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:
Recognize clinical signs and symptoms of common types of vaginitis
Recognize clinical signs and symptoms of common sexually transmitted diseases
Understand basic vaginitis and sexually transmitted disease therapy
Understand the basic issues of HIV in women
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
Outline
Lower Tract Infections
Upper Tract Infections
Sexually Transmitted Diseases
HIV in Women
Outline
Lower Tract Infection
Candida
typically Candida albicans but non-albicans rising prevalence
sexual transmission not clinically significant
epithelial microtrauma probably allows infection to develop
immunocompromise must be considered in recurrent cases
AIDS
endocrinopathies
autoimmune diseases (Lupus, RA, temporal arteritis)
leukemia, lymphoma, etc
patients on chemotherapy
responds well to topical antifungal agents
150 mg fluconazole now approved as single oral dose therapy
Trichomonas
strawberry cervix, cobblestone vagina
sexually transmitted
responds well to metronidazole
Bacterial Vaginosis
related to loss of hydrogen peroxide-producing lactobacilli
associated with Gardnerella and Mobiluncus species
pathogen that inhibits lactobacilli has not been identified
sexually transmitted in most cases
but treatment of male not usually necessary
instigating microbe autoeliminates after a few days?
responds well to metronidazole or cleocin (oral or topical)
similar to an abscess in types and numbers of organisms
Upper Tract Infection
Salpingitis
initially due to gonococcus
quickly becomes polymicrobial (aerobic/anaerobic)
actinomyces can cause unilateral salpingitis (oophoritis)
role for chlamydia postulated but not proven
broad spectrum antibiotic therapy is necessary
Sexually Transmitted Diseases
Human Papillomavirus Infection
strains 6,11--low malignant potential
strains 16, 18--potential for malignant transformation
virus persist for many years in the genital epithelium
high prevalence (30% of college students PCR positive)
therapeutic goal is generally cosmetic
high recurrence (persistence) rate with standard therapies cryotherapy, podophyllin, bichloroacetic acid, laser
add local interferon injections for recurrent cases
Chlamydia
significant pathogen for men (urethral strictures, Reiter's)
significant pathogen for infants (conjunctivitis, pneumonia)
potential pathogen for women (immune salpingitis?)
produces mucopurulent endocervicitis in some cases
responds well to tetracycline, erythromycin
single dose therapy with 1 gm azithromycin
Gonorrhea
50% of patients will also have chlamydia
less than 3% of strains produce penicillinase
produces mucopurulent endocervicitis in some cases
significant risk for salpingitis
responds well to ceftriaxone, quinolone antibiotics
Herpes simplex
clinical virulence may be declining?
high risk of spread to other sites (eyes) and to others
responds well to acyclovir
Syphilis
rising prevalence
a rash in an adult is syphilis until proven otherwise
benzathine penicillin is standard therapy
we need new therapies
AIDS patients progress in spite of penicillin
penicillin-allergic patients present a problem
Chancroid
epidemic in coastal cities
incidence in men 10 times females
results in painful lymphadenopathy
responds well to ceftriaxone, erythromycin
H. ducreyi produces penicillinase
Hepatitis B
infection is generally asymptomatic
50% of carriers do not show hepatitis risk factors
up to 30% risk of perinatal spread from maternal carrier
infectious risk is greatest if mother surface and E antigen +
all infants should be vaccinated for hepatitis
HIV in Women
11% of U.S. HIV cases are female
6th leading cause of death in young women in 1989
6000 HIV infected deliveries in the U.S. per year
In Africa, 5-10% of infants HIV positive, 40% of 30-34 year olds positive
risk of perinatal transmission is 10-50% (average around 25%)
maternal factors increase the risk of transmission:
preterm labor before 34 weeks
severity of mother's illness
prior delivery of an infected infant
immunocompromise
prolonged labor
C-section may lower the rate of HIV transmission in asymptomatic cases
pregnancy probably does not alter course of maternal HIV
ziduvidine is offered during pregnancy
if CD4 count is low
as prophylaxis to lower perinatal transmission rate to 8%
Female to male heterosexual transmission rate is lower than Male to Female
Virus is in semen, cervical secretions, blood
CD4 receptor sites are not prevalent in the vagina
inflammation causes CD4 lymphocytes, macrophages, Langerhans cells to appear in the vagina
rapid progression of dysplasia to invasive cervical cancer in AIDS
Take Home Points
The pathophysiology of vulvovaginal candidiasis is not well understood.
Vulvovaginal candidiasis should respond well to any oral or topical antifungal
agent.
It is not generally necessary to treat the male for Bacterial Vaginosis.
Limited-spectrum therapy that only covers the gonococcus is only appropriate for asymptomatic gonorrhea carriers.
Broad-spectrum therapy that also covers gram positive bacteria and anaerobic bacteria is necessary for all cases of symptomatic salpingitis.
The main goal of genital Human Papillomavirus infection is cosmetic, and may not influence transmission rate.
Endocervical chlamydia and gonococcal infection is often totally asymptomatic.
A rash in an adult is syphilis (or early HIV infection) until proven otherwise.
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.