors and use
of recommended prevention services
2. Pre-exposure vaccination for vaccine-preventable STIs
3. Identification of persons with an asymptomatic Infection and persons
with symptoms associated with an STI
4. Effective diagnosis, treatment, counseling, and follow-up of persons who
are infected with an STI
5. Evaluation, treatment, and counseling of sex partners of persons who are
infected with an STI
HIV/AIDS
The causative agents of HIV are strains HIV1 and HIV2, which belong to the
retrovirus family. HIV has the ability to transcribe its RNA into DNA using the
enzyme reverse transcriptase. Once the viral DNA is incorporated into the
host cell genome, chronic infection occurs. The structure of HIV consists of a
core protein (P-24) with glycoprotein envelope (GP 120 and GP 41). The CD4
receptor molecule is the target for HIV, affecting CD4+ T lymphocytes,
monocytes, macrophages, and other antigen-presenting cells. This leads to
profound cellular immunodeficiency as CD4+ cells are progressively depleted.
flu-like symptoms in the 1st 8-12 weeks such as:
● Fever
● Skin rash
● Joint pain
● Swollen lymph nodes
● And diarrhea.
After this initial stage, the person remains without symptoms for several
years.
the immune system weakens opportunistic infections.
AIDS-related complex (ARC) refers to individuals with nonspecific symptoms
like weight loss, fever, diarrhea, rash, swollen lymph nodes, herpes,
oral/genital fungal infections, and ulcers without fully developed AIDS.

CD4+ T cell count below 200/μL= AIDS, regardless of symptoms or

opportunistic diseases.
Risk factors
❖ having unprotected sex;
❖ having another sexually transmitted infection (STI) such as syphilis,
herpes, chlamydia, gonorrhoea and bacterial vaginosis;
❖ engaging in harmful use of alcohol and drugs in the context of sexual
behaviour
❖ sharing contaminated needles, syringes and other injecting equipment
and drug solutions when injecting drugs;
❖ receiving unsafe injections, blood transfusions and tissue transplantation,
and medical procedures that involve unsterile cutting or piercing; and
❖ experiencing accidental needle stick injuries, including among health
workers.
RELATIONSHIP BETWEEN STIs and HIV
● STIs enhance the sexual transmission of HIV
● STIs that primarily cause inflammation such as gonorrhea, trichomoniasis,
and chlamydial infections present a weak barrier to HIV.
● Increase likelihood of infection to the partner( in both the above
scenarios, infected lymphocytes among HIV infected individuals are
attracted to the lesions)
● STIs Increase viral shedding (reported in genital fluids of patients with
STIs) and increase susceptibility to HIV (STI treatment has been
demonstrated to significantly reduce viral shedding).
HIV infection affects STIs
● HIV alters susceptibility of STI pathogens to antibiotics
● Increased susceptibility to STIs among immune suppressed individuals
● The clinical features of various types of STIs are influenced when there is
co-infection with HIV.
● The treatment of conventional STIs is also affected when infection with
HIV coexist.
● Topical anti-fungals are less effective and hence oral antifungals like
ketoconazole may be indicated for patients with candidiasis.
● Severe genital herpes may require treatment of primary episode or
suppression of recurrence with acyclovir. However, resistance to acyclovir
may subsequently develop.
Mode of Transmission
Sexual intercourse

Transfusion of infected blood or blood products.

Use of contaminated needles, needlestick injuries.

Breastfeeding (10–20%)

Perinatal transmission (25–35%)

Treatment
There are two types of HIV/AIDS treatment: preventative and definitive.

Antiretroviral therapy is the only effective treatment for HIV/AIDS.

The most common ART drug classes are

1. NRTIs (Nucleoside Reverse Transcriptase Inhibitors): zidovudine, zalcitabine, lamivudine, and abacavir.
2. Non-nucleoside reverse Transcriptase Inhibitors (NNRTIs): Delavirdine, Nevirapine, Efavirenz.
3. Protease inhibitors (PI): Indinavir, Saquinavir, and Ritonavir.
4. Entry inhibitor
5. Integrase inhibitor

These medication combinations are successful at increasing CD4 counts while decreasing viral load. Monotherapy is
not recommended since it promotes medication resistance. The abbreviation HAART (Highly Active Antiretroviral
Therapy) refers to combination therapy.

Efavirenz is the first-line medication in all patients unless the woman is planning to conceive and has primary NRTI or
NNRTI resistance.
Preventive measures
Promote safer and responsible sexual behavior and practices

Male circumcision reduces transmission by 50%.

Screening of blood donors

Preexposure(Tenofovir 300 mg and Lamivudine 300 mg once daily) and

Postexposure prophylaxis with zidovudine and lamivudine is advisable.

Widespread integrated counseling and testing (ICT) in the clinic.

Prevention of mother to child transmission (PMTCT)

Prevention of Mother-to-Child Transmission
(PMTCT)
Prevention of mother to child transmission (PMTCT) refers to a set of interventions
aimed at reducing the transmission of HIV from an HIV-positive mother to her child.
Significance of PMTCT:
1. Health of the child: PMTCT interventions significantly reduce the risk of the child
acquiring HIV, leading to better health outcomes.
2. Prevention of new infections: PMTCT helps prevent new cases of HIV infection in
infants, thereby contributing to the overall reduction in HIV transmission rates.
3. Impact on the epidemic: PMTCT plays a vital role in breaking the cycle of HIV
transmission and reducing the burden of the disease in future generations.
Transmission routes
HIV can be transmitted from an infected mother to her child during pregnancy,
childbirth, and breastfeeding.
Risk factors
Maternal Factors Infant Factors

High maternal viral load First infant in multiple birth

New or recently acquired maternal Pre-maturity and low birth weight
HIV infection Longer duration of breastfeeding
Low CD4 count Mixed feeding during the first six
Advanced maternal disease months of life
Viral or parasitic placental infections Oral diseases in child
during pregnancy, labor and childbirth
Maternal malnutrition
Nipple fissures, cracks, mastitis and breast
abscess
Poor ART adherence
Active lower genital tract infections
like herpes simplex
Obstetric and delivery factors
Ante-partum procedures (e.g. amniocentesis,
external cephalic version)
Rupture of membrane for more than four
hours
Vaginal delivery compared to CS Injuries to
birth canal during child
birth (vaginal and cervical tears)
Invasive childbirth procedures
The first twin in vaginal delivery of multiple
pregnancies
Delayed infant drying with clean towels and
eye care
Routine vigorous infant airway suctioning
Instrumental deliveries (vacuum & forceps)
Fetal birth trauma
Internal fetal monitoring (fetal scalp
electrodes/sampling)
Diagnostic tests for assessing maternal and fetal
infection status
To assess maternal and fetal infection status, the following tests are commonly used:
1. Maternal HIV testing
2. Viral load testing and CD4 count
3. Clinical symptoms and signs of opportunistic infections should be thoroughly looked for
and appropriate laboratory tests should be requested & the clinical stage of the disease
assigned.
4. Fetal testing: In certain cases, such as when there is a high risk of transmission, tests such
as amniocentesis or chorionic villus sampling can be done to detect HIV in the fetus.
5. If the test is negative, repeat HIV counseling and Testing in the third trimester preferably
between 28 to 36 weeks or during labor as appropriate
PREVENTION OF MTCT OF HIV
The PMTCT of HIV has four main prongs.
Prong 1, there is a focus on primary prevention to keep people HIV-negative
and reduce new infections.
Prong 2, there is an emphasis on preventing unintended pregnancies in HIV-
positive women.
Prong 3, there is a focus on preventing HIV transmission from HIV-positive
women to their infants.
Prong 4, there is a provision of treatment, care, and support to women living
with HIV and their families.
Management
preconception:-
Diagnosis counseling
baseline investigations (CD4 and viral load)
advice on contraception with dual methods
including condoms
guidance on general health and nutrition
prevention of malaria
screening and treatment for opportunistic
infections and STIs
initiation of ART (antiretroviral therapy) and
linkage to PMTCT (prevention of mother-
to-child transmission) unit
provision of prophylaxis for opportunistic
infections
partner involvement and screening
avoiding pregnancy for 6 months after
recovery from chronic infections,
counseling on the impact of HIV on
pregnancy and methods to reduce mother-
to-child transmission.
Antepartum care:

➢ As soon as a missed period occurs, the woman should visit the antenatal care clinic for a pregnancy test.
➢ Once pregnancy is confirmed, a detailed clinical evaluation should be done.
➢ All HIV positive pregnant, laboring, and lactating women should be retested when they start HAART (highly
active antiretroviral therapy) to ensure accurate diagnosis.
➢ All HIV positive pregnant, laboring, and lactating women should be initiated on HAART for life.
➢ Pregnant women with WHO clinical stage 1 and 2 can safely start ART (antiretroviral therapy) in ANC (antenatal
care), while those with advanced HIV disease should be referred to an ART clinic promptly.
➢ Monitoring and support for HAART adherence is essential.
➢ Early ultrasound is performed to determine gestational age.
➢ Routine laboratory screening tests, such as VDRL, HBSAg, CBC, blood group and Rh, are done, and CD4 count is
used to monitor the response to treatment.
➢ Viral load monitoring is effective in detecting treatment failure.
➢ The importance of strict ANC follow-up and the risks associated with
mother-to-child transmission (MTCT) are discussed.
➢ Vaccinations like TT, pneumococcal, and HB are administered.
➢ Nutritional supplementation is provided.
➢ Fetal growth is monitored with serial ultrasounds.
➢ The mode of delivery is discussed based on national guidelines.
➢ Postpartum infant feeding and administration of ART to the neonate for
reducing MTCT are discussed.
➢ The patient's support system is assessed and counseling is offered if
needed.
Intrapartum care:

➢ Focuses on safe delivery practices and infection prevention. This

includes:Avoiding unnecessary procedures, such as artificial rupture of
membranes and routine episiotomy.
➢ Vacuum extraction should be limited, and obstetric forceps preferred
when instrumental delivery is needed.
➢ Repeated vaginal examinations during labor should be avoided,
➢ and chorioamnionitis (infection of the placenta) treated with antibiotics.
➢ Essential newborn care should also be provided.
Regarding mode of delivery for women on HAART (highly active antiretroviral
therapy), if the viral load is > 1000 copy/ml, elective cesarean section at 38
weeks gestational age is recommended. If the viral load is ≤ 1000 copies/ml,
vaginal birth preparedness should be counseled unless there are other
medical reasons for a cesarean section. For women adherent to HAART for at
least one month without a viral load test, clinical judgment can guide the route
of delivery.
ART (antiretroviral therapy) should be continued intrapartum for mothers
already on it. For newly diagnosed patients with HIV and no ART, it should be
started intrapartum and continued post-partum, regardless of CD4 count.
Emergency cesarean section is reserved for patients with obstetric indications.
Post-partum care:
➢ Includes continuing antiretroviral therapy (ART) and starting ART for breastfeeding
mothers.
➢ Formula feeding should be considered for mothers who meet certain criteria, while
exclusive breastfeeding is recommended for others.
➢ HIV exposed infants should receive nevirapine (NVP) and zidovudine (AZT) syrup
and be monitored for early infant diagnosis of HIV.
➢ Family planning counseling, immunization, and growth monitoring should be
provided.
➢ Follow-up should occur at the Maternal, Newborn, and Child Health (MNCH) clinic,
and mothers should be linked to an ART clinic in specific situations.
Abnormal Vaginal Discharge
Vaginal discharge is the term for fluid or mucus that comes from the vagina In women who are
premenopausal, it is normal to have approximately 2 to 5 mL of white or clear, thick, mucus-like, and mostly
odorless vaginal discharge every day.

Normal vaginal secretions:

1. Cervical mucus: The cervix produces mucus throughout the menstrual cycle, and its consistency varies
depending on hormone levels. During ovulation, cervical mucus becomes clearer and stretchier because it
facilitates sperm.

2. Vaginal discharge: Normal vaginal discharge can be thin to thick, clear or white, and odorless. Its
consistency and amount can vary during different phases of the menstrual cycle. Increased discharge is
often seen when a woman is sexually aroused, breastfeeding, or during pregnancy due to hormonal changes
( estrogen and progesterone).

3. Menstrual blood
Abnormal vaginal discharge is defined as a discharge that is different from usual with
respect to color/odour/consistency (e.g. discolored or purulent or malodorous)
Abnormal vaginal discharge may be a sign of infection of the vagina (vaginitis) and/or the
cervix (cervicitis) or upper genital tract infection. The most common causes of vaginal
discharge are
● Neisseria gonorrhea
● Chlamydia trachomatis
● Trichomonas vaginalis
● Gardnerella vaginalis (Polymicrobial).
Candida Bacterial vaginosis (Gardnerella vaginalis) is the leading cause of vaginal discharge
in Ethiopia followed by candidiasis, trichomoniasis, gonococcal, and chlamydia cervicitis in
that order.
 Gonorrhe
a Trichomoniasis

Yeast infection Bacterial vaginosis

History taking
Any underlying concerns (e.g. STI or cancer) or specific expectations that
should be explored

Sexual history (e.g. number of partners, sexual activities, use of condoms)

should be taken to assess the risk of STIs.

sexually active women are at higher risk of STI if they are

● aged <25 years; or

● have changed their sexual partner or
● had more than one sexual partner in the last 12 months
the characteristics of the vaginal discharge Enquiry should also cover any associated
should be determined: symptoms:

what has changed Itching

onset dyspareunia
duration vulval or vaginal pain
odour dysuria
cyclical changes abnormal bleeding (heavy, intermenstrual or
colour postcoital)
consistency pelvic or abdominal pain
exacerbating factors (e.g. after intercourse) fever
Physical exam
inspection of the vulva (for obvious discharge, vulvitis, ulcers, other lesions or
changes)
Speculum examination (inspection of: vaginal walls, cervix, foreign bodies;
amount, consistency and colour of discharge)
Where there is any suggestion of upper genital tract infection physical
examination should also include:
Abdominal palpation (for tenderness/mass)
Bimanual pelvic examination (adnexal and/or uterine tenderness/mass,
cervical motion tenderness)
Treatment
The recommended treatment of vaginal discharge syndrome in Ethiopia is:

Risk Assessment Positive:

Ceftriaxone 250mg IM stat/Spectinomycin 2 gm IM stat Plus

Azithromycin 1gm po stat/Doxycycline 100 mg po bid for 7 days Plus

Metronidazole 500 mg bid for 7 days

If discharge is white or curd-like add Clotrimazole vaginal pessary 200 mg at

bed time for 3 days
Risk Assessment Negative

Metronidazole 500 mg bid for 7 days

If discharge is white or curd-like add Clotrimazole vaginal pessary 200 mg at

bed time for 3 days
Complications
Untreated vaginal discharge can cause reproductive, sexual and other health complications. Some
of the complications are:
1. Pelvic Inflammatory Disease (PID)
2. Peritonitis and intra-abdominal abscess
3. Adhesions and intestinal obstruction
4. Ectopic pregnancy
5. Premature Rupture of Membrane (PROM) in case of pregnant women
6. Chorioamnionitis
7. Post-partum endometritis
8. Pre-term labor in case of pregnant women
9. Low birth weight
10. Infertility
11. Chronic pelvic pain
GENITAL ULCER

Genital ulcer is an open sore or a break in the continuity of the skin or mucous membrane of
the genitalia as a result of sexually acquired infections.
Commonly genital ulcer is caused by bacteria and viruses. Genital ulcer facilitates the
transmission of HIV more than other sexually transmitted infections because it disrupts the
continuity of skin and mucous membranes significantly.
Different kinds of bacteria and viruses cause genital ulcers. Some of the common etiologies of
genital ulcer syndrome are:
● Herpes simplex virus (HSV-1 and HSV-2)
● Treponema pallidum
● Haemophilius ducreyia
● Chlamydia trachomatis
● Klebsiella granulomatis (donovanosis)
Herpes simplex virus Treponema pallidum ( syphilis)

Chancroid Klebsiella granulomatis (donovanosis)

Clinical manifestations of genital ulcer
Constitutional symptoms such as fever, headache, malaise and muscular pain
Recurrent painful vesicles and irritations
Shallow and non-indurated tender ulcers
Common sites in male are: glans penis, prepuce and penile shaft
Common sites in women are: vulva, perineum, vagina and cervix and can
cause occasionally severe vulvovaginitis and necrotizing cervicitis
Painless indurated ulcer(Chancre)
Regional lymphadenopathy
Treatment
➢ Treatment for Non- Vesicular Genital Ulcer
Benzathine penicillin 2.4 million units IM stat /Doxycycline(in penicillin
allergy) 100mg bid for 14 days plus Ciprofloxacin 500mg bid orally for 3
days /Erythromycin 500mg tab qid for 7 days plus Acyclovir 400mg tid orally
for 10 days (or 200mg five times per day of 10 day)
➢ Treatment for Vesicular, multiple or recurrent genital ulcer
Acyclovir 200 mg five times per day for 10 days Or Acyclovir 400 mg tid for
7 days
➢ Treatment for recurrent infection: Acyclovir 400 mg tid for 7 days
COMPLICATIONS OF GENITAL ULCER
● Locally destructive granulomatous lesions occur (Gummas) on the skin, liver, bones, or
other organs
● Tabes dorsalis and dementia, often with paranoid features
● Latent meningovascular parenchymatous
● Optic atrophy
● General paresis
● Aortic aneurysm and aortic valve insufficiency
● Asymptomatic aortitis
● Angina pectoris
● Recurrent disease
● Aseptic meningitis
● Encephalitis
● Phimosis in men
● Destruction of the penis or auto amputation
● Extra genital lesions
References
● DC Dutta’s Textbook of Gynecology, 7th Edition
● National Guidelines For The Management Of Sexually Transmitted
Infections Using Syndromic Approach, july 2015
● National Guideline for Prevention of MTCT HIV, Syphilis and Hepatitis B
Virus, Nov 2021
● MANAGEMENT PROTOCOL ON SELECTED OBSTETRICS TOPICS FOR
HOSPITALS
● uptodate 2023
● Sexually Transmitted Infections Treatment Guidelines, 2021
THANK YOU!
Stay smart, protect yourself from STIs!