Sexually Transmitted Infections – Part 3

Syphilis

Transmission “is thought to be by entry in the subcutaneous tissue through microscopic abrasions that can occur during sexual intercourse (Lowdermilk & Perry, 182)”. It also can be transmitted through kissing, biting, and oral-genital sex.

The rate of transmission declined from 1995-2004. Syphilis continues to be at a high rate in the southern states.

Primary syphilis appears 5-90 days after as a lesion or chancre, usually painless. Then it erodes into an ulcer appearing sore.

Secondary syphilis occurs 6 weeks to 6 months after transmission. Its appearance is a widespread, symmetric rash on the palms and soles of the feet; with affected lymph nodes. Some individuals also have a fever, headache, and generalized malaise (under-the-weather sensation).

In the vulva, perineum, or anal area Condylomata lata may develop. If left untreated the female may enter a latent phase. If still left untreated, tertiary syphilis will develop, in approximently 1/3 of these women. In this third stage, neurologic, cardiovascular, musculoskeletal, or multi-organ system complications can develop.

Screening and Diagnosis

All women who are diagnosed with another STI or with HIV should have a screen form syphilis. All pregnant women should be screened at the first prenatal visit.

Diagnosis is dependent upon the microscopic exam of primary and/or secondary lesion tissues during the latent or late infection. Serologic tests of antibodies may not be reactive, in early tests.

There may be false-positives with VDRL or RPR screenings. This is not unusual for several reasons, such as: drug addiction or acute infection. To confirm the positive results the use of treponemal tests, fluorescent treponemal antibody absorbed (FTA-ABS) and microheagglutination assays of antibody to T. palidum (MHA-TP) are used to confirm positive results.

Testing should be repeated at 1 to 2 months when genital lesions exist. This is due to early exposure not showing results until 6 to 8 weeks after exposure.

Other STI tests should be done at this juncture, for chlamydia, gonorrhea, et al. HIV should be also offered as a test if indicated.

Management

Penicillin is the preferred drug for treatment. Doxycycline, tetracycline, and erythromycin are alternative treatments. Tetracycline and Doxycycline are contraindicated in pregnancy.

Some pregnant women may get what is known as “Jarisch Herxheimer ” reaction, that may be accompanied with headaches, myalgias, and arthalgias . If the treatment occurs at the second half of pregnancy, it may cause early labor and birth. Their doctor should be contacted if fetal movement stops or if contractions occur.

Women should abstain from sexual activity during treatment and all evidence of primary or secondary syphilis is gone. She should also tell all partners that have been exposed, and that this disease is to be reported.

Sexually Transmitted Infections – Part 2

Gonorrhea

Gonorrhea is exclusively transmitted sexually, genital-to-genital contact; but can also be transmitted oral-to-genital or anal-to-genital. In females the disease can spread from the genitals to the rectal area. It can be spread to the newborn in the form of ophthalmia neonatorum through vaginal birth.

AGE is the most important factor. Statistically, sexually active teens, young adults, and African Americans are at the highest risk. The majority of those who have contracted this disease are under the age of 20.

Girls who are prepubescent the two most common symptoms is vaginitis and vulvitis. There may be signs of infection, or vaginal discharge, dysuria and swollen, reddened labia.

The factor of concern, most adolescent females show no signs or symptoms. When they DO have symptoms they are less pronounced than those of men. In women there may be some cervical discharge, but usually it is minimal of lacking altogether. Irregularity of the menses may be the presenting symptom or complaints of pain within the pelvis.

In rectal gonorrhea, the symptoms may not be asymptomatic or the opposite with severe discharge, pain and blood in the stool. There may be rectal itching, fullness, pressure, and pain…as well as diarrhea.

Since Gonorrhea is a highly transmittable disease all recent partners (30-days prior) should be reported, cultured, and examined. Most treatment failures occur due to reinfection.

Screening and Diagnosis

All pregnant women should be screened at the first appointment. Those women with risky behaviors indicated, should be re-screened at 36 weeks. The screening is done through “cultures”.

Management

45% of those women who are found to have Gonorrhea also have Chlamydia. For both pregnant and non-pregnant women, the treatment should be cefixime in a single dose.

All women with co-existing syphilis infections should be treated as for syphilis. Penicillin is the preferred drug for treatment. The alternative (especially for those allergic to penicillin) is Doxycycline, Tetracycline, and erythromycin. Tetracycline and Doxycycline are contraindicated in pregnant.

Pre-Natal Tests

What are the Different Prenatal Tests Women are Offered?

The following discussion is about tests conducted,
beyond the usual blood panel and vaginal cultures…

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DOPPLER OR ULTRASOUND

As with EFM, there have been questions raised regarding the use of Ultrasound, as to whether it is actually useful and if it is safe. Just like EFM it was in use before the safety of Ultrasound was confirmed. Now it is commonly used, expected by pregnant mothers.

With its use, are three ways in which women are exposed to ultrasound. First, the Doptone used in listening to the fetal heartbeat. Secondly when doctors order its use during exams, in order to check the fetal position and its growth along with the placenta (and take a picture of the baby within the womb). Third, Electronic Fetal Monitoring uses ultrasound to detect the fetal heartbeat.

So is it SAFE? Well, no one really knows for sure. The “problem lies in what happens when energy-containing sound waves strike growing fetal tissues (Sears & Sears, 82).” It is uncertain if the delicate tissues become damaged on a subtle level.

What happens is the sound-waves bombard the tissues, shaking up molecules causing heat. The heating up of the molecules cause gas bubbles of a microscopic size in the cell which are called cavitation. It is uncertain whether the heat or the bumbles damages the cells.

Not like EFM, Ultrasound has improved the practice of Obstetrics. Since it seems to be safer than X-rays, it can be used to give a more precise dating of gestational age of the fetal in early pregnancy. It also is helpful to determine if the placenta has any abnormalities, whether there is more than one fetus, and if there are abnormalities with the fetus.

Unfortunately, no study has been conducted to confirm whether there is an improvement in the outcome of mothers and their babies. Most likely, there never will be any studies, either.

Maternal Serum Alpha-Fetoprotein (MSAFP) Testing
(also known as: Alpha-Feto Protein (AFP) Screen)

The best time for this test is between 15 to 18 weeks gestation. This time frame seems to be best because the results are the most accurate.
(AFT) Alpha-fetoprotein is a substance that is produced by the liver of a fetus. It enters the bloodstream of the mother by way of amniotic fluid and placenta. It is found in the mother’s bloodstream in minute quantities. In pregnancy the level of AFP raises in progression with the duration of pregnancy. An abnormal low or high level is an indication of fetal anomalies.

MSAFP test does not harm a pregnant woman. It does seem to have an unusually high rate of false positives. If a woman has a very high level she may be referred for amniocentesis. She could be subjected to more tests that have higher risks for both herself and baby.

  • AFP increases as the baby grows.
  • It reads as “elevated” for multiples and for neural tube defects.
  • It reads low when the baby has Down’s Syndrome
  • If baby is found to have anomalies then the choices are: abortion, or keep the baby.


AMNIOCENTESIS

How the test is done:

The doctor inserts a long, sterile needle through the abdominal wall and the uterine wall, into the amniotic fluid. The test is conducted with an ultrasound, so that the fetus and placenta can be viewed.

What does the collected Amniotic fluid tell the Doctor?

The fluid contains cells from the fetus that would indicate certain birth defects. Such as: Down’s syndrome, hemolytic anemia (the destruction of red blood cells due to an Rh disease)metabolism disorders, Cystic Fibrosis, and many other diseases. It can tell the doctor the maturity of the lungs if an early labor or Cesarean is indicated.

What are the risks?

Puncture of other areas of the uterine area, such as the umbilical cord, placenta, or another area of the uterus. It can cause infection or miscarriages.

Not only that, but if an inadequate amount of fluid is collected, or the cells of the fetus do not grow in the culture, another test will be necessary.

What Happens then?

  • If the baby is found to have a disorder, then the mother needs to choose what to do next. Does she keep or abort the baby?
  • Is the test able to screen for all disorders of the fetus?No it does not. In fact it can damage the fetus.


CHORIONIC VILLI SAMPLING (CVS)

How is it done?

Tissues are removed from what will develop into the placenta. These tissues are gathered by one of two ways: either through the abdomen or the cervix, using an instrument to collect tissue while looking at the area.

At what point in the pregnancy is the test conducted?

The test is done at the nine to eleven weeks’ gestational point.

What would it indicate?

It would indicate whether there are any chromosomal abnormalities in the fetus. It is not able to detect all the abnormalities that can be seen in an Amniocentesis.

What are the risks of taking this test?

The risks include possible damage to the embryo, damage to the uterus, infection, hemorrhage, and miscarriage. It should not be conducted when an infection is already present, if there is a known Rh factor, or multiple gestations. It has a high false positive rate.


GLUCOSE TOLERANCE TEST (GTT)

This test is conducted around 24-28 weeks of pregnancy, and then repeated again at around 32-34 weeks for high risk mothers.

How is the test done?
A sweet liquid called glucola is given to her and then the blood sugar is checked an hour later. If positive, the doctor may then order the 3 hour test, which is more accurate. Only 15% of the women with abnormal results from the 1 hour test will have the same results in the 3 hour test.

Why would the test be important?

The hormones of pregnancy normally suppress insulin release, allowing more glucose to be released for the developing baby. Occasionally the blood sugar is too high (2-10% of pregnant women) causing blood sugar levels to be raised. This is condition called gestational glucose intolerance or gestational diabetes.

  • A lengthy exposure to the high blood sugar in pregnancy causes the infant to grow exceptionally large.
  • Babies of women with blood sugar issues also tend to be born prematurely and have respiratory problems.
  • The baby may manufacture too much of his / her own insulin instead. The manufacture of too much insulin would cause the baby’s blood sugar to drop quickly and dangerously once born.

Who would be at risk?

High blood sugar during pregnancy is more common in obese women, older women, and those who have a family history of diabetes, or in women who have delivered a baby weighing more than 9 pounds previously. If discovered early in pregnancy, by being tested, the pregnant woman can alter her diet to alleviate the issue of high blood glucose.


X-RAY PELVIMETRY AND / OR FETAL INDEX X-RAY (prelabor or labor)

How is it Done and why?

A series of x-rays are done in which the radiologist measures various dimensions of the pelvic passage in order to determine if it large enough for the baby to pass through safely. These measurements are compared to tables of “normals”.

  • The test is done on a mother whose baby is failing to descend during labor.
  • If delivery is contemplated for a breech birth
  • Or if there is a previous history of a difficult birth because of a presumed cephalopelvic disproportion (CPD)*

What Problems Can it Potentially Create?

The X Ray Pelvimetry is being used less often because of concerns over safety and accuracy. Studies have linked X Ray exposure of the fetus to higher odds of childhood cancers. This correlation is not determined accurate because of conflicting study results.

Considerations Regarding the Pelvic Opening:

What is not considered is that the process of labor is an amazing one, that changes of position such as using squatting, can increase the pelvic outlet by as much as 20%. This test also only considers the outlet, not the size of the baby itself.

A newer technique using measurements of the pelvis by X ray and the size of the baby by ultrasound, called the Fetal Pelvic Index (FPI). It considers the size of the whole baby, not just the head. It is useful for those mothers considering VBAC who have had a previous diagnosis of CPD based upon X rays.

 

* To be discussed in a future blog.  Next topic coming up: Teen Pregnancy and Nutrition