Sexually Transmitted Infections (STIs) and Perinatal Infections

What should woman to taught about preventing vulvovaginitis?

- DO NOT DOUCHE! - Cotton undies are BEST - Avoid tight-fitting clothing (especially tight jeans). - Limit time spent in damp exercise clothes (especially swimsuits, leotards, and tights). - Limit exposure to bath salts or bubble bath. - Avoid colored or scented toilet tissue. - Discontinue use of feminine hygiene deodorant sprays. - Use condoms and void before and after intercourse.

What are maternal effects of herpes?

- Painful genital lesions - Primary infection will have fever, malaise, myalgia - Lymphadenopathy - Urinary retention

What are the 3 methods for preventing HPV?

1) *Gardasil vaccine* - which is typically given to girls and boys between the ages of 11 or 12 2) *Cervarix* - another vaccine which should be given before the first sexual encounter 3) *Condom use*

What should pregnant women be taught to prevent toxoplasmosis?

1) AVOID drinking untreated water 2) Wear gloves during any contact with soil or sand 3) Do NOT handle cat litter 4) Eat well cooked meat and wash hands thoroughly 5) Wash fruits and veggies well 6) AVOID sushi

How is CMV treated?

1) NO current treatment except Gancylovir 2) Treat symptoms 3) Place on isolation precautions 4) Prevent by teaching women to wash their hands thoroughly after handing diapers or toys

What should be done for HIV+ woman? What about when they become pregnant?

1) Pap smears should be done *every 6 months* and they should be screened for other STIs. 2) Oral ZDV (zidovudine) should be started between *14-34 weeks* and continued until labor. 3) The newborn should receive oral ZDV for *6 weeks* to decrease the risk of transmission 4) Breastfeeding is *contraindicated*! 5) Baby should be tested AFTER 6 weeks since after birth, they will automatically have a POSITIVE result, not necessarily because the have HIV, but because the test will look for HIV antibodies in the blood and will find them because of maternal transmission.

What are the 4 modes of transmission for Toxoplasmosis?

1) Raw meat 2) Cat feces 3) Contaminated soils 4) Placenta It can NOT be transmitted to others!

What are nursing implications for Rubella?

1) Rest and mild analgesics for mom 2) Place mom on *droplet isolation* 3) Therapeutic abortion 4) Vaccination is CONTRAINDICATED during pregnancy! - May be done after delivery and subsequent breastfeeding will be fine (however conception is avoid for a month)

What maternal infections do we worry about perinatally?

1) TORCH infections 2) Group B Strep 3) HIV

What is the treatment and nursing implications for HSV?

1) Treat with antivirals - *IV Acyclovir* - Vidarabine ointment 2) C/S is indicated if lesions are present 3) AVOID use of scalp electrodes and pH.

What are nursing implications for HIV?

1) Triple drug regimen and/or zidovudine (ZDV) should be initiated at 14-34 weeks or earlier! 2) C/S may be indicated 3) *AVOID* FSE, IUPC, scalp pH, or amnicentesis 4) DELAY rupture of membranes - ROM for greater than 4 hours increases the risk of transmission 5) NO BREASTFEEDING 6) Wipe newborn secretions immediately 7) Give eye prohylaxis and Vitamin K after their bath 8) Start them on AZT 8-12 hours after birth!!!

What are nursing implications for Hepatitis B?

1) Vaccinate mom - SAFE during pregnancy! 2) *AVOID* internal monitoring and related procedures 3) Administer Hep. B vaccine and immunoglobulins 4) *Breastfeeding in NOT contraindicated!!!* - assuming vaccine and IgGs were given. 5) Follow universal precautions when dealing with bodily fluids

Is a history of genital herpes an indication for C/S?

A *history of herpes* is NOT an indication for a C/S. If mom has a history and hasn't had an outbreak in a long time, she at least has antibodies that she passed to the baby to help fight the infection IF it presents, so it won't be as dangerous, so if visible lesions are NOT present at onset of labor, vaginal birth is acceptable! However, C/S within 4 hours after labor begins or membranes rupture is recommended if visible lesions are present!

How is GBS discovered? What are risk factors?

ALL pregnant women are screened at 35-37 weeks! Risk factors include: - Positive GBS culture or urine - Preterm birth of < 37 weeks gestation - ROM > 12 hours - Intra-amniotic infection - Previous delivery of an infant with GBS disease

What is HPV? How is it diagnosed

Human Papilloma Virus (HPV) also known is "genital warts" is a common viral infection that results in cauliflower-like projections and it is associated with cervical cancer! It is diagnosed with a physical exam or HPV-DNA testing via a Pap smear.

What is rubella? How is it transmitted?

It is a HIGHLY teratogenic virus for baby if exposed in the first three months. It is transmitted via nasopharyngeal secretions (respiratory droplets) to transplacental.

What is syphilis? How is it treated?

It is a potentially devestating bacterial infection that woman should be screened for at *the first prenatal visit* and repeat RPR in the *third trimester* It is treated with *Benzathine Penicillin* (or doxycycline/tetracycline for those with an allergy)

What is Trichomoniasis? What is an important consideration for this?

It is a vaginal infection caused by *protozoa* that result in *yellow-greenish, frothy discharge* *The partner HAS to be treated!!!*

What is a yeast infection?

It is a vaginal infection caused by the fungi candida albicans (typically from antibiotic use) and results in: - *White curdy discharge* that is odorless - *Budding hyphae and WBCs* It is treated with *Fluconozole*

What is bacterial vaginosis? How is it treated?

It is a vaginal infection where there is overgrowth of gardnerella which results in: - *Grey thin discharge that has a FISHY odor* - pH *greater than 4.5* - Presence of *clue cells* under the microscope It is treated with *Metronidazole*

What is genital herpes? How is it treated?

It is a viral infection caused by the herpes simplex virus (HSV-2). It is often manifested by painful lesions, however, in a woman with a good immune system, it is possible for the infection to become latent (hide) and then present itself when the woman is stressed or immunocompromised (like pregnancy or labor...) which can be dangerous for the baby since mom hasn't made any antibodies for it. It is treated with *Acyclovir*

What is Cytomegalovirus?

It is a viral infection of the herpes family which is not routinely tested for prenatally.

How is chlamydia diagnosed?

It is diagnosed through a *culture*. Young woman should be screened for it yearly and pregnant woman should be screened for it during the FIRST prenatal visit.

How is CMV transmitted?

It is primarily transmitted by close contact with infected secretions. It can also be transferred through droplets, sexual contact, and congenitally.

What is chlamydia?

It is the most common bacterial infection which is asymptomatic, but can be detrimental to the mother because it can cause inflammation in that vagina that can block the fallopian tubes causes *infertility* More importantly, if the mother has an unknown active infection and the baby is exposed to it in the vagina, it can get into their eyes and respiratory tract causing conjunctivitis leading to blindness and pneumonia.

What is gonorrhea? How is it treated? What is an important consideration?

It is the second most common bacterial infection which may also be asymptomatic. It is treated with *Ceftriaxone*. It is also important to consider the close to HALF of woman with gonorrhea have a concurrent chlamydia infection, so it is important to culture for BOTH because they are treated *DIFFERENTLY*!

How is GBS transmitted?

It is transmitted "vertically" at ROM or at the time of birth through the colonized birth canal. It can also be transmitted "horizontally" after birth.

How is Hepatitis B transmitted?

It is transmitted through direct contact with infected *blood or body fluids* such as: - During sex - Blood - Stool, saliva, *breast milk* - Shared needles, razors, toothbrushes, towels, etc. - Tattoos - *Perinatal, transplacental, and during delivery*

How is HIV transmitted?

It is transmitted through: - Sexual contact - In utero near time of delivery - Contaminated needles or other sharp objects - Blood, semen, cervical secretions, and breastmilk

How is herpes simplex (HSV) transmitted?

It is transmitted via: - Intimate mucocutaneous exposure - Passage through the birth canal - Ascending infection with ROM - Transplacental with initial infection during pregnancy

How is chlamydia treated? Does the partner need to be treated?

It is treated with one dose of *Azithromycin* THE PARTNER *NEEDS* TO BE TREATED!!!

What are the maternal and fetal effects of HIV?

Maternal symptoms include fever, malaise, fatigue, A/N/V/D, weight loss, generalized lymphadenopathy and *opportunistic infections*

What are maternal and fetal effects of rubella?

Maternal symptoms include rash, lymphadenopathy, fever, malaise, headache, and arthralgia. If exposed in the first trimester, fetal effects include: - Deafness - Eye defects - Congenital heart defects - CNS anomalies

What are maternal and fetal effects of CMV?

Most infections are asymptomatic, but some experience mono-like symptoms. Neonatal effects include: - IUGR - Microcephaly - Hepatoslenomegaly and jaundice - CNS abnormalities - Developmental disability - Intracranial calcifications - Deafness - Blindness

What maternal and fetal effects does Toxoplasmosis have?

Most women are asymptomatic, but some can have lymphadenopathy, fatigue, myalgia, or preterm labor. Fetal effects include: - Permanent disabilities - Hepatosplenomegaly - Anemia - Neurologic Disease - Hydrocephalus

How is HPV treated?

Patients can apply Imiquimod (Aldara) cream or Podofilox gel. The provider can administer Cryotherapy (liquid nitrogen), Bichloroacetic acid, or surgically remove the warts.

What are maternal and fetal effects of GBS?

Pregnant woman are usually asymptomatic, but may have chorioamnionitis, endometritis, or UTIs. It can cause SIGNIFICANT morbidity and mortality in infants!!! Effects include: - Respiratory distress - Lethargy, poor feeding, glucose instability - Temperature instability - Sepsis - Pneumonia - Meningitis

What are nursing implications for GBS?

Prophylaxis with *Penicillin or Ampicillin* should be given AT LEAST 4 before birth to those with: 1) A previous infant with GBS disease 2) Positive GBS culture or urine 3) Unknown GBS status AND either: - Deliver at less than 37 weeks - Intrapartum temperature greater than 100.4 F (or 38 C) - ROM for longer than 18 hours A sepsis workup should be done for symptomatic newborns and they should be treated with Ampicillin and Gentamycin for 48 hours until culture results! :(

What are fetal effects of herpes simplex?

RISK OF MISCARRIAGE! If local, it results in lesions of the skin, eyes and mouth. If disseminated or widespread, it can involve any organ such as the adrenal glands, liver, or lungs, resulting in death...

What maternal and fetal effects does Hepatitis B have?

Symptoms for the mother include: - Low grade fever - Jaundice - Hepatomegaly - Malaise, fatigue, loss of appetite, muscle aches - Nausea - Premature labor It does *NOT* cause birth defects, however, infants infected at birth have a 90% risk of chronic infection (carrier state) and a 25% chance of liver disease!

What is TORCH?

TORCCHHH stands for: - *T*oxoplasmosis - *O*ther (Varicella, Gonorrhea, Syphilis) - *R*ubella - *C*ytomeglovirus and *Chylamida* - *H*erpes Simplex (HSV), *H*epatitis B, *H*IV

Why do we worry about TORCH infections?

They all cross the placenta and are teratogenic meaning they cause significant PHYSICAL defects! :(

What should woman with genital herpes be taught?

They should be taught to abstain from sexual activity when lesions or prodromal symptoms present!

What do woman taking Metronidazole?

Women being treated with Metronidazole for BV or Trich should be told: Do *NOT* use any alcohol when you're on this med!!!