DISEASES OF GENITAL

TRACT

SUBMITTED TO, SUBMITTED BY,

Mrs Smitha Jose Arathy Unnithan
Associate professor 2nd year MSc Nursing
TMM college of Nursing TMM College of Nursing
Thiruvalla Thiruvalla

SUBMITTED ON

INTRODUCTION
Infections during pregnancy may affect a developing fetus. If left untreated, these infections can
lead to the death of the mother, fetus, or neonate and other adverse sequelae. There are many
factors that impact infection during pregnancy, such as the immune system changes during
pregnancy, hormonal flux, stress, and the microbiome. We review some of the outcomes of
infection during pregnancy, such as preterm birth, chorioamnionitis, meningitis, hydrocephaly,
developmental delays, microcephaly, and sepsis. Transmission routes are discussed regarding
how a pregnant woman may pass her infection to her fetus. This is followed by examples of
infection during pregnancy: bacterial, viral, parasitic, and fungal infections. There are many
known organisms that are capable of producing similar congenital defects during pregnancy;
however, whether these infections share common mechanisms of action is yet to be determined.
To protect the health of pregnant women and their offspring, additional research is needed to
understand how these intrauterine infections adversely affect pregnancies and/or neonates in
order to develop prevention strategies and treatments.

INFECTIONS IN PREGNANCY

 STD’S
 Toxoplasmosis
 Rubella
 RTI’S
 Vaginal infections

DEFINITIONS

 SEXUALLY TRANSMITTED DISEASES

A group of communicable diseases that are transmitted predominantly by sexual contact and
caused by a wide range of bacterial , viral , protozoal , fungal and ectoparasitites.

 REPRODUCTIVE TRACT INFECTIONS

 Infections that occur in the reproductive tract and it encompasses both sexually transmitted and
other common genital tract infections.

PREVALENCE

1. True incidence of STD’S unknown – because of inadequate reporting and secrecy that surround
them
1. gonorrhea – 6.2 million
2. genital chylamyidial infections – 89 million
3. syphyillis – 12 million
4. chancroid – 2 million

Viral STD’S genital

 herpes – 20 million
 human papilloma virus infection- 30 million
 trichomoniasis – 170 million ( who health situvation 1994)

Prevalance of disease

In india

 SYPHILLIS – a prevalence of 2.4

 GONORRHEA – most cases are unreported 80% INFECTED women are asymptomatic
carriers
 CHLAMYDIA – mostly prevalent in the southern states
 DONOVANOSIS- Greater prevalence in the coastal region , endemic in T.N, A.P,
ORISSA

EPIDEMIOLOGY
1. HOST FACTORS
 AGE – 20- 24 years old,followed by 25- 29 yrs and 15- 19 yrs
  SEX- morbidity is higher for men then for women, but morbidity caused by infection is
generally much more severe in women
 MARITAL STATUS – the frequency of STD’S is higher among single , divorced and
separated womens than among married couples
 SOCIO ECONOMIC STATUS – individual from low socio economic have higher
morbidity
2. SOCIAL FACTORS
 PROSTITUTION- prostitutes act as reservoir of infections major incidences in asia is
accounted to prostitution
 BROKEN HOMES – promiscuous women are drawn from broken homes eg. Homes
that are broken due to death of parents , or their separations , reared in unhappy homes
 SEXUAL DISHARMONY – married people with strained relations, divorced and
separated persons are often victims of STD’S
 EASY MONEY-prostitution provides way for occupation and for earning easy money ,
fostered with lack of female employement
 EMOTIONAL IMMATURITY
 URBANIZATION AND INDUSTRIALIZATION- type of life styles contribute to
infections
 SOCIAL DISRUPTION- caused by disasters , wars , civil unrest
 INTERNATIONAL TRAVEL – travellers can import and export infections
 CHANGING BEHAVIOUR PATTERN – Moral and cultural value , tendency to break
from traditional ways of life to newer ways of living
 SOCIAL STIGMA – Leads to non-detecting of cases , not disclosing the case nor the
source and hence it leads to infection
 ALCOHOLISM- effect boast prostitution
CLASSIFICATION OF SEXUALLY TRANSMITTED DISEASES

A. BACTERIAL INFECTIONS
1. gonnorrhea- Neisseria Gonorrhea
2 chlamydia
 3. syphilis -Treponema pallidium
4. chancroid -Hemophilus ducreyi
5. Lymphogranuloma venerum- Donavanis granulomatis
6. genital mycoplasmas- Mycoplasma vaginalis
7. group B streptococcus
B.VIRAL INFECTIONS
 AIDS – HIV
 GENITAL HERPES – Herpes simplex virus (HSV)
 CONDYLOMA ACCUMINATA- HPV
 MOLLUSCUM CONTAGIOSUM- HPV -16,18,31
 VIRAL HEPATITIS – Pox virus
C. PROTOZOAL TRICHOMONAS
 VAGINITIS- trichomonas vaginalis
D. FUNGAL MONILIA
 vaginitis - candida albicans
e. PARASITES
 Scabies – sarcoptes scabies Pediculosis pubis
EFFECTS OF SEXUALLY TRANSMITTED DISEASES
1.EFFECT IN THE REPRODUCTIVE TRACT
Females- Infections , development of ectopic pregnancy, infertility , pelvic inflammatory
diseases, , chronic pelvic pain
Males- inflammation of the epididymis , infertility, urethral stricutre Infants- eye infection,
blindness
2. GENTIAL TRACT, mouth, rectum , cardiovascular complications , peripheral nervous
inflammatory disease ,
3. TRICHOMONIASIS- parasitic infection causing vaginitis , arthritis, adverse effect of
pregnancy – low birth weight babies , premature rupture of membrane
4. Inflammation of the lymph node , ulcerative genitalia and elephantiasis – effects of chancroid
and lymphogranuloma
5. Genital herpes –Papular lesions and ulceration Carcinomas- hepatocellular carcinomas ,
caused by hepatitis B, Kaposi’s sarcoma , b cell lymphomas.
 Protozoal infection
TRICHOMONAS VAGINALIS(VAGINAL INFECTION)
A unicellular protozoan flagellate Transmitted through sexual intercourse Women usually
infects vagina and skene’s duct in men Can be present in the lower.
SYMPTOMS
 vaginal discharge – yellow green , frothy or bubbly and copious with a strong foul odour
 Cervix and upper vagina often tiny petechiae , due to inflammation
 With severe inflammation-vaginal wall, cervix and vulva may be oedematous and
erythematous
 Moderate to severe itching
 Women- dysuria and dyspareunia secondary to inflammation vary form mild to severe
 MILD SYMPTOMS can be- discharge that is thin, slight , whitish yellow , without
typical foul odour
 Often cervix and vagina demonstrate “ strawberry spot”
DIAGNOSIS
DURING PELVICEXAMINATION

 Discharge samples placed on a saline mount and examined microscopically

 Motile trichomonades are seen
 Under high power seen as 2 to 3 times the size of WBC and their flagella may be seen
moving
 Lactobacilli are usually absent, many WBC are present, array of vaginal intermediate and
parabasal epithelial cells are present
 Routine pap smear indicates presence of trichomonades
 TREATMENT
 Treated with metronidazole (flagyl) 2 gm orally in a single dose or 250mg tid for 5 to 7
days( contraindicate during the first trimester of pregnancy )
 Womens sexual partner also to be treated with 2 gm single dose
 When taking to avoid alcohol , because it produces abdominal cramps , nausea,
vomiting , headache and flushing
  Lactating women be treated with 2 grams metronidazole , but not to breast feed for 24
hours after the therapy
 Metronidazole is contraindicated during pregnancy , especially during the first trimester .
Clotrimazole vaginal cream or tablets at bedtime for 7days can provide symptomatic
relief
 Local vulvar inflammation and dysuria - to be treated with Sitz bath or steriod creams 
 For Dyspareunia – avoided for 2 to 3 days to allow for healing.
FUNGAL INFECTIONS
 CANDIDA VAGINITIS ( vaginal infection)/ VULVO VAGINAL or yeast infection 
It isCaused by fungus Candida albicans widely distributed in nature , found in skin and mucous
membrane 
 Causes : occurs frequently in women with DM
o Women taking systematic antibiotics are more susceptible to candidas due to
suppression of normal vaginal flora and changes in PH and enzymes 
o Stress – decreases resistances to candida vaginitis and hygiene practices such as
douching , using perfumed oils
 SYMPTOMS
Common symptoms is – vulvar and possible vaginal pruritis
 Itching may be mild or intense , interfere with rest and activities , occur during or after
intercourse
 Women c/o of period of dryness
 Others- have painful urination , usually results because of excoriation , resulting from
scratching
 discharge is white , lampy and cottage cheese like
 Discharge may found on vaginal walls , cervix and labia
 Commonly vulva is red ,&swollen labial folds , vagina and cervix may also be swollen
 Rarely a yeast or musty smell occurs
SCREENING AND DIAGNOSIS
 Complete history acts as the valuable screening tool
 Physical examination – including complete examination of the vulva and vagina
 Speculum examination – always essential
  Saline and potassium hydrooxide (KOH) mounts – Prepared from vaginal or labial
secretion, vaginal ph is normal in yeast infection
 Microscopic examination- Shows hypae and spores of candida albicans
 On saline mounts the vaginal epithelium cells appear normal , there are numerous
lactobacilli ( normal flora and few white blood cells )
TREATMENT
 Vaginal tablets or creams such as mycostatin , miconazole , clotrimazole, terconazole and
triconozole are prescribed for insertion once daily for 7 to 14 days
o Shorter regimen : terazol and butaconazole( femstat) in a 3 day regimen... &
mycelex G-500 AND vagistat ( 0.5%in a single treatment)
 Persistent or chronic candida vaginitis treated with oral anti fungal medications , such as
mycostatin , ketoconazole or fluconazole
 Single oral dose of fluconozole is as effective as 3days of intravaginal clotrimazole
 Prophylactic oral fluconozole once a month can control recurrent infections( can cause liver
toxicity , hence liver test to be done)
 Minipad can be advised during the day to absorb the drainage
 Women should not use tampoons during treatment , as it absorbs the medication
 Douching to be avoided , and intercourse to preferably stopped or a condom used during the
intercourse
 Vulvar inflammations and itching are severe – antifungal or steroidal creams can be applied for
several days
 If candida vagnitis is recurrent , male partner should be examined and skin scraping to be done
BACTERIAL INFECTIONS
BACTERIAL VAGINOSIS ( VAGINAL INFECTIONS)
Caused by gardnerella vaginalis or haemophilus vaginitis , a short gram negative rod ( cocco
bacillus) often seen in combination with mobiluncus species , mycoplasma hominis and
anaerobic bacteria , such as non- fragile bacteroides species Common in vaginal flora , but
cause symptoms when crowded out the lactobacillus species
o Etiology
Exact is unknown
o PATHOPHYSIOLOGY
 Normal h202 lactobacilli are replaced with high concentration of anaerobic bacteria ( gardnerella
and mobilluncus)

With more proliferation of anaerobic , the level of vaginal amines is increased and normal acidic
ph of vagina is altered

Epithelial cell slough and numerous bacteria attach to their surface

Amines are volatilized , then the characteristic odour of BV occurs

o Symptoms
 FISHY ODOUR in the vaginal area
 .Vaginal discharge is usually profuse , thin, vulvar and vaginal inflammation are
commonly seen
 Serious consequences can arise if infection is severe –cellulitis , PID , intra-amniotic
infections , post partum endometriosis , preterm labour , recurrent urinary tract infection
o Screening and diagnosis
 Careful history – to help distinguish from other vaginal infections Microscopic
examination of vaginal secretion
 Normal saline and 10% potassium hydroxide smear to be made
 Presence of clue cells by wet smear is highly diagnostic – is specific to BV
 Clue cells appearances is due to vaginal epithelial cells appear stippled due to growth of
gardenerella and other organisms
o MANAGEMENT
 oral metronidazole 5oomg orally twice a day for 7 days 0r 2gms in a single dose
 Clindamycin 300 mg orally tid for 7day s is an alternative
 Clindamycin phosphate vaginal cream 2%at bed time for 7days or metronidazole vaginal gel at
bedtime for 5 days
 When administering metronidazole advice to be given for avoiding alcohol
 Side effects of metronidazole – sharp , unpleasant metallic taste in mouth , furry tongue , central
nervous system reaction, urinary tract disturbances
 Metronidazole contraindicated in pregnancy and lactating mother , high concentration seen in
infants . If necessary to follow pump and dumb method
o BV AND PREGNANCY COMPLICATIONS
 Postpartal infections
 Preterm labour and delivery
 Preterm rupture of membrane
 Fever during labour
 Postpartal endometriosis
 Intra amniotic infections
 Post caesarean endometriosis
o CASE DETECTION
 clinicalcriteria and through vaginal examination
 B.V is diagnosed when atleast three of the follwoing criteria are present
 Vaginal ph is above 4.5
 Thin, homogenous , white or gray vaginal discharge
 .Clue cells present on saline prep of vaginal discharge
 presence of fishy amine odour with additional of 10%potassium hydroxide to vaginal fluid
GROUP B STREPTOCOCCUS
 Group b streptococcus considered as a part of the normal vaginal flora in women and is present
in 9 to 23% of the healthy pregnant women
 Incidences is Associated with poor pregnancy outcomes
o RISK FACTORS
 positive culture for Group b STREPTOCOCCUS
 Preterm of less than 37 weeks of gestation
 Premature rupture of membrane for a duration of 18 hours or more
 Intrapartum maternal fever higher than 38 c
o DIAGNOSIS
 Prenatal screening done by vaginal or cervical cultures at 26 to 32 weeks gestation
 GBS culture is recommended for pregnant women admitted for premature or prolonged rupture
of membrane , premature labour, fever during labour and multiple births
 EIA TEST for GBS antigen provides for rapid detection but sensitivity may be low , leading to
false negative
GROUP B STREPTOCOCCAL DISEASES IN NEONATES
o Occurs in 2 to 4% of 1000 live births
o Rates of infections are 1 to 2 per 1000 births , and mortality rate of 30%
o Sepsis apparent birth or may not appear until after 1 week
o Infection lead to puenmonia, bacteremia , meningitis with residual neurologic
development deficits or deaths
o Late onset of disease – occurs after 7days and may cause meningitis , bacteremia
and bone and joint infection
 TREATMENT
 prenatal
 Ampicillin 500mg orally QID for 7days given in the third trimester ( rdeuce colonization
prior to delivery)
 Erythromycin used in case for penicillin sensitive client
 Sexual partners treated with ampicillin to prevent recolonization
 Use of condom
o INTRAPARTUM
 Ampicillin iv intially followed by 1 t0 2 g iv q6h during labour
 Erthromycin or clindamycin is used with penicillin allergy
NEOANATE WITH EVIDENCE OF INFECTION
Parental ampicillin 75 mg /kg q12h plus gentamycin 2.5 mg/ kg q12h starting within 2 hours
after birth continuing for 10 days
 EFFECTS OF GROUP B STREPTOCCCOUS INFECTIONS
 Pregnancy effects
 Preterm labour
 Premature rupture of membrane
 Chorioamniotis
 Postpartum sepsis
 Urinary tract infections
 fetal effects
  preterm birth
CHLAMYDIA TRACHOMATIS INFECTION
 EPIDEMIOLOGY
 Caused by chylamydia trachomatis
 High prevalence among adolescents and young adults
 More than 4 million cases annually
 Is a intracellular organism that infects the lower genital tract of women and men causing
urethritis
RISK FACTORS
 Age of 24 or younger
 multiple sexual partner
 New sexual partner
 friable cervix
 non barrier method of contraception or no contraception
SYMPTOMS
 Two third of the cases are asymptomatic Symptom consists a complex of pelvic pain ,
fever , tenderness and muco-purulent cervical discharge indicating PID OR salphingitis
ANTEPARTUM
 Reviews of various studies show that ante partum trachomatis causes amniotis and
postpartum endometroisis
 Chylamydia cerviticis occurs in 30% pregnant women
o NEWBORN
 Newborn infections – upto 60 to 70% i.e during passage via the birth cannael
 Inclusion conjuntivitis of newborn – most common infection occuring in upto 50% of exposed
newborns
 Chlamydia neonatal ophthalmia is also seen
 Infected neonate many also develop pneumonia
DIAGNOSIS
 Direct immunofluroscent monoclonal antibody stain and enzyme linked immunosorbent
assay ( ELISA) and polymerase chain reaction – provide rapid and accurate diagnosis
 Elisa and PCR developed that can be used in urine and genital swab specimens
 Treatment
 Acc to CDC recommendes – treating women and partner
 treatment regimen includes :
 Doxy cycline hyclate 100 mg orally BD for 7days
 Azithromycin 1 gram orally single dose
 Erthromycin 500mr orally QID for 7days
 Ofloxacin 300mg orally bid for 7days
 Sulfisoxozole 500 mg orally qid for 10 days
TREAMENT DURING PREGNANCY......
 Doxycycline, erythromycin, estolate and ofloxacin are contraindicated
 Erthromycin or sulfisoxazole may be used , but sulfisoxazole is less effective
 Amoxicillin or clindamycin is also effective treatment
Prevention
 prevention neonatal trachomatis infections:
 Newborns routinely treated prophylactically aganist ocular chylamdial infection
 Topical erythromycin or tetracycline ointments are used
 Chlymadial pneumonia and conjunctivits in neonates – treated with systemic
erthromycin
GONORRHEA
 One of the oldest communicable sexuaaly transmitted disease
 caused by gram negative Coccus Nesserei gonorrhea – commonly infects the mucosa of
the lower genital tract
 Other sites of infections include endocervical glands , urethra, anus and oropharynx
 Also spread by oral to genital and anal to genital
 Evidence show infection spread from vagina to rectum
 Also transmitted to neonate in the form of ophthalmic neonatorum
 Risk factors
 sexually active individuals
 Young adults
 African – amercian
 Multiple sexual partners
 SYMPTOMS
Womens are asymptomatic : one third of infections seen in adolescents, symptoms are unnoticed
 Purulent endocervical dischanrge , dicharge minimal or absent
 complaints of Pain Chronic or acute severe pelvic or lower abdominal pain or longer ,
painful menses
 Infrequent dysuria, vague abdominal pain or lower back pain
 Gonococcal rectal infection – Occur in women after anal intercourse with 10 % to 30 %
urogential infections
 individual with rectal gonnorhoea – may be completely asymptomatic or conversely have
severe symptoms with profuse purulent anal discharge , rectal pain and blood in stool
 Rectal itching , fullness , pressure are common symptoms
Gonorrhoea infection in pregnancy...
 Gonococcal infection in pregnancy affects mother and fetus – so routine gonorrhea
testing is recommended in early pregnancy and repeated at 28 weeks
 Women with cervical gonorhinginits may develop in first trimester
 Perinatal infection with gonorhaea can lead to premature rupture of membranes , preterm
births , chorioamniotics , sepsis , intrauterine growth restrictions and maternal postpartum
sepsis
GONORHEA IN NEWBORNS
CAUSES
 OPTHALMIC NEONATORIUM is the common manifestaion – highly contagious , if
untreated can lead to blindness
 INFECTIONS OF the nasopharygeal passage , vagina , anus , earcannals and scalp
abscesses
SCREENING ND DIAGNOSIS
 CDC recommends screening of all women
 All pregnant women routinely screened at the first prenatal visit and infected those
identified with risky behaviours are rescreened
 For diagnosis cultures are obtained from – endocervix, the rectum and the pharynx
 Diagnosis is confirmed if it shows intracellular gram negative diplococci .i.e culture
done on a gram stain
 Management
 CDC recomendation for uncomplicated urethral , endocervical or rectal infections are
dual therapy with one of the following
 ceftriaxone sodium 125mg IM single dose
 Cefixime (suprax) 400mg oral single dose
 Ciprofloxacin HCL 500MG orally single dose
 Ofloxacin (fluxacin) 400mg orally single dose
 Spectinomycin hcl ( TROBIN) 2GM im single dose combined with doxycycline 100 mg
orally bd for 7days
 fluroquinine to be used in pregnant and younger than 18 years
 Gonorrhoea with co-existing Chlamydi- 7days of doxycycline ( not used for prg
women)or single dose of azithromycin is added
Gonorrhoea during pregnancy
 Treated with ceftrixone 125 mg IM or other cephalosporins ( spectinomycin 2 gm IM if
allergic) plus erythromycin base 500 mg orally QID for 7days

 In neonates prophylatically against gonococcal opthalmia - topical application of 1%

silver nitrate - also erythomycin , tetracycline ointment
 NEWBORNS INFECTED PERINATALLY – treatment with parental antibiotics
SYPHILLIS
 Caused by spirochete treponema pallidum
 one of the earliest described diseases STI’S
 Transmitted through exposure to infected exudate during sexual contact, by contact with open
wound or infected blood or congenitally
 Rate of acquisition from that of a infected person is 30%
 Disease also transmitted by kissing, biting, hugging.
INCIDENCES
 More than 30,000 new cases of primary and secondary occur anually
 Incidences increased during the 1985 to 1990 , presently still continue to increase in
incidences
SYMPTOMS
  Infection manifest itself in stages with different symptoms
 Primary syphilis is characterized by primary lesion . Ie the CHANCRE , appears 5 to 90
days after infection
 Lesion begins as painless papule then erodes to form a non tender , shallow , indurated ,
clean ulcer with several millimeters to centimeters to size
 Secondary syphiilis – occurs 6 weeks to 6 months after apperance of chancre
Characterized widespread , symmetric maculopapular rash on the palms and soles with
generalized lymphanopathy
 May also develop fever , headache and malaise
 Condylomata (broad, painless, pink grey wart like infection ) develop on vulva , the
perineum or anus
 If untreated , some women enter latent phase others develop teritary syphilis – 1/3 rd of
women
 cardiovascular musculoskeletal or multiorgan complications can develop in third stage
Syphilis during pregnancy
 Can be transmitted to fetus through placental circulation as early as 6th week
 Clinical manifestation of disease in foetus usually do not occur unless infection is present
in women after 16 week of gestation
 Risk of prematurity , perinatal death and congential syphilis is greater during primary or
secondary syhilis
 Congenital syphilis – is systemic infections,newborns affected heptosplenomegaly ,
hemolytic anemia , osteochondritis , bullous skin eruptions containing spirochetes
Screening and Diagnosis
 All women diagnosed with another STI’ S OR WITH HIV infections TO BE screened for
syphillis
 All pregnant women to be screened for syphillis at first prenatal visit
 Two types of serologic tests are used : NON TREPONEMAL and TREPONOMAL
 non treponemal tests- SUCH AS VDRL , rapid plasma reagin are used as screening tests False
postive test results are seen for acute infections, autoimmune , malignancy .
 The TREPONEMAL tests – FLURORESCENT TREPONEMAL antibody absorbed and micro
hemagglution assays for antibody to T.pallidium, are used to confirm POSTIVE TESTS
 Tests results for early or incubating syphillis may be negative
MANAGEMENT
 Pencillin is drug of choice
 Proven therapy used even during pregnancy
 Parental penicillin – drug of choice treatment for all stages of syphillis
 dosage less than 1 year duration single dose of 2.4 million U benzathine penicillin G IM
 More than 1 year duration , three doses of 2.4 million U BENZATHINE penicillinG im
WEEKLY for 3 weeks
 Neuro syphilis 10 to 14 days of iv penicillin or procaine penicillin IM plus oral
probenecid
 Penicillin allergy in non pregnant client -Erthromycin
CHANCROID
Disease caused by H.ducreyi
INCIDENCE
 Prevalent in India
 Incidence now found to have decline
 Different states present with different status, highest amoung them been recorded in the northeast
with retropective data showing highest incidences of about 25.7%
 Diseases is less common in the developed and more prevalent in the developing countries
 Found in minority ethincity , multiple sexual partners, prostitution, and drug users
Diagnosis
 MADE BY presences of a powerful genital ulcer ,a negative test for syphilis and
herpes and bilateral inguinal lymphdenopathy
 Ulcer – usually deeper , softer at edges and more irregular than syphilitic chancre
 More painfull and one or more lesions will be present
TREATMENT
 azithromycin 1gm orally single dose or ceftriaxone 250 mg im single dose or ciprofloxacin 500
mg orally , twice daily for 3days or erthromycin base 500mg orally , 3times daily for7day
erthromycin contraindicated during pregnancy, Following treatment women to be reexamined
MOLLUSCUM CONTAGIOSUM
 member of the pox virus
  frequently seen in chlidren as skin infections
 found commonly in the tropical areas , disturbution is world wide
Risk factors
 Among the adults through sexual transmission – more common spread
 poverty
 Inadequate resource for good hygiene
 Overcrowding
 Transmission occurs through contact with infected skin.
 Apart from sexual route also transmitted through from personal objects , that has been
contact with lesions by skin to skin contact
 Infection also transmitted by touching infected areas and then touching other body parts
Signs and symptoms
 Cause a benign infection of skin
 Firm raised flesh coloured nodules with a softly indented centres from small papules
 Average size less than 0.5 cm
 Central area is filled a soft curd like materials , that can be expressed
 Nodule appear on the genitals , buttocks and thighs and chest
 Large lesion seen in immune suppressed patients

DIAGNOSIS
 presumptive diagnosis made – on clinical presentation
 staining of the material expressed form the nodules can identify typical molluscum bodies in the
cytoplasm
TREATMENT
 a benign disease with limited course , it resolve spontaneously after week or month
 Cryotherapy , scraping the core material with a sharp object , curetting the lesion , applications
of podophyllins in the office or podofilox at home
LYMPHANOGRANULOMA VENEREUM
 It is caused by some subgroup of cotrachomatis
 Genital ulcer may appear at site of initial infections , but resolves quickly
  More prominetly seen as tender lymphedenopathy , most commonly in the inguinal
areas/femoral areas
Diagnosis
 By exclusion of other causes of lyphadenopathy or by compliment fixation testing
 Treatment
 Doxycycline – 100mg orally twice a day for 21days
 Erythromycin base 500mg – orally four times a day for 21 days
 All partners to be tested
VIRAL SEXUALLY TRANSMITTED DISEASES
HUMAN PAPILLOMA VIRUS
 Hpv also known as condylomata accuminata or genital warts
 Most common viral STI’S in ambulatory health setting
 HPV a double stranded DNA virus , which has more than 30 serotypes ,that can be
sexually transmitted , five of which are known to cause genital warts formation , eight of
which causes oncogenic potential
 About 70 tyoes of hpv virus , skin commonly infected by 1,2 ,3 ,4 and mucuosa by hpv 6,
11, 16, 18

Incidences
 Dramatic rise in hpv infections in last 20 years with estimated incidences at about 17%
 Younger women have higher rate of incidences
 Cervical hpv rates 33% and combined cervix and vuvla rates of 46%
Risk factors
 younger age
 Multiple sexual partners
 Failure to use condom
Signs and symptoms
 Lesions large , cauliflower like clusters or condyloma ,usally multiple , although single
lesions can be seen on the vulva, vagina ,cervix and rectum
 Lesions are small 2 to 3 mm in diameter and 10 to 15 mm in height
  Papillary swelling occuring singly or in clusters on the genital and anal rectal regions
 Infection of longer duration look like cauliflower like mass
 In moist areas such as vaginal introtus , lesions look like multiple fine finger projections
 complain of , irritating vaginal discharge , itching , dyspareunia or post costal bleeding
 Women may report of bumps on her vulva
 Flat topped papules 1 to 4 mm in diameter are seen in cervis
 DURING PREGNANCY , the lesions become so large during pregnancy that the affect
urination , defecation , mobility and fetal descent
 Hpv infection can also be acquired by neonate during birth
Screening and Diagnosis
 Complete h/o OF signs and symptoms , pap tests and physical examination
 Hpv – DNA test can be used in women over the age of 30 in combination with PAP test
to screen for types of HPV or in women with abnormal PAP test
 Only definitive diagnosis is - for presences of histological evaluation of a biopsy
specimen
MANAGEMENT
 Untreated warts may reslove on their own in young women , because of strong immune
system
 No therapy eradicates HPV
 GOAL of treatment is removal of warts and relief of signs and symptoms , not
eradication of HPV
 For pregnant women – cryotherapy with liquid nitrogen, TCA OR BCA 80 – 90%
 Women with discomfort associated with genital warts find bathing with oats meat
solution and drying the area with cool bar drier.
 Keep the area clean and dry.
 Cotton underwear and loose fitting clothes decrease friction and irritation and decrease
discomfort.
 Women to be counseled regarding diet, rest and exercises.
 also to be taught on virus transmission.
  Sexually active women with multiple partener or history of HPV to encourage to use
latex condom.
 To be instructed about medications and therapies available.
 Importance of concurrent treatment of vaginitis and other STD’S to be emphasized.
 Educate the importance of annual health examination to screen disease reoccurrence.
 Women should be counselled for regular pap screening.
prevention
 prevention abstinence from sexual activity.
 Staying in longterm monogamous relationship.
 Prophylactic vaccination(HPV) vaccine..
HERPES SIMPLEX VIRUS
 Incidence or history : Unknown until point of middle of 20th centuary, now a wide
spread problem especially in the united states.
 Caused by two antigen subtypes, herpes simplex virus 1(HSV1) and herpes simplex virus
2(HSV2)
 HSV 2 is usually transmitted sexually and HSV1 non-sexually.
 HSV1 /commonly associated with gingivostomatitis and oral labio ulcers.
 HSV2 with genital lesions.
 hsv 1 mainly seen as cold sores of lips.

 Risk factors:
o Lower income and educational levels.
o Multiple sexual partners
o African americans or hispanic race.
o Female gender
 SYMPTOMS
 Multiple painful lesions , fever ,chills, malaise and severe dysuria and last upto 2 to 3
weeks
 Incubation period for primary infections is 3 to 14 days
  Following this incubation period the women with HSV – 2 will develop painful vesicles
in the vulva and perineal areas
 Women with primary genitla herpes progress forming vesciles , pustules and ulcers that
crust and heal without scarring
 Ulcers become tender
 Women also have itching , inguinal tenderness and lymphadenopathy
 Severe vulvar edema may develop and have diffculty sitting
 Cervix may appear normal or be friable , reddened , ulcerated or necrotic
 Heavy, watery to purulent vaginal discharge is also seen
 Extragental lesions may also be present
 Urinary retention and dysuria may occur secondary
 women with recurrent episodes of HSV infection commonly have only local symptoms ,
which are less severe
 DURING PREGNANCY
 adverse effects both on mother and fetus
 Primary infection during the first trimester have been associated with increasing
miscarriage rates
 More severe complications of HSV infections is neonatal herpes
 Risk for neonatal infections is heightened among women with primary herpes infection
who are near term
 Screening and Diagnosis
 A thorough history and physical examination
 History taking into account-any viral symptoms , malaise , headache, fever ,local
symptoms like vulvar pain , dysuria, itching or burning at site of infection.
 A thorough physical examination – emphasis on vulva, perineal, vaginal and cervical
area to be carefully inspected
 Confirmed by viral cultures or antibody titres using ELISA technique .
 Multinucleated giant cells on a pap smear also support diagnosis
 MANAGEMENT
 CHRONIC recurrent disease , for which there is no cure
  Mx aimed at specific treatment during primary and recurrent infections , preventions ,
self help measure and psychological support
 Systemic anti viral medication partially control symptoms and signs of HSV infection
 in pregnant women
 Acyclovir 200mg orally five times daily or 400 mg threee times daily for 10 days
recurrent infections – acyclovir 200mg five times for daily for 5 days or 800 mg twice
daily for 5days started within 2 days after appearance of lesion CHRONIC
SUPPRESSIVE THERAPY – with 400 mg acyclovir twice daily , helps reduce
recurrences
In pregnant women
 Safety of acyclovir not established
 ACYCLOVIR can be used if benefits outweight the potential harm to the fetes
 Cleaning lesion twice a day with saline will help prevent secondary infection
 Measures that increase comfort – warm sitz bath with baking soda
 keeping lesions dry by blowing the area ,
 pat dry the area with soft towel
 Wearing cotton underwear and loose clothing
 Using drying aids such as hydrogen peroxide , burrows solutions or oatmeal baths , applying
cool , wet , black tea bag to lesions and applying compress with infusion of cloves or pepper oil
to lesions
 Oral analgesics such as aspirin or ibubrofen is used to reduce pain sensation
 Non viral ointment , especially containing cortisol are extremely sensitive and such agents
should be avoided
 A thin layer of lidocaine ointment or antiseptic spray may be applied to decrease discomfort
 Diet rich in vitamin c , B-complex vitamins , zinc and calicium – to help prevent recurrences
 Amino acid l-lysine has been used in doses of 750 – 1000 mg daily while lesions are active and
500 mg during asymptomatic period
 Counselling and education
 Referral for stress reduction therapy , yoga , meditation
 Avoiding exercise , heat and sun , hot baths and using lubricant during sexual intercourse to
reduce friction , to use condoms during intercourse
 Vaginal births is preferred if there is not visible vaginal lesions
 A Cesearen birth within 4 hours after labour begins or membranes rupture is recommened if
visible lesions are present
 Infant delivered through infected vagina to be carefully observed and cultured
VIRAL HEPATITIS
 Five different viruses (hep A,hep B, C, D & E)
 HEPATITIS A
 Acquired primarily through feco- oral route by ingestion of contaminated foods,
particularly milk, shell fish or polluted water or person to person contact
 Also transmitted through sexual contact
symptoms
 Abrupt onset of flu like symptoms
 Abdominal pain
 Fever
 Malaise , anorexia
 Nausea, vomiting
 Jaundice and puriritis incubation period of 15 to 20 days Transplacental transmission of
HAV to fetus occurs rapidly
DIAGNOSIS
 Detection of antiHAV antibodies in serum is elevated
 LFT –show elevated aspartate transaminase (AST) , Alanine aminotransferase (ALT),
alkaline phosphates , cholestrol, and bilirubin
TREATMENT
 Prevention-vaccine ‘havrim” made from inactivated hepatitis virus , FDA approved this vaccine
in 1995
 One dose is 96% effective
 Non immunized people who come in close contact with infected person to be given serum
immunoglobulin within 14 days of exposure
2.HEPATITIS B
 cause of acute and chronic hepatitis
 Transmitted through sexual contact and blood fluids
Risk factors
 women of asian, pacific islands or alaskan eskimo descent , women both in haitior , sub
saharan africa
 Women with history of acute or chronic ulcer disease who work or receive treatment in
dialysis unit
 Women with histroy of multiple blood transfusions
 Prison inmates
 Homesexuals
 Iv drug users
 Frequent blood users
Transmission -Perinatal transmission occur in infants of mother who have acute infection in the
third trimester or during postpartum or during intrapartum from exposure to positive vaginal
secretion , blood amniotic fluid and breastmilk
Also transmitted through artificial insemination
SYMPTOMS
 Many are asymptomatic
 Classic symptoms – fatigue , nausea , anorexia , abdominal pain, low grade fever , and in
25% of cases jaundice
 Later women develop clay coloured stools, dark urine , increased abdominal pain and
jaundice
 Infection become chronic , ranging from asymptomatic carriers to persistent hepatitis
Screening and diagnosis
 Thorough history and physical examination
 Serological testing for hepatitis B surface antigen (HBsAG)
HEP B IN pregnancy
 Newborns to receive prompt treatment and health care worker to take appropriate
precaution
 HBV can be prevented in 85 – 95% OF NEWBORN by administering hepatitis B
immunoglobulins , as soon as possible , within 12 to 48 hours after birth
TREATMENT
  HBV vaccine is administered in 3 doses , first two are given 1 month apart and third
given in 6 months
 Pregnant women with definite exposure to HBV to be given hep b immunoglobins and to
begin hep B vaccine series with 14 days of most recent contact
 Vaccine a series of three doses over 6 months period , with the first two doses given at
least 1 month apart , given in detoid muscle
 Prevention – to decrease transmission , women with positive HBV should maintain high
level of personnel hygiene
HEPATITIS C VIRUS
 VIRUS rarely tranmitted through sexual route , mostly by blood or blood products , feco
oral route
 RISK FACTORS
1. h/o of injections , intravenous drugs
2. h/o of STI such as hep b , Hiv
3. Multiple sexual partners
4. h/o of blood transfusion
Symptoms

 clients are usally asymptomatic or have general flu like symptoms

DIAGNOSIS
 Confirmation of HCV is confirmed by presences of anti- c antibody
during laboratory testing
TREATMENT
 Interferon alfa – 2b alone or with ribaviran for 6 to 12 months is the main
therpay for HCV INFECTIONS
HEPATITIS E VIRUS
 Usually causes an acute , self limiting icteric illness without chronic infections or liver
diseases
 DELTA HEPATITIS
  OCCURS in inconjunction with HBV INFECTIONS
 Found in people with multiple parental exposures , such as iv drug users , hemophilias
and those having repeated blood transfusions
 No treatment , should be encouraged plenty of sleep, eat nutritious food
HUMAN IMMUNODEFICIENCY VIRUS
 Spread throug HIV 1 AND HIV 2 . HIV 1 causes infections in europe and western hemisphere
 HIV 2 – is a retrovirus ENDEMIC in west africa
Transmission
Primirly sexual contact , also through blood and body fluids , transplacentally and through
breast milk
SYMPTOMS

 Headache
 Night sweats
 Malaise
 Generalized lymphadenopathy
 Myalgia
 Nausea
 Diarrhoea
 Weight loss
 Sore throat
 fever
Diagnosis
 from 6 weeks to 1 year after exposure , hiv antibodies appear in serum and detected by ELISA,
which is usally confirmed by western blot test
 Antibody testing is done sensitive screening test such enzyme immunoassay (eia)
 Reactive screening test must be confirmed by additional tests such as western blot or an
immunofluorescence test
INCIDENCE
 About million people are estimated by CDC IN 1991
HIV INFECTION IN PREGNANCY
  Druing prenatal visit , women to be screened for HIV
RISK FACTORS
 Early indication of possible HIV infection include persistent candida infections ,
anogential condyloma and herpes simplex
 Hiv infection causes premature rupture of membranes , foetal death and low birth weight
babies
 Higher incidences of infectious diseases during pregnancy – bacterial pneumonia ,
PERINATAL TRANSMISSION
FACTORS AFFECTING-
 Preterm neonates are more like to be infected
 Identical twins more likely to be infected
 Vitamin A Deficiency
 Newborns of symptomatic mothers
 Mothers with lower CD4 – CD 8
 newborn born by C section are slightly less likely to be infected Invasive procedures such as
episiotomy , internal foetal monitoring, foetal scalp sampling , use of forceps and vacuum
extraction during labour.
Management for perinatal transmission
 Zidovudiene administered to a symptomatic seropositive women during pregnancy and labour
and to newborn
 According to the united states public health service , issued recommendation regarding use of
ZIDOVUDIENE
 Asymptomatic women with CD4 lymphocyte count above 200 , not yet taken zidovudiene-
decrease the risk for prenatal transmission
 Pregnant women with HIV who have lower cd4 counts or more than 34 weeks gestation
Treatment
 All pregnant women CD4 COUNT to be detremined
 IF > 600 cells/ul , repeat count not needed If 200 – 600 cells/ul repeat each trimester
 If < 200 celles/ul repeat every 3 months to monitor antiretroviral therapy
 When CD4 COUNT is less than 500 cell/ul pregnant women to be started with
antiretroviral therapy
 Pelvic inflammatory disease
 Infectious process that commonly involve the uterus ( fallopian ) tubes , and rarely the
ovaries and peritoneal surfaces
 Causes
o Multiple organism
o Common causitive organisms is n. Gonnorrhea and chlamydia
Risk factors
 young age
 Multiple partners
 High risk of new partners
 History of sti’s
 Women who use IUD
 SYMPTOMS
Acute subacute and chronic
Pain is a common- dull , intermittent
ACUTE PID
intermentrual bleeding
 Fever of 39 c or above , uretheral or cervical discharge , often purulent
 Peritonitis
 .Pelvic tenderness, adnexal tenderness
 WOMEN WITH SUBACUTE PID
 Far less dramatic .with lesser severity and extent of sypmtoms , that women
ignores them
 Symptoms –
 chronic lower abdominal pain ,
 dyspareunia ,
 menstrual irregularities
 urinary discomfort ,
 low grade fever
 low back pain
  Abdominal examination shows no rebound tenderness
Screening and diagnosis
 Carefull h/o and vital signs
 Complete physical examination
CRITERIA FOR DIAGNOSIS
 Oral temp greater than 38.3 Abnormal cervical or vaginal discharge Elevated erythrocyte
sedimentation rate Laboratory documentation with cervical infections with n.gonorrhea
or trachomatis
Management
Prevention
 counselling
 Instructing women for safe sex guideline
 Partner notification when STI’S is diagnosed
 CDC’S recommendation for hospitilization
 SURGICAL emergencies such as appendicitis
 Women with tuboovarian abscess
 Women is pregnant
 Women unable to follow outpatient command
 Failed to respond to out pt treatment
Treatment regimen vary depending on the infecting organisms , a broad spectrum antibiotics
are generally given
 TORCH INFECTIONS,
Toxoplasmosis and other infections ( eg . Heptatitis) rubella virus , cytomeglovirus (cmv) and
herpes simplex virus , collectively called as TORCH infections
Toxoplasmosis
 A protozoal infection caused by toxoplasmagondi
 Infection transmitted through encysted organisms by eating infected raw or uncooked
meat , through contact with infected cat feaces
 Fetal risk for infection with duration of pregnancy is 15% , 30%,60%in the first trimester,
2 nd 3 rd trimester
 Increased risk for abortion, still births , and IUGR
  AFFECTED develop hydrocephalous , choroidentitis . Microcephaly and mental
retardation
 it is a self limited illness in an immuno-competent adult and does not require any
treatment
DIAGNOSIS
 Acute infection is diagnosed by detecting IgM specific antibody
 Current infection is confirmed then the following test are carried out
 aminocentesis and cordoocentesis for detection of I g M antibodies
TREATMENT
 Pyrimethamine 25 mg orally daily or oral sulphiazine 1 gm four times a day is effective
 Luecovorin is added to minimize toxicity , for 4- 6 weeks consecutively
 Pyrimethamine not given in first trimester – spiramycin has been used as alternatively
PREVENTION
Avoid uncooked meat, unpasturized milk , contact with stray cat or
Rubella Or german measles
TRANSMITTED BY respiratory droplet exposure
Fetal affect is through transplacental route
Risk for major anomalies when infection occurs int the first , second, and 3rd trimester are 50%,
25% and 10% respectively
Signs
 Multi system abnormalities, following cogenital rubella
 Cochlear , cardiac , haematologic and chromosomal abnormalities
 Virus predominant affect the fetus especially during 1 st trimester and ITS IS
EXTREMELY TETRATROGENIC
 Increased chance for abortions , stillbirths and congential malformed baby
DIAGNOSIS
 Test for rubella psecific antibody to be done within 10 days of exposure , to know whther
pateint is still immuno or not
Treatment
 Active Immunity can be conferred in non immune clients
 Clients given live attenuated rubella virus vaccine during 11 – 13 yrs
 NOT RECOMMENDED in pregnant women, when given during child bearing period ,
pregnancy to be prevented within 3 months by contraceptive measures
 CONTROL OF STD’S
1. INTIAL PLANNING
Based on the prevalence of the area – to be obtained
Prioritization to be based on multiple infected areas
Appropriate strategies to be layed down
3. INTERVENTION STRATEGIES
 Cases under doubt- confirmed using screening and contact tracking technique
 In cluster testing – pt asked to name persons moving in the same socio – sexual
environment, on contact treatment to control the spread of STD’S
 Consists – administering full therapeutic dose of treatment to persons exposed to STD’S
 Pts adviced to follow the appropriate contraceptive during sexual activity
 Through functional STD’S clinic operable at the district level even at PRIMARY
HEALTH CENTER
 Suitable arrangement for treating female patients
 the clinic health centre / hospital ,to have adequate laboratory facility to provide basis for
correct aetiological diagnosis, treatment, and follow up care
 Taking complete history , including the behavioural risk management
 Early diagnosis of RTI/STD an integral part of chain of prevention of life threatening
diseases
 Management and counselling for safe sex pratices
 safe sex pratice
 Reducing the numbers of partners and avoiding partners who have had previous sexual
practices
 Discussing new partners previous sexual history and exposure to STI will help reduce the
risks
 Women to be taught low risk sexual practice and which sexual practice to avoid
 Sexual fantasizes is safe , as are hugging , body rubbing and massage
 Women to be taught in the clinic , where to purchase condoms, how to use them ,
motivating them to use condoms
 All clinics , gynaecological procedure to be carried out in aseptic way , otherwise lead to
RTI
 SOCIAL WELFARE – to eradicate the existence of RTI/STI include rehabilitation of
prostitution , provision of descent living condition , marriage , counselling , prohibiting
the sale of sexual stimulating literature, pronographic books and photographs
4. MOINTORING AND EVALUATION
 Monitoring the disease trends and evaluation of the program
 Periodic evaluation direct method to judge effectively

CONCLUSION
Many infectious diseases have the potential to complicate pregnancy. Some illnesses may
only impact maternal health, but others can infect the fetus with possible devastating or long-
term sequelae. In this chapter we aim to review common infectious diseases such as urinary
tract infections and influenza as well as those that can cause major neonatal morbidity and
mortality including TORCH infections. We will also discuss the challenges that pregnancy
creates for the management of these infectious diseases as some antibiotics that would
typically be used may not be safe for the developing fetus depending on the stage of
pregnancy.

BIBLIOGRAPHY
 Hiralal konar “DC Duttas text book of Gynaecology”9th editon(2019)jaypee brothers and
medical publishers,New Delhi.
 Nima Bhaskar “textbook of Midwifery and obstetrical Nursing”3rd
edition(2019)Emmess medical publishers,Banglore
 Diane M Fraser,Margaret A Cooper “Myles textbook for Midwives” 14th
edition(2003)Elsevier medical publishers