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Infectious Diseases in Ob-Gyn

Paul R. Summers, M.D.
Associate Professor
Department of Obstetrics and Gynecology

Objectives

Definitions

Outline

Take Home Points






Objectives

At the end of this lecture you should be able to:

  1. Recognize clinical signs and symptoms of common types of vaginitis

  2. Recognize clinical signs and symptoms of common sexually transmitted diseases

  3. Understand basic vaginitis and sexually transmitted disease therapy

  4. Understand the basic issues of HIV in women

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Definitions

Strawberry Cervix:  diffusely visible punctate cervical erythema

Cobblestone Vagina:  Thickening of the natural vaginal folds due to chronic vaginitis

Mucopurulent Endocervicitis:  yellow or brown pus in the endocervical canal

Dysplasia:  pre-cancerous change in the cervical epithelium

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Outline

  1. Lower Tract Infections

  2. Upper Tract Infections

  3. Sexually Transmitted Diseases

  4. HIV in Women

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Outline

  1. Lower Tract Infection

    1. Candida

      1. typically Candida albicans but non-albicans rising prevalence

      2. sexual transmission not clinically significant

      3. epithelial microtrauma probably allows infection to develop

      4. immunocompromise must be considered in recurrent cases
        1. AIDS
        2. endocrinopathies
        3. autoimmune diseases (Lupus, RA, temporal arteritis)
        4. leukemia, lymphoma, etc
        5. patients on chemotherapy

      5. responds well to topical antifungal agents

      6. 150 mg fluconazole now approved as single oral dose therapy

    2. Trichomonas

      1. strawberry cervix, cobblestone vagina

      2. sexually transmitted

      3. responds well to metronidazole

    3. Bacterial Vaginosis

      1. related to loss of hydrogen peroxide-producing lactobacilli

      2. associated with Gardnerella and Mobiluncus species

      3. pathogen that inhibits lactobacilli has not been identified

      4. sexually transmitted in most cases
        1. but treatment of male not usually necessary
        2. instigating microbe autoeliminates after a few days?

      5. responds well to metronidazole or cleocin (oral or topical)

      6. similar to an abscess in types and numbers of organisms


  2. Upper Tract Infection

    Salpingitis

    1. initially due to gonococcus

    2. quickly becomes polymicrobial (aerobic/anaerobic)

    3. actinomyces can cause unilateral salpingitis (oophoritis)

    4. role for chlamydia postulated but not proven

    5. broad spectrum antibiotic therapy is necessary


  3. Sexually Transmitted Diseases

    1. Human Papillomavirus Infection

      1. strains 6,11--low malignant potential

      2. strains 16, 18--potential for malignant transformation

      3. virus persist for many years in the genital epithelium

      4. high prevalence (30% of college students PCR positive)

      5. therapeutic goal is generally cosmetic

      6. high recurrence (persistence) rate with standard therapies cryotherapy, podophyllin, bichloroacetic acid, laser

      7. add local interferon injections for recurrent cases

    2. Chlamydia

      1. significant pathogen for men (urethral strictures, Reiter's)

      2. significant pathogen for infants (conjunctivitis, pneumonia)

      3. potential pathogen for women (immune salpingitis?)

      4. produces mucopurulent endocervicitis in some cases

      5. responds well to tetracycline, erythromycin

      6. single dose therapy with 1 gm azithromycin

    3. Gonorrhea

      1. 50% of patients will also have chlamydia

      2. less than 3% of strains produce penicillinase

      3. produces mucopurulent endocervicitis in some cases

      4. significant risk for salpingitis

      5. responds well to ceftriaxone, quinolone antibiotics

    4. Herpes simplex

      1. clinical virulence may be declining?

      2. high risk of spread to other sites (eyes) and to others

      3. responds well to acyclovir

    5. Syphilis

      1. rising prevalence

      2. a rash in an adult is syphilis until proven otherwise

      3. benzathine penicillin is standard therapy

      4. we need new therapies
        1. AIDS patients progress in spite of penicillin
        2. penicillin-allergic patients present a problem

    6. Chancroid

      1. epidemic in coastal cities

      2. incidence in men 10 times females

      3. results in painful lymphadenopathy

      4. responds well to ceftriaxone, erythromycin

      5. H. ducreyi produces penicillinase

    7. Hepatitis B

      1. infection is generally asymptomatic

      2. 50% of carriers do not show hepatitis risk factors

      3. up to 30% risk of perinatal spread from maternal carrier

      4. infectious risk is greatest if mother surface and E antigen +

      5. all infants should be vaccinated for hepatitis


  4. HIV in Women

    1. 11% of U.S. HIV cases are female

    2. 6th leading cause of death in young women in 1989

    3. 6000 HIV infected deliveries in the U.S. per year

    4. In Africa, 5-10% of infants HIV positive, 40% of 30-34 year olds positive

    5. risk of perinatal transmission is 10-50% (average around 25%)

    6. maternal factors increase the risk of transmission:

      1. preterm labor before 34 weeks

      2. severity of mother's illness

      3. prior delivery of an infected infant

      4. immunocompromise

      5. prolonged labor

    7. C-section may lower the rate of HIV transmission in asymptomatic cases

    8. pregnancy probably does not alter course of maternal HIV

    9. ziduvidine is offered during pregnancy

      1. if CD4 count is low

      2. as prophylaxis to lower perinatal transmission rate to 8%

    10. Female to male heterosexual transmission rate is lower than Male to Female

      1. Virus is in semen, cervical secretions, blood

      2. CD4 receptor sites are not prevalent in the vagina

    11. inflammation causes CD4 lymphocytes, macrophages, Langerhans cells to appear in the vagina

    12. rapid progression of dysplasia to invasive cervical cancer in AIDS

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Take Home Points

  1. The pathophysiology of vulvovaginal candidiasis is not well understood.

  2. Vulvovaginal candidiasis should respond well to any oral or topical antifungal agent.

  3. It is not generally necessary to treat the male for Bacterial Vaginosis.

  4. Limited-spectrum therapy that only covers the gonococcus is only appropriate for asymptomatic gonorrhea carriers.

  5. Broad-spectrum therapy that also covers gram positive bacteria and anaerobic bacteria is necessary for all cases of symptomatic salpingitis.

  6. The main goal of genital Human Papillomavirus infection is cosmetic, and may not influence transmission rate.

  7. Endocervical chlamydia and gonococcal infection is often totally asymptomatic.

  8. A rash in an adult is syphilis (or early HIV infection) until proven otherwise.

  9. The risk of transmission of HIV to the newborn of an HIV-infected mother can be decreased by 2/3 if prenatal, intrapartum, and postpartum ziduvidine is administered.

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