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SECTION II: MANAGEMENT OF DISORDERS AND SPECIAL SITUATIONS


SEVERE DISORDERS

Other Sexually Transmitted Infections (STIS)

There are various types of STIs that could occur during pregnancy and can have detrimental effects on the fetus if left untreated. These include:


Gonorrhoea

Gonorrhoea is a common sexually transmitted disease caused by the bacterial organism, Neisseria gonorrhoea. It affects both sexes especially the younger adult population. In males, a purulent discharge from the urethra is the most obvious symptom and is accompanied by burning on micturition. The discharge appears 2 to 7 days after exposure to an infected person.

In females, symptoms may go unnoticed. The infection may ascend to affect the fallopian tubes causing salpingitis or even tubo-ovarian abscesses. The changes that occur in the fallopian tubes increase the possibility of the woman having an ectopic pregnancy and may also lead to infertility. Other sequelae are chronic pelvic abdominal pain and recurrent menstrual irregularity.

N. gonorrhoea may also be transmitted from mother to neonate while it traverses the birth canal. In the neonate this produces a gonococcal conjunctivitis characterized by severe eyelid oedema and abundant purulent discharge, which may spurt from the eyes when the eyelids are separated. This appears 2-5 days after birth. The newborn should be hospitalized and treated to prevent secretions from adhering. Topical antimicrobial preparations alone are not sufficient. The diagnosis is confirmed when a gram stain and culture are taken of the discharge (eye swab). Routine use of 1 % silver nitrate drops instilled into each eye after delivery is recommended for prevention of neonatal gonococcal conjunctivitis.


Chlamydia

Chlamydia trachoma is becoming increasingly recognized as the cause of many human infections. Its serotypes cause among other diseases lymphogranuloma venereum, genital infections and conjunctivitis. Genital infections are not always clinically apparent. The manifestations are almost indistinguishable from those of gonorrhoea and both infections may co-exist. In males, the main symptom is urethritis and in females a muco-purulent cervicitis. Complications can result in infertility in both males and females. The infection can be passed on to infants during childbirth. Silver nitrate is not an effective prophylaxis measure against the conjunctivitis of chlamydia.

Treatment
Tetracycline or erythromycin ointments can be used topically. Oral therapy is preferable as the neonate can develop Chlamydia pneumonia. Erythromycin suspension is given for 10- 14 days.


Syphilis

Syphilis is caused by a spirochete, which is a delicate spiral micro-organism called Treponema pallidum. The infection may be: transmitted from one sexual partner to another and from a pregnant woman to her unborn child.

The disease develops in several stages if untreated:

Stage 1 or Primary Syphilis
Painless ulcer called chancre appears on the site of invasion (usually penis or vagina) within 4 weeks of infection. After 4 to 8 weeks the chancre usually heals even if no treatment is given.

Stage 2 or Secondary Syphilis
Six (6) to 12 weeks after infection rashes appear about the body including the palms of the hands and the sole of the feet. This is accompanied by enlarge lymph nodes and mild constitutional symptoms of malaise, anorexia, easy fatigability, etc. The lesions may persist for months. In untreated patients they frequently heal but fresh ones may appear within weeks or months. In a few patients the hair may fall out in patches.

Latent Stage
One (1) to 2 years after infection all symptoms may disappear. This stage may last for a few years.

Stage 3 or Tertiary Syphilis
About 1/3 of all untreated patients will progress to this stage which affects:

  • Skin, bones and internal organs
  • Cardiovascular system
  • Nervous system.

Congenital Syphilis
A pregnant woman who has untreated primary or secondary syphilis may infect her fetus. Infection hardly occurs before the eighteenth week of pregnancy and treatment of the mother during the first 4 months of pregnancy virtually eliminates the risk of congenital syphilis. Untreated maternal infection may result in prematurity, stillbirth, neonatal death and early or late congenital syphilis.

Early Congenital Syphilis: Symptoms appear before the child is 2 years old. Vesicular and bullous skin lesions appear about the body including on the palms and soles, blood stained nasal discharge causing snuffles, generalized lymphadenopathy, failure to thrive, enlarged liver and spleen and osteochondritis with characteristics changes in the bones.

Late Congenital Syphilis: This comprises of symptoms that occur after 2 years of life and is likened to tertiary syphilis in adults. Periostitis and osteochondritis result in anterior bowing of the tibia. Widely spaced, tapered incisors with a central notch are called Hutchinson’s teeth. This finding along with nerve deafness and interstitial keratitis comprise the Hutchinson triad. Diagnosis is often made on the result of the VDRL test, but it should be noted that this test may give false positive results and that there are more specific tests. A reactive VDRL in a newborn may be due to the passive transfer of maternal antibodies across the placenta and a rising titer will indicate the presence of the disease.

Management
The management of maternal syphilis and children with congenital syphilis is described in the PAHO (2011) publication.

Counselling: The client with a sexually transmitted infection should be counselled and informed about the particular infection.

Contact Tracing: A careful history should be taken and efforts should be made to identify the sexual partners. They should also undergo testing and treated if necessary.

Treatment: The drug of choice for syphilis is Benzathine Penicillin G. Patients sensitive to penicillin may be treated with Erythromycin or Tetracycline but the latter is contraindicated in pregnant women.

The client should be treated adequately and advised to take the full course of medications to prevent drug resistance. The partner (s) should also be treated.

Contraceptives: The clients should be advised on the role of condoms in reducing the incidence of STIs. He/she should also be advised to always use a condom to reduce the risk of being infected again.


Caribbean Public Health Agency © 2014