STI Recognition and Treatment 2011
By Tara Daystar
Herpes Simplex Virus (HSV) – (two serotypes: HSV-1 and HSV-2) No cure for HSV. Instruct future use of condoms during sexual exposure. Antiviral therapy not recommended for women without clinical manifestations of infection.
Primary site of initial infection: genital or oral areas-skin and mucus membranes S/S: with genital herpes usually area becomes sensitive and inflamed and is often accompanied by swollen glands in the groin. Within a few days, this area erupts into sores that become small red blisters. At rupture the blisters bleed or weep a clear fluid. After 5-7 days a crust forms on them then they heal and disappear until next outbreak. Specific ulcers diffuse inflammation and friability may be noted over the cervix and vaginal walls. Possible vaginal or urethral discharge. Vulvar lesions extremely painful/ may be itching, swelling. May experience tender inguinal lymphadenopathy. Often reoccurring with lesser severity. Often preceded by fever, stress, itching or tingling, burning. Complications in Pregnancy: transmitted to baby in approximately 50% of vaginal births by mothers with active infection. If transmitted at birth may result in neonatal death in approximately 60% those infected or severe central nervous system or ocular damage. Baby may also contract HSV through an ascending infection in case of ROM. If herpes acquired in first half or late part of pregnancy, high risk of transmission to baby. Pregnancy Regimen: Suppressive therapy may be used although it does not totally eliminate viral shedding or potential for transfer to baby or partner. Treat primary and nonprimary first episodes and recurrent episodes with acyclovir. May continue with suppressive therapy for duration of pregnancy; for women with hx of HPV, mayuse suppressive therapy starting at 36 weeks to reduce potential of recurrence at term; systemic acyclovir crosses the placenta, is concentrated in amniotic fluid and breast milk and reaches therapeutic levels in the fetus. Natural support: B-vitamin rich foods and supplement, use safe herbs during pregnancy to support immune system and reduce stress –Echinacea, skullcap. Avoid chocolate, nuts (arginine) sugars. Increase lysine and vit. C If active herpes lesions at time of labor= c-sec. If water breaks and lesions=immediate c-section.
Pelvic Inflammatory Disease (PID)– (Neisseria gonorrhoeae or Chlamydia trachomatis and possible bacteria vaginoso). Primary site of initial infection: begins as a lower genital tract infection, which then ascends, eventually leading to inflammatory process in the tubes and inflammation of the peritoneum. S/S: lower abdominal pain bilaterally, vaginal/cervical mucopurulent discharge indicative of infecting organism, dysuria, frequency, urgency. Metrorrhagia. If fever above 101F and nausea/vomiting present, can be severe. Upon pelvic examination, cervical motion tenderness, bilateral adnexal tenderness and adnexal enlargement. Leukocytes will outnumber epithelial cells in a wet mount. Complications in Pregnancy: Increased risk of ectopic pregnancy. Pregnancy Regimen: treat empirically in presence of cervical motion tenderness or uterine adnexal tenderness and no other cause of pain. IUD’s should be removed. Hospitalize for parenteral antibiotics; contraindicated for oflocin, levofloxacin, doxycycline. Ensure sexual partner treated during 60 days preceding woman’s symptoms imperative to prevent reinjection.
Syphilis (primary, secondary, early latent) – (spirochete bacteria Treponema pallidum) Primary site of initial infection: through placenta, through chancre, primary ulcerous lesion at site of infection. Appears 10-90 days after infection, and in women is most common in the genital area, on the clitoris, labia, fourchette, vulva or cervix. test all patients with syphilis for HIV infection. S/S: chancre/lesion on body especially mucus membranes or rash (esp. hands and feet), symptoms of a systemic illness: low grade fever, sore throat, hoarseness, malaise etc. Condylomata are highly contagious flat, moist wart-like lesions. Latent syphilis has no clinical manifestations. Tertiary syphilis can occur with tumors, teeth and organ malformation, diseases and death. Neurosyphilis can occur in any stage of syphilis. S/S: cranial nerve palsies, personality changes, loss of reflexes…). May also present as meningitis, syphilis of the spinal cord, vascular neurosyphilis or eye disease.
S/S placenta: abnormally large and heavy with a pale yellowish-gray color.
Complications during pregnancy: can be passed to baby through placenta, or infect baby in the birth canal, or post birth during maternal care giving. Risk of still birth, congenital infection, malformation, lesions and death for baby (part of TORCH). Treatment to the mother can also harm baby but is considered the lesser risk. Mothers with syphilis face risks if not treated as their overall health and neurologic stability is jeopardized. Pregnancy Regimen: pregnant women who have primary, secondary, or early latent syphilis may have two doses of benzathine penicillin G, 2.4 million units IM, and the second occurring 1 week after the initial dose. Doxycycline and tetracycline are contraindicated in pregnancy. Women who are allergic to penicillin should be treated with penicillin after desensitization. (late latent, latent of unknown duration or tertiary) – receive a total of three benzathine penicillin G, 2.4 million units, administered in three doses at 1 week intervals. Natural support: cleansing, immunse supporting herbs like burdock and Echinacea, goldenseal. Lemon juice and pure diet.
Gonorrhea – (gram negative bacteria Neisseria gonorrhoeae) Primary site of initial infection: lower genital tract. Often asymptomatic until infection has ascended to upper genital tract and PID noted or other problems. S/S: lower abdominal pain, urethritis with tenderness, urinary frequency and dysuria, tenderness or expression of purulent discharge from Skene’s or Bartholin’s glands or urethra, acute PID in the non-pregnant woman, history of vaginal discharge, metrorrhagia and menorrhagia, yellowish, purulent, or mucopurulent vaginal discharge. Diagnosis by culture or DNA probe. If present, also treat for Chlamydia and syphilis. Ensure partner is evaluated and treated. Quinolones (ciprofloxacin, ofloxacin, levofloxacin) contraindicated for pregnancy. Pregnancy Regimen: treat with cephalosporin. If unable to tolerate use spectinomycin. TOC unnecessary if asymptomatic after treatment or reinfection not suspected.
Chlamydia– (Chlamydia trachomatis) – Primary site of initial infection: Most prevalent STI. Pregnancy Complications: can result in ophthalmai neonatorum and chlamydial neonatal pneumonia. In the mother a number of urogential infections can occur: endocervicitis, salpingitis, PID, urethritis, cystitis and postpartum infection. Chlamydia is also implicated in infertility, ectopic pregnancy, premature rupture of the fetal membranes and preterm labor/preterm delivery. Often found coexisting with Trichomonas and gonorrhea S/S: 50% unsymptomatic but if symptomatic could include: mucopurulent discharge from cervix, edematous, congested cervix with ectropy of the columnar epithelial cells. There will not be vaginal symptomatology as it does not infect the squamous epithelial cells. Pregnancy Regimen: treat presumptively for Chlam. if client has gonorrhea as high incidence of coexisting infection. Abstain from sex for 7 days and until all sex partners cured. TOC needed if pregnant even if no continuing symptoms. The treatments Doxycycline and erythromycin estolate are contraindicated in pregnancy. erythromycin base 500mg po QIDx7days. If not tolerated, amoxicillin 500mg TIDx7 days instead. Natural remedies: echinacea and especially Goldenseal
Condylomata– (human papilloma virus –clinical, subclinical, and latent) Primary site of initial infection: occurs through direct contact with the virus. 3-month incubation period (although may occur anytime 3 weeks to 8 months) They occur in the anal area and penis in men and the anal area and vagina/cervix, urethral, vulvar areas in women. Most common STD in USA. Pregnancy Complications: women with HPV should also be screened for syphilis, gonorrhea, Chlamydia, Trichomonas and BV. HPV condylomata often increase in size and number in pregnancy. If birth occurs while condylomata present, care must be taken to avoid tearing or cutting as bleeding may be excessive. Extensive growth in vagina and over cervix may necessitate c-section. Pediatrician should be notified of baby born vaginally to woman with condylomata as baby has increased risk of developing laryngeal papillomatosis. C-section does not eliminate this risk. Cancer risks: HPV disease carries the risk of developing a dysplasia (pre-malignancy) and squamous cell carcinoma (cancer of the anal canal). Types 16, 18, 31 considered high-risk as have potential to produce tumors, especially malignant tumors. Of many types of HPV, <1% develop cancer. . The greatest risk factor for HPV disease is immunosuppression (diseases, such as HIV infection). S/S: may start as single growths but usually come together in clumps. appear as white raised irregular lesions, often with “cauliflower-like” appearance –although some are pigmented or flat. May be visible outside anus/vagina, or be hidden inside. Pregnancy Regimen: Pediatrician should be notified of baby born vaginally to woman with condylomata as baby has increased risk of developing laryngeal papillomatosis. C-section does not eliminate this risk. Treatment during pregnancy directed toward reducing possibility of condylomata complicating delivery. Even with surgical removal, there is a high incidence of regrowth. “As there is the possibility of spontaneous resolution of the warts and treatment is not without side effects, a woman may choose not to be treated” (Varney’) cryotherapy with liquid nitrogen can be used on external genital, vaginal, urethral meatus and anal warts. Cryoprobe may be used on external warts only. Acids (trichloroacetic or bichloroacetic) may also be used on external genital, vaginal and anal warts. Podofilox, imiquimod, and podophyllin contraindicated during pregnancy. In the long term, treatment of both interior and exterior warts is recommended to increase efficacy. Annual pap spears recommended.
Natural support: quite or reduce smoking, increase Vitamin C, A and B, Zinc and Selenium and immune enhancing foods/herbs (Echinacea).
Gladstar, Rosmary. Herbal Healing for Women. New York: Fireside, 1993.
Murray, Michael & Joseph Pizzorno. Encyclopedia of Natural Medicine. Rocklin,CA: Prima Publishing, 1991.
Varney, et al. Varney’s Midwifery, 4th Edition. Boston: Jones andBartlett Publishers, 2004.