Sexually Transmitted Diseases

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Gonorrhea and Chlamydia. Infection with Neisseria gonorrhoeae and/or Chlamydia trachomatis may have a deleterious effect on both mother and fetus, including preterm delivery, premature rupture of membranes, chorioamnionitis, and postpartum infection. Because of these consequences and the fact that the majority of gonorrheal and chlamydial infections are asymptomatic during pregnancy, routine endocervical culture is indicated in high-risk populations. Primary treatment of gonorrhea infections during pregnancy is ceftriaxone administered intramuscularly at 125 mg once or spectinomycin in penicillin-allergic patients. Alternatives to the tetracyclines and quinolones that are used for the treatment of chlamydial infection but are contraindicated during pregnancy include erythromycin and amoxicillin.

Bacterial Vaginosis. Bacterial vaginosis is a common syndrome in which the normal, lactobacillus-predominant vaginal flora is replaced with multiple organisms, including Gardnerella vaginalis, Mycoplasma hominis, and anaerobic bacteria. It is one of the most common genital infections found during pregnancy, with between 12% and 22% of gravid women affected. Bacterial vaginosis has been associated with preterm delivery, premature rupture of membranes, chorioamnionitis, and postpartum infection. A recent study confirms the association between bacterial vaginosis and the preterm delivery of low-birth-weight infants. Though screening and treatment of bacterial vaginosis during pregnancy may significantly reduce the risk of preterm birth in the general population, further prospective, randomized clinical trials are needed to help establish practice guidelines for the treatment of this syndrome in all pregnant women. Currently, screening is generally advocated for women at high risk for delivering a premature infant.

Syphilis. Because of its detrimental fetal and maternal effects, including congenital disease, syphilis must be treated as soon as the diagnosis is confirmed by specific serologic tests. Nonspecific serologic tests (Venereal Disease Research Laboratory [VDRL], rapid plasma reagin [RPR]) should be performed monthly after treatment. Rising titers indicate inadequate therapy.

Herpes Simplex. The incidence of neonatal herpes simplex virus (HSV), which includes central nervous system infection leading to mental retardation and sometimes death, appears to be increasing as genital herpes becomes more common. Exposure of the infant to HSV can often be prevented by cesarean delivery if maternal genital herpes lesions are recognized at the onset of labor. Unfortunately, most neonatal HSV infections result from asymptomatic maternal shedding of HSV, as indicated by the fact that only one third of the mothers of infants with neonatal herpes have signs of HSV infections.

Recently, the Infectious Disease Society for Obstetrics-Gynecology has endorsed the following recommendations for women with a history of genital herpes.
A. In women with a history of genital herpes, but without lesions:1. Weekly prenatal cultures should be abandoned because there is poor predictive value for identifying the patient who will be shedding virus at the time of delivery.

2. In the absence of genital herpetic lesions, vaginal delivery should be expected (unless other indications for cesarean delivery are present).

3. To identify potentially exposed neonates, a culture for herpes virus may be obtained from either the mother on the day of delivery or from the neonate.

4. Isolation is not necessary for the mother.

5. It is recognized that, with such a policy, there is a small risk (approximately 1 per 1000) of neonatal infection.
B. In women with herpetic lesions of the genital tract when either labor or membrane rupture occurs:

6. Cesarean delivery can reduce the risk of neonatal herpes virus infection.

7. Ideally, cesarean delivery should be performed before or within 4 to 6 hours of membrane rupture, but it may be of benefit in preventing neonatal herpes regardless of duration of membrane rupture.
C. In women with genital herpetic lesions at or near term, but before labor or membrane rupture, cultures collected at 3- to 5-day intervals may be performed to ensure the absence of virus at the time of birth and to increase the likelihood of vaginal delivery.

RELATED STORIES:
Viral Infections   Toxoplasmosis

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