Sexually Transmitted and Other Infections

Sexually Transmitted and Other Infections

LEARNING OBJECTIVES

* Describe prevention of sexually transmitted infections in women.

* Diferentiate signs, symptoms, diagnosis, and management ща nonpregnant and pregnant women with bacterial sexually transmitted infections.

* Examine the care of nonpregnant and pregnant women with selected viral infections (human immunodeficiency virus; hepatitis A, B, C; human papillomavirus).

* Discuss the effect of group β streptococcus (GBS) on pregnancy and management of pregnant clients with GBS.

* Compare and contrast signs, symptoms, and management of selected vaginal infections in nonpregnant and pregnant women.

* Review principles of infection control for human immunodeficiency virus (HIV) and blood-borne pathogens.

 

Sexually transmitted diseases (STDs), or sexually transmitted infections (STIs), are infections or infectious disease syndromes primarily transmitted by close intimate contact (Box 1). These terms, used interchangerably in this text, have replaced the older designation, venereal disease, which described primarily gonorrhea and syphilis. Caused by a wide spectrum of bacteria, protozoa, and ectoparasites (organisms that live on the outside of the body, such as a louse), STIs are a direct t tremendous human suffering, place heavy demands on health care services, and cost hundreds of millions dollars to treat. The term sexually transmitted disease specific for any one disease; rather the term includes than 25 infectious organisms that are transmitted through sexual activity and the dozens of clinical syndromes that they cause (Institute of Medicine, Committee on prevention and Control of Sexually Transmitted Disease, 1997). Despite the U.S. Surgeon General's targeting STIs as a priority for prevention and control efforts, STIs are among the most common health problems in the US (Institute of Medicine, Committee on Prevention and Control of Sexually Transmitted Diseases, 1997). The Centers for Disease Control and Prevention (CDC) estimates that more than 15 million Americans are infected with STIs every year (Workowski, Levine, & Wasserheit, 2002). The most common STDs or STIs in woman are chlamydia, human papillomavirus, gonorrhea, herpes simplex virus type 2, syphilis, and HIV infection; are discussed in this chapter.

 

 

PREVENTION

Preventing infection (primary prevention) is the most effective way of reducing the adverse consequences of STIs for women and for society. With the advent of serious and potentially lethal STIs that are not readily cured or are incurable, primary prevention becomes critical. Prompt diagnosis and treatment of current infections (secondary prevention) also can prevent personal complications and transmission to others.

Preventing the spread of STIs requires that women at risk for transmitting or acquiring infections change their behavior. A critical first step is for the nurse to include questions about a woman's sexual history, sexual risk behaviors, and drug-related risky behaviors as a part of her assessment (Box 2). When risk factors or risky behaviors are identified, the nurse has an opportunity to provide prevention counseling. Techniques that are effective in providing prevention counseling include using open-ended questions, using understandable language, and reassuring the woman that treatment will be provided regardless of consideration such as ability to pay, language spoken, or lifestyle (Centers for Disease Control and Prevention [CDC], 2002b). Prevention messages should include descriptions of specific actions to be taken to avoid acquiring or transmitting STIs (e.g., refrain from sexual activity if you have STI-related symptoms) and should be tailored to the individual woman, with attention given to her specific risk factors.

To be motivated to take preventive actions, a woman must believe that catching a disease will be serious for her and that she is at risk for infection. Unfortunately most individuals tend to underestimate their personal risk of infection in a given situation; thus many women may not perceive themselves as being at risk for contracting an STI, and telling them that they should carry condoms may not be well received. Although levels of awareness of STIs are generally high, widespread misconceptions or specific gaps in knowledge also exist. Therefore nurses have a responsibility to ensure that their clients have accurate, complete knowledge about transmission and symptoms of STIs and risky behaviors that place them at risk for contracting an infection (Hutchinson, 1999).

Primary preventive measures are individual activities aimed at deterring infection. Risk-free options include complete abstinence from sexual activities that transmit semen, blood, or other body fluids or that allows skin-to-skin contact (CDC, 2002b). Alternatively, involvement in a mutually monogamous relationship with an uninfected partner also eliminates risk of contracting STIs. When neither of these options is realistic for a woman, however the nurse must focus on other, more feasible measure.

 

BOX 2 Assessing STI/HIV Risk Behaviors SEXUAL RISK Are you sexually active now? If no, have you had sex in the past? Ever had an oral, vaginal, or anal sexual experience with another person? With how many different people? I ? 2 or 3? 4 to 10? More than 10? Have your partners been men, women, both? Ever thought that a sex partner put you at risk for AIDS/STI (IV drug user, bisexual)? Ever had an STI (herpes, gonorrhea, genital warts, chlamydia)? Ever had sex against your will? What do you do to protect yourself from AIDS/STIs? Do you use male condoms? Female condoms? Other barriers? DRUG USE-RELATED RISK Ever injected drugs using shared equipment, including street drugs, steroids? Ever had sex with a person who uses and shares? Ever had sex while stoned, high, or drunk, so that you can't remember the details? Ever exchanged sex for drugs, money, shelter? BLOOD-RELATED RISKS Ever had a blood transfusion? Ever had sex with a person who had a blood transfusion? Ever had sex with a person with hemophilia? Ever received donor semen, egg, transplanted organ or tissue? Ever shared equipment for tattoo, body piercing? OTHER Ever had a test for HIV? Ever worried about AIDS and would like to talk with someone about it?

 

Safer Sex Practices

An essential component of primary prevention is counseling women regarding safer sex practices, including knowledge of her partner, reduction of number of partners, low risk sex, and avoiding the exchange of body fluids.

No aspect of prevention is more important than knowing one's partner. Reducing the number of partners and avoiding partners who have had many previous sexual partners decreases a woman's chance of contracting an STI. Deciding not to have sexual contact with casual acquaintances also may be helpful. Discussing each new partner's previous sexual history and exposure to STIs wil augment other efforts to reduce risk; however, sexual partners are not always truthful about their sexual history. Women must be cautioned that safer sex measures are always advisable, even when partners insist otherwise. Critically important is whether male partners resist or accept wearing condoms. This is crucial when women are not sure about their partners' history. Women should be cautioned against making decisions about a partner's sexual and other behaviors based on appearances and unfounded assumption such as the following (Hatcher et al., 2003):

·          Single people have many partners and risky practices.

·          Older people have few partners and infrequent sexual encounters.

·          Sexually experienced people know how to practice safer sex.

·          Married people are heterosexual, low risk, and monogamous.

·          People who look healthy are healthy.

·          People with good jobs do not use drugs.

Sexually active persons also may benefit from carefully examining a partner for lesions, sores, ulcerations, rashes, redness, discharge, swelling, and odor before initiating sexual activity.

Women should be taught low risk sexual practices and which sexual practices to avoid (Table 1). Sexual fantasizing is safe, as are caressing, hugging, body rubbing, and massage. Mutual masturbation is low risk as long as there is no contact with a partner's semen or vaginal secretions. All sexual activities when both partners are monogamous, trustworthy, and known to be free of disease (by testing) are safe.

 

Table 1 Safer Sex Guidelines
SAFEST	LOW RISK	POSSIBLY RISKY (POSSIBLE EXPOSURE)	HIGH RISK (UNSAFE)
Behavior
Abstinence Self-masturbation Monogamous (both partners and no high risk activities) Hugging, massage, touching Dry kissing Mutual masturbation Drug abstinence Sexual fantasy Erotic conversation, books, movies, video Erotic bathing, showering Eroticizing feet, fingers, buttocks, abdomen, ears	Wet kissing Vaginal intercourse with condom Anal intercourse with condom Urine contact with intact skin	Cunnilingus Fellatio Mutual masturbation with skin breaks Vaginal intercourse after anal contact without new condom	Unprotected anal intercourse Unprotected vaginal intercourse Oral-anal contact Any sex (fisting, rough vaginal or anal intercourse, rape) that causes tissue damage or bleeding Multiple sexual partners Sharing sex toys, douche equipment Sharing needles Blood contact, including menstrual blood
Prevention
Avoid high risk behaviors	Avoid exposure to potentially infected body fluids Consistent use of condom and spermicide Avoid anal intercourse	Use dental dam or female condom with cunnilingus Use condom with fellatio Use latex gloves	Avoid exposure to potentially infected body fluids Use condom and spermicide consistently Avoid anal penetration If anal penetration occurs, use condom with intercourse, latex glove with hand penetration Avoid oral-anal contact Do not share sex toys, needles, douching equipment If sharing needles, clean with bleach before and after use

 

The physical barrier promoted for the prevention of sexual transmission of HIV and other STIs is the condom (male and female). Nurses can help motivate clients to use condoms by first discussing the subject with them. This gives women permission to discuss any concerns, misconceptions, or hesitations they may have about using condoms. The nurse may initiate a discussion of how to purchase and use a condom. Information to be discussed includes the importance of using latex or plastic male con­doms rather than natural skin condoms for STI protection. The nurse should remind women to use a condom with every sexual encounter, to use each one only once, to use a condom with a current expiration date, and to handle it carefully to avoid damaging it with fingernails, teeth, or other sharp objects. Condoms should be stored away from high heat. Although it is not ideal, women may choose to safely carry condoms in wallets, shoes, or inside a bra. Women can be taught the differences between condoms: price ranges, sizes, and where they can be purchased.

The female condom-a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina-has been shown in laboratory studies to be an effective mechanical barrier to viruses, including HIV. Although no clinical studies have been completed to evaluate the efficacy of female condoms in protecting against STIs, the CDC (2002b) states that, when used correctly and consistently, the female condom may substantially reduce STI risk and recommends the use when a male condom cannot be used properly. What is important and should be stressed by nurses is the consistent use of condoms for every act of sexual intimacy where there is the possibility of transmission of disease.

Recent evidence has shown that vaginal spermicides do not protect against certain STIs (e.g., chlamydia, cervical gonorrhea) and that frequent use of spermicides containing nonoxynol-9 has been associated with genital lesions and may increase HIV transmission (Wilkerson et al., 2002). Condoms lubricated with nonoxynol-9 are not recommended (CDC, 2002b).

A key issue in condom use as a preventive strategy is to stress to women that in sexual encounters, men must com­ply with a woman's suggestion or request that they use a condom. Moreover, condom use must be renegotiated with every sexual contact, and women must address the issue of control of sexual decision making every time they request a male partner to use a condom. Women may fear that their partner would be offended if a condom were introduced. Some women may fear rejection and abandonment, conflict, potential violence, or loss of economic support if they suggest the use of condoms to prevent STI transmission. For many individuals, condoms are symbols of extra relationship activity. Introduction of a condom into a long-term relationship where one has not been used previously threatens the trust assumed in most long-term relationships.

Many women do not anticipate or prepare for sexual activity in advance; embarrassment or discomfort in purchasing condoms may prevent some women from using them. Cultural barriers also may impede the use of condoms; for example, Latino gender roles make it difficult. for Latina women to suggest using condoms to a partner. Suggesting condom use implies that a woman is sexually active, that she is "available" for sex, and that she is "seeking" sex; these are messages that many women are uncomfortable conveying, given the prevailing mores of o country. In a society that commonly views a woman who: carries a condom as overprepared, possibly oversexed, and willing to have sex with any man, expecting her to insist on the use of condoms in a sexual encounter is unrealistic:

Finally, women should be counseled to watch out for situations that make it hard to talk about and to practice: safer sex. These include romantic times when condoms are not available and when alcohol or drugs make it impossible to make wise decisions about safer sex.

Certain sexual practices should be avoided to reduce one's risk of infection. Abstinence from any sexual activities that could result in exchange of infective body fluids will help decrease risk. Anal-genital intercourse, anal-oral contact, and anal-digital activity are high risk sexual behaviors and should be avoided. Sexual transmission occurs through direct skin or mucous membrane contact with infectious lesions or body fluids. Because mucosal lining are delicate and subject to considerable mechanical trauma during intercourse, small abrasions often may occur, facilitating entry of infectious agents into the bloodstream The rectal epithelium is especially easy to traumatize with penetration. Sexual practices that increase the likelihood of tissue damage or bleeding, such as fisting (inserting a first into the rectum), should be avoided. Deep kissing when lips, gums, or other tissues are raw or broken also should be avoided (Hatcher et al., 2003). Because enteric infections are transmitted by oral-fecal contact, avoiding or anal activities, "rimming" (licking the anal area), and digital-anal activities should reduce the likelihood of infection. Vaginal intercourse should never follow anal cc tact unless a condom has been used and then removed and replaced with a new condom.

Nurses must suggest strategies to enhance a woman’s condom negotiation and communication skills. Suggesting that she talk with her partner about condom use at a time removed from sexual activity may make it easier to bring up the subject. Role playing possible partner reactions with a woman and her alternative responses can be helpful. Asking a woman who appears particularly uncomfortable to rehearse how she might approach the topic is useful, particularly when a woman ears her partner may be resistant. The nurse might suggest her client begin by saying, "I need to talk with you about something that is important to both of us. It's hard for me, and I feel embarrassed, but I think we need to talk about safer sex." If women are able to sort out their feelings and fears before talking with their partners, they may feel more comfortable and in control of the situation. Woman can be reassured that it is natural to be uncomfortable and that the hardest part is getting started. Nurses should help their clients clarity what they will and will not do sexually because it will be easier to discuss their concerns with their partners if they have thought about what say. Women can be reminded that their partner may need time to think about what they have said and that they must pay attention to their partner's response. It the partner seems to be having difficulty with the discussion, a woman may slow down and wait a while. She can be reminded that if her partner resists safer sex, she may wish to reconsider the relationship.

Woman may delay seeking care tor STIs because they fear sicial stigma, they have little access to health care services, they are asymptomatic, or they are unaware that they have an infection.

 

BACTERIAL SEXUALLY TRANSMITTED INFECTIONS

CHLAMYDIA

Chlamydia trachomatis is the most common and fastest spreding STI in American women, with an estimated 3 million new cases each year (Walsh & Irwin, 2002). These infections are often silent and highly destructive; their sequelae and complications can be very serious. In woman, chlamydial infections are difficult to diagnose; the symptoms if present, are nonspecific, and the organism is expensive to culture.

Early identification of C. trachomatis is important because untreated infection often leads to acute salpingitis or pelvic inflammatory disease. Pelvic inflammatory disease is the most serious complication of chlamydial infections, and past chlamydial infections are associated with an increased risk of ectopic pregnancy and tubal factor infertility. Furthermore, chlamydial infection of the cervix causes inflammation, resulting in microscopic cervical ulcerations, and thus may increase the risk of acquiring HIV infection. More than half of infants born to mothers with chlamydia will develop conjunctivitis or pneumonia after perinatal exposure to the mother's infected cervix (Walsh & Irwin, 2002). Chlamidia is the most common infectious cause of ophthalmia neonatorum. Neonatal ocular prophylaxis with silver nitrate solution or antibiotic ointment does not prevent perinatal transmission from mother to infant, not does it adequately treat chlamydial infection. Systemic treatment with erythromycin is recommended (CDC, 2002b).

Sexually active women younger than 20 years are 2 to 3 times likely to become infected with chlamydia as are woman between 20 and 29 years. Women older than 30 years have the lowest rate of infection. Risky behaviors, incluing multiple partners and nonuse of barrier methods of birth control, increase a woman's risk of chlamydial infection. Lower socioeconomic status may be a risk factor, especially with respect to treatment-seeking behaviors.

Screening and Diagnosis

In addition to obtaining information regarding the presence of risk factors, the nurse should inquire about the presence of any symptoms. The CDC (2002b) and U.S. Preventive Services Task Force (USPSTF, 2001a) strongly recommend screening of asymptomatic women at high risk in whom infection would otherwise go undetected. CDC guidelines recommend screening of sexually active adolescents, women between ages 20 and 25 years, women older than 25 years who do not use barrier contraceptives, and women older than 25 years with new or multiple partners. In addition, whenever possible, all women with two or more of the risk factors for chlamydia should be cultured. All pregnant women should have cervical cultures for chlamydia at the first prenatal visit. Repeated culturing late in the third trimester (36 weeks) should be carried out if the woman was positive previously or if she is younger than 25 years or has a new sex partner or multiple sex partners.

Although chlamydia infections are usually asymptomatic, some women may experience spotting or postcoital bleeding, mucoid or purulent cervical discharge, or dysuria. Bleeding results from inflammation and erosion of the cervical columnar epithelium. Women taking oral contraceptives also may have breakthrough bleeding.

Diagnosis of chlamydia is by culture (expensive and la­bor intensive), DNA probe (less expensive but less sensi­tivity), enzyme immunoassay (less expensive but less sen­sitivity), and nucleic acid amplification (expensive but about 90% sensitivity) (Rawlins, 2001). The chlamydial culture procedure requires collection of a sample that con­tains many epithelial cells. Endocervical (columnar) cells are required; cell scrapings provide better specimens, so the cervix should be swabbed with cotton or rayon swabs before collecting the specimen to remove mucus and discharge from the cervical os. Special culture media and proper handling of specimens are important, so the nurse should always know what is required in her individual practice site. Chlamydial culture testing is not always available, primarily because of expense.

Management

The CDC recommendations for treatment of urethral, cervical, and rectal chlamydial infections are doxycycline (100 mg orally twice a day for 7 days) or azithromycin (1 g orally in a single dose) (Table 2) (CDC, 2002b). Azithromycin is often prescribed when compliance may be a problem, because only one dose is needed; however, expense is a concern with this medication. If the woman is pregnant, erythromycin (500 mg orally 4 times a day for 7 days) or amoxicillin (500 mg orally 3 times a day for 7 days) is used. Women who have a chlamydial infection and also are infected with HIV should be treated with the same regimen as those who are not infected with HIV.

 

Table 2 Sexually Transmitted Infections and Drug Therapies for Women
DISEASE	NONPREGNANT WOMEN (13-17 YR)	NONPREGNANT WOMEN (>I8 YR)	PREGNANT WOMEN	LACTATING WOMEN
Chlamydia	Recommended: Azithromycin, 1 g orally once or Doxycycline, 100 mg orally bid for 7 days Alternatives: Erythromycin or sulfamethoxazole/ Trimethoprim regimens or Levofloxacin, 500 mg orally for 7 days	Recommended: Azithromycin, 1 g orally once or Doxycycline, 100 mg orally bid for 7 days Alternatives: Erythromycin base, 500 mg orally qid for 7 days or Erythromycin ethylsuccinate, 800 mg orally qid for 7 days or Ofloxacin, 300 mg orally bid for 7 days or Levofloxacin, 500 mg orally for 7 days	Recommended: Erythromycin base, 500 mg orally qid for 7 days or Amoxicillin, 500 mg orally TID for 7 days Alternatives: Erythromycin base, 250 mg orally qid for 14 days or Erythromycin ethyl-succinate, 800 mg orally qid for 14 days or Erythromycin ethyl-succinate, 400 mg orally qid for 14 days or Azithromycin, 1 g orally once	Recommended: Erythromycin base, 500 mg orally qid for 7 days or Amoxicillin, 500 mg orally, tid for 7 days or Alternatives: Erythromycin base, 250 mg orally qid for 14 days or Erythromycin ethyl-succinate, 800 orally qid for 7 days or Erythromycin ethyl-succinate, 400 mg orally qid for 14 days Azithromycin, 1 g orally once
Gonorrhea	Recommended: Ceftriaxone, 125 mg IM once (Adolescents who weigh >45 kg can be treated with any regimen recommended for adults)	Recommended:  Ceftriaxone, 125 mg IM once or Ciprofloxacin, 500 mg orally once or Ofloxacin, 400 mg orally once or Levofloxacin, 250 mg orally once PLUS Azithromycin, 1 g orally once or Doxycycline, 100 mg orally bid for 7 days	Recommended: Ceftriaxone, 125 mg IM once If cephalosporin allergic, Spectinomycin, 2 g IM once PLUS Erythromycin base, 500 mg orally qid for 7 days or Amoxicillin, 500 mg orally tid for 7 days	Recommended: Ceftriaxone, 125 IM once If cephalosporin allergic, Spectinomycin, 2 g IM one PLUS Erythromycin base, 500 mg orally qid for 7 days or Amoxicillin 500 mg orally tid for 7 days
Syphilis	Primary, secondary, early latent disease: Recommended: Benzathine penicillin G, 2.4 million units IM once Late latent or unknown duration disease: Recommended: Benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at l-wk intervals Penicillin allergy: Doxycycline, 100 mg orally bid for 14 days or Tetracycline, 500 mg orally qid for 14 days	Primary, secondary, early latent disease: Recommended: Benzathine penicillin G, 2.4 million units IM once Late latent or unknown duration disease: Recommended: Benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at 1-wk intervals Penicillin allergy: Doxycycline, 100 mg orally qid for 14 days or Tetracycline, 500 mg orally qid for 14 days	Primary, secondary, early latent disease: Recommended: Benzathine penicillin G, 2.4 million units IM once (Some experts recommend a second dose of benzathine penicillin, 2.4 million units, 1 wk later) Late latent or unknown duration disease: Recommended: Benzathine penicillin G, 7.2 million units total, administered as three doses, 2.4 million units each, at 1 - wk intervals No proven alternatives to penicillin in pregnancy. Pregnant women who have a history of allergy to penicillin should be desensitized and treated with penicillin	Primary, secondary, early latent disease: Recommended: Benzathine penicillin G, 2.4 million unit IM once (Some experts recommend a second dose of benzathine penicillin, 2.4 million units, 1 wk later)
Human papillomavirus	Recommended for external genital warts: Client applied Podofilox, 0.5% solution, or gel to wart BID for 3 days followed by 4-day rest for ≤ 4 cycles or Imiquimod, 5% cream, at hs 3 times a week for ≤ 16 wk Provider applied: Cryotherapy with liquid nitrogen or cryoprobe or Podophyllin resin, l0%-25% in tincture of benzoin compound weekly (wash off in 1-4 hr). Repeat weekly as necessary or TCA or BCA, 80%-90% weekly	Recommended for external genital warts: Client applied Podofilox, 0.5% solution, or gel to wart bid for 3 days followed by 4-day rest for ≤ 4 cycles or Imiquimod, 5% cream, at hs 3 times a week for ≤ 16 wk Provider applied: Cryotherapy with liquid nitrogen or cryoprobe or Podophyllin resin, 10%-25% in tincture of benzoin compound weekly (wash off in 1-4 hr). Repeat weekly as necessary or TCA or BCA, 80%-90% weekly	Recommended for external genital warts: Provider applied: Cryotherapy with liquid nitrogen or cryoprobe or TCA or BCA 80%-90% weekly Imiquimod, podophyllin, and podofilox should not be used in pregnancy	Recommended for external genital warts: Provider applied: Cryotherapy with liquid nitrogen or cryoprobe or TCA or BCA 80%-90% weekly Imiquimod, podophyllin, and podofilox should not be used during lactation
Genital herpes simplex virus (HSV type 1 or 2)	Primary infection: Acyclovir. 400 mg orally tid for 7-10 days or Acyclovir, 200 mg orally 5 times a day for 7-10 days or Famciclovir, 250 mg orally tid for 7-10 days or Valacyclovir, 1 g orally bid for 7-10 days Recurrent infection: Acyclovir, 400 mg orally tid for 5 days or Acyclovir, 200 mg orally 5 times a day for 5 days or Acyclovir, 800 mg orally tid for 5 days or Famciclovir, 125 mg oralfy bid for 5 days or Valacyclovir. 500 mg orally bid for 5 days Suppression therapy: Acyclovir, 400 mg orally bid or Famciclovir, 250 mg orally bid or Valacyclovir, 250 mg orally bid or Valacyclovir, 500 mg orally qd or Valacyclovir, 1000 mg orally qd	Primary infection: Acyclovir. 400 mg orally tid for 7-10 days or Acyclovir, 200 mg orally 5 times a day for 7-10 days or Famciclovir, 250 mg orally tid for 7-10 days or Valacyclovir, 1 g orally bid for 7-10 days Recurrent infection: Acyclovir, 400 mg orally tid for 5 days or Acyclovir, 200 mg orally 5 times a day for 5 days or Acyclovir, 800 mg orally tid for 5 days or Famciclovir, 125 mg oralfy bid for 5 days or Valacyclovir. 500 mg orally bid for 5 days Suppression therapy: Acyclovir, 400 mg orally bid or Famciclovir, 250 mg orally bid or Valacyclovir, 250 mg orally bid or Valacyclovir, 500 mg orally qd or Valacyclovir, 1000 mg orally qd	Safety of acyclovir use not established in pregnancy; may be used orally for first episode or severe recurrence	Safety of acyclovir use not established for lactating women; drug may be used with caution

 

 

Because chlamydia is often asymptomatic, the woman should be cautioned to take all medication prescribed. All exposed sexual partners should be treated. Woman treated with doxycycline or azithromycin do not need to be retested unless symptoms continue. Women treated with erythromycin may be retested 3 weeks after completing the medication, although the validity of this practice has not been established (CDC, 2002b).

 

GONORRHEA

Gonorrhea is probably the oldest communicable disease in the United States. An estimated 600,000 American men and women contract gonorrhea each year (CDC, 2002b). The incidence of drug-resistant cases of gonorrhea, in particular, penicillinase-producing Neisseria gonorrhoea* (PPNG), is increasing dramatically in the United States.

Gonorrhea is caused by the aerobic, gram-negative diplococci, N. gonorrhoeae. Gonorrhea is almost exclusively transmitted by the contact of sexual activity. The principal means of communication is genital-to-genital contact; however, it also is spread by oral-to-genital and anal-to-genital contact. There also is evidence that infection may spread in females from vagina to rectum. Gonorrhea also can be transmitted to the newborn in the form of ophthalmia neonatorum during birth by direct contact with gonococcal organisms in the cervix. Although the organism has been recovered from inanimate objects artificially inoculated with the bacteria, no evidence exists that natural transmission occurs this way (Schaffer, 1998).

Age is probably the most important risk factor associated with gonorrhea. The majority of those contracting gonorrhea are younger than 20 years. Traditionally the reported incidence of gonococcal disease has been higher in minority groups. Many of the apparent differences in infection rates can be explained by the disproportionate representation of African-Americans among the nation's poor and among inner city dwellers. Rates of gonorrhea are higher in urban areas than in rural areas, with even higher rates in the inner city. Adolescent girls have the highest rates of infection, and the incidence is higher in African-American adolescents than in Hispanic or Caucasian teens (Bonny & Biro, 1998). Sex workers and their partners, intravenous drug users, and crack cocaine users are considered groups at high risk

Other risk factors include early onset of sexual activity and multiple sexual partners.

Women are often asymptomatic, with one third of infections adolescent women going unnoticed; when symptoms are present, they are often less specific than are the symptoms in men. Women may have a purulent endocervical discharge, but discharge is usually minimal or absent. Menstrual irregularities may be the presenting symptom or women may complain of pain-chronic or acute severe pelvic or lower abdominal pain or longer, more painful menses. Infrequently, dysuria, vague abdominal pain, or low backache prompts a woman to seek care. Gonococcal rectal infection may occur in women after anal intercourse, with 10% to 30% of urogenital intections accompanied by rectal infection. Individuals with rectal gonorrhea may be completely asymptomatic or, conversely, have severe symptoms with profuse purulent and discharge, rectal pain, and blood in the stool. Rectal itching, fullness, pressure, and pain also are common symptoms, as is diarrhea. A diffuse vaginitis with vulvitis is the most common form of gonococcal infection in prepubertal girls. There may be few signs of infection, or vaginal discharge, dysuria, and swollen, reddened labia may be present.

Gonococcal infections in pregnancy potentially affect both mother and infant. In women with cervical gonorrhea, salpingitis may develop in the first trimester. Perinatal complications of gonococcal infection include premature rupture of membranes, preterm birth, chorioamnionitis, neonatal sepsis, intrauterine growth restriction, and maternal postpartum sepsis. Amniotic infection syndrome manifested by placental, fetal, and umbilical cord inflammation after premature rupture of the membranes may result from gonorrheal infections during pregnancy. Ophthalmia neonatorum, the most common manifestation of neonatal gonococcal infections, is highly contagious, and if untreated, may lead to blindness of the newborn.

Screening and Diagnosis

Because gonococcal infections in women often are asymptomatic, the CDC recommends screening all women at risk for gonorrhea (CDC, 2002b). All pregnant women should be screened at the first prenatal visit, and infected women and those identified with risky behaviors rescreened at 36 weeks of gestation. Gonococcal infection cannot be diagnosed reliably by clinical signs and symptoms alone. Individuals may have "classic" symptoms, vague symptoms that may be attributed to a number of conditions, or no symptoms at all. Cultures with selective media are considered the gold standard for diagnosis of gonorrhea. Cultures should be obtained from the endocervix, rectum, and when indicated, the pharynx. Thayer-Martin cultures are recommended to diagnose gonorrhea in women. Any woman sus­pected of having gonorrhea should have a chlamydial culture and serologic test for syphilis if one has not been done in the past 2 months, because coinfection is common.

Management

Management of gonorrhea is straightforward, and the cure is usually rapid with appropriate antibiotic therapy (see Table 8-2). Single-dose efficacy is a major consideration in selecting an antibiotic regimen for women with gonorrhea. Another important consideration is the high percentage (45%) of women with coexisting chlamydial infections. The treatment of choice for uncomplicated urethral, endocervical, and rectal infections in pregnant and nonpregnant women is cefixime (400 mg orally once) or ceftriaxone (125 mg intramuscularly [IM] once). The CDC recommends concomitant treatment for chlamydia because coinfection is common (CDC, 2002b). All women with both gonorrhea and syphilis also should be treated for syphilis according to CDC guidelines (see discussion of syphilis in this chapter).

Gonorrhea is a highly communicable disease. Recent (past 30 days) sexual partners should be examined, cultured, and treated with appropriate regimens. Most treatment failures result from reinfection. The client must be informed of this, as well as of the consequences of reinfection in terms of chronicity, complications, and potential infertility. Women are counseled to use condoms. All clients with gonorrhea should be offered confidential counseling and testing for HIV infection.

Gonorrhea is a reportable communicable disease. Health care providers are legally responsible for reporting all cases to the health authorities, usually the local health department in the client's county of residence. Women should be informed that the case will be reported, told why, and informed of the possibility of being contacted by a health department epidemiologist.

Treatment failure after combined ceftriaxone/doxycycline therapy is rare; therefore follow-up culture (test of cure) is not essential. A more cost-effective approach is reexamination with a culture 1 to 2 months after treatment. This approach will detect both treatment failures and reinfections. Clients also should be counseled to return if symptoms persist after treatment.

 

SYPHILIS

Syphilis, one of the earliest described STIs, is caused by Treponema pallidum, a motile spirochete. Transmission is thought to be by entry in the subcutaneous tissue through microscopic abrasions that can occur during sexual intercourse. The disease also can be transmitted through kissing, biting, or oral-genital sex. Transplacental transmissior may occur at any time during pregnancy; the degree of risk is related to the quantity of spirochetes in the maternal bloodstream.

The 2000 rate of primary and secondary syphilis was 2.2 per 100,000, the lowest rate ever reported in the United States (CDC, 2001a). Rates are highest among adolescents and women of color, and in southern states (Toney & Montero, 2001). Much of the increase in cases seen since 1990 is directly attributable to illicit drug use - particularly crack cocaine-and the exchange of sex for drugs and money.

Syphilis is a complex disease that can lead to serious systemic disease and even death when untreated. Infection manifests itself in distinct stages with different symptoms and clinical manifestations. Primary syphilis is characterized by a primary lesion, the chancre, that appears 5 to 90 days after infection; this lesion often begins as a painless papule at the site of inoculation and then erodes to form a nontender, shallow, indurated, clean ulcer several millimeters to centimeters in size (Fig. 1).

 

FIG. 1 Syphilis. A, Primary stage: chancre with inguina adenopathy. B, Secondary stage: condylomata lata.

 

Secondary syphilis occurs 6 weeks to 6 months after the appearance of the chancre and is characterized by a widespread, symmetric maculopapular rash on the palms and soles and generalized lymhadenopathy. The infected individual also may experience fever, headache, and malaise.

Condilomata lata (broad, painless, pink-gray, wartlike infectious lesions) may develop on the vulva, perineum, or anus. If the woman is untreated, she enters a latent phase that is asymptomatic for the majority of individuals. If it is left untreated, tertiary syphilis will develop in about one third these women. Neurologic, cardiovascular, musculoskeletan multiorgan system complications can develop in the third stage.

Screening and Diagnosis

All woman who are diagnosed with another STI or with HIV should be screened for syphilis. All pregnant women should be screened for syphilis at the first prenatal visit and again in the late third trimester. Diagnosis is dependent on microscopic examination of primary and secondary lesion tissue and serology during latency and late infection. A test for antibodies may not be reactive in the presence of active infection because it takes time for the body’s immune system to develop antibodies to any antigens. Up to one third of people in early primary syphilis may have nonreactive serologic tests. Two types of serologic test are used: nontreponemal and treponemal. Nontreponemal antibody tests such as the VDRL (Venereal Disease Research Laboratories) or RPR (rapid plasma regain) are used as screening tests. False-positive results are not usual, particularly when conditions such as acute infection, autoimmune disorders, malignancy, pregnancy, and drug addiction exist and after immunization or vaccination. The treponemal tests, fluorescent treponemal antibody absorbed (FTA-ABS) and microhemagglutination as say for antibody to T. pallidum (MHA-TP). are used to confirm positive results. Test results in clients with early primary or incubating syphilis may be negative. Serocoversion usually takes place 6 to 8 weeks after exposure, so testing should be repeated in 1 to 1 months when a suggestive genital lesion exists.

Test for concomitant STIs should be done (e.g., wet preps and cultures) and HIV testing offered if indicated.

Management

Penicillin is the preferred drug for treating clients with syphilis (see Table 2). It is the only proven therapy that has been widely used tor clients with neurosyphilis, congenital syphilis, or syphilis during pregnancy. Intramuscular benzathine penicillin G (2.4 million units IM once) is used to treat primary, secondary, and early latent syphilis, Woman with syphilis of longer than 1 year's duration (late, latent or tertiary stages) require weekly treatment of 2.4 million units of benzathine penicillin G for 3 weeks. Although doxycycline, tetracycline, and erythromycin are alternative treatments for penicillin-allergic clients, both tetracycline and doxycycline are contraindicated in pregnancy, and erythromycin is unlikely to cure a fetal infec­tion. Therefore pregnant women should, if necessary, receive skin testing and be treated with penicillin or be desensitized (CDC, 2002b). Specific protocols are recom­mended by the CDC.

 

NURSE ALERT

Clients treated for syphilis may experience a Jarisch-Herxheimer reaction. This acute febrile reaction is often accompanied by headache, myalgias, and arthralgias that develop within the first 24 hours of treatment. Women treated in the second half of pregnancy are at risk for preterm labor and birth if treatment precipitates this reaction. They should be advised to contact their health care provider if they notice any change in fetal movement or have any contractions.

 

Monthly follow-up is mandatory so that repeated treatment may be given if needed. The nurse should emphasize the necessity of long-term serologic testing even in the absence of symptoms. The woman should be advised to practice sexual abstinence until treatment is completed, all evidence of primary and secondary syphilis is gone, and serologic evidence of a cure is demonstrated. Women should be told to notify all partners who may have been exposed. They should be informed that the disease is reportable. Preventive measures should be discussed.

 

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease (PID) is an infectious process that most commonly involves the uterine (fallopian) tubes (salpingitis), uterus (endometritis), and more rarely, the ovaries and peritoneal surfaces. Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. In the past, the most common causative agent was thought to be N. gonorrhoeae; however, C. trachomatis is now estimated to cause half of all cases of PID. In addition to gonorrhea and chlamydia, a wide variety of anaerobic and aerobic bacte­ria are recognized to cause PID. PID encompasses a wide variety of pathologic processes; the infection can either be acute, subacute, or chronic and can have a wide range of symptoms.

Most PID results from ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. This spread most frequently happens at the end of or just after menses following reception of an infectious agent. During the menstrual period, several factors facilitate the development of an infection: the cervical os is slightly open, the cervical mucus barrier is absent, and menstrual blood is an excellent medium for growth. PID also may develop after an abortion, pelvic surgery, or childbirth.

PID is the single most frequent serious infection encountered by women. Each year more than 1 million women in the United States have an episode of symptomatic PID (Institute of Medicine, Committee on Prevention and Control of Sexually Transmitted Diseases, 1997). Risk factors for acquiring PID are those associated with the risk of contracting an STI, including young age, multiple partners, high rate of new partners, and a history of STIs. Women who use intrauterine devices (IUDs) may be at in­creased risk for PID if they have more than one sexual partner or if the partner has other sexual partners, because they are at higher risk for acquiring an STI (World Health Organization, 2000). Most of this risk occurs in the first months after IUD insertion. PID tends to recur, with nearly one in five clients having recurrent PID (Bonny & Biro, 1998).

Women who have had PID are at increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. After a single episode of PID, a woman's risk for ectopic pregnancy increases sevenfold compared with the risk for women who have never had PID. Other problems associated with PID include dyspareunia (painful intercourse), pyosalpinx (pus in the uterine tubes), tuboovarian abscess, and pelvic adhesions.

The symptoms of PID vary depending on whether the infection is acute, subacute, or chronic; however, pain is common to all clinical presentations. It may be dull, cramping, and intermittent (subacute) or severe, persistent, and incapacitating (acute). The woman with acute PID also may complain of intermenstrual bleeding. Physical examination reveals adnexal tenderness, with or without rebound, and exquisite tenderness with cervical movement (Chandelier sign). Pelvic tenderness is usually bilateral.

There may or may not he a palpable adnexal swelling or thickening. A urethral or cervical discharge, often purulent, may be present. A fever of 39° C or above is characteristic. Significant laboratory data include an elevated white blood cell count and markedly elevated erythrocyte sedimentation rate. Fever and peritonitis are more characteristic of gonococcal PID than of PID caused by other organisms that are more likely to be "silent." Because PID caused by chlamydia is more commonly asymptomatic, it more often results in tubal obstruction from delayed diagnosis or inadequate treatment.

Subacute PID is far less dramatic, with a great variety in the severity and extent of symptoms. At times they are so mild and vague that the woman ignores them. Symptoms that suggest subacute PID are chronic lower abdominal pain, dyspareunia, menstrual irregularities, urinary discomfort, low-grade fever, low backache, and constipation. Abdominal examination usually reveals no rebound tenderness; there is slight adnexal tenderness with cervical movement, and cervical or urethral discharge may be present.

Screening and Diagnosis

A careful history is necessary to distinguish between PID and other conditions that cause abdominal pain, such as an ectopic pregnancy or appendicitis. A menstrual history is useful in establishing the relation of onset of pain to menses and in identifying any variations from normal in the cycle. Other relevant history includes recent pelvic surgery, birth, induced abortion, or dilation of the cervix; purulent vaginal discharge; irregular bleeding; and a longer, heavier menstrual period. A sexual history will assist in identifying possible increased risk for STI exposure. Symptoms of an STI in a woman's partner(s) also should be noted.

Vital signs are obtained, and a complete physical examination performed. CDC routine criteria for diagnosing PID include oral temperature greater than 38.3° C, abnormal cervical or vaginal discharge, elevated erythrocyte sedimentation rate, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis. Physical findings of lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness are important in making a clinical diagnosis of PID. Essential laboratory data are a complete blood count with differential and cervical cultures for gonorrhea and chlamydia.

Management

Perhaps the most important nursing intervention is prevention. Primary prevention would be education in avoiding acquisition of STIs, whereas secondary prevention involves preventing a lower genital tract infection from ascending to the upper genital tract. Instructing women in self-protective behaviors such as practicing safer sex and using barrier methods is critical. Women using hormonal contraception or the IUD and those who have chosen tubal ligation must be reminded to use a condom with intercourse when indicated. Also important is the detection of asymptomatic gonorrheal and chlamydial infections through routine screening of women who practice risky behaviors or have specific risk factors such as young age. Partner notification when an STI is diagnosed is essential to prevent reinfection.

When and if women with PID are hospitalized varies. The CDC recommends hospitalization in the following situations (CDC, 2002b):

* Surgical emergencies such as appendicitis cannot be excluded.

* The woman has a tuboovarian abscess.

* The woman is pregnant.

* Severe illness precludes outpatient management.

* The woman is unable to tolerate or follow an outpatient oral regimen.

* The woman has failed to respond to oral outpatient therapy.

Although many experts recommend that all women with PID be hospitalized so that parenteral antibionc treatment can be done, the CDC does not.

Although treatment regimens vary with the infecting organism, a broad-spectrum antibiotic generally is used. Several antimicrobial regimens have proved to be effective, and no single therapeutic regimen of choice exists (Table 3). The woman with acute PID should be on bed rest in a semi-Fowler's position. Comfort measures include analgetics for pain and all other nursing measures applicable to a client confined to bed. Few pelvic examinations should be done during the acute phase of the disease. During the recovery phase, the woman should restrict her activity and make every effort to get adequate rest and a nutritionally sound diet. Follow-up laboratory work after treatment should include endocervical cultures for a test of cure.

Health education is central to effective management of PID. Nurses should explain the nature of the disease to women and should encourage them to comply with all therapy and prevention recommendations, emphasizing the necessity of taking all medication, even if symptoms disappear. Any potential problems (such as lack of money for prescriptions or lack of transportation to return to return to the clinic for follow-up appointments) that would prevent a woman from completing a course of treatment should be identified and the importance of follow-up visits stressed. Women should be counseled to refrain from sexual intercourse until their treatment is completed. Contraceptive counseling should be provided, including barrier methods such as condoms, contraceptive sponge, or diaphragm. A woman with a history of PID should not choose an IUD as her contraceptive method.

The woman with PID may be acutely ill or have long-term discomfort. Either or both take an emotional toll.

Pain in itself is debilitating and is compounded by the infectious process. The potential or actual loss of reproductive capabilities can be devastating and can adversely affect the woman's self-concept. Part of the nurse's role is to help the woman adjust her self-concept to fit reality and to accept alterations in a way that promotes health. Because PID is so closely tied to sexuality, body image, and self-concept, the woman diagnosed with it will need supportive care. Her feelings should be discussed and her partner(s) included when appropriate.

 

Table 3. Treatment of Pelvic Inflammatory Disease
	TREATMENT OF CHOICE	ALTERNATIVES
Parenteral regimen	Cefotetan, 2 g IV every 12 hr or Cefoxitin, 2 g IV every 6 hr PLUS Doxycycline, 100 mg IV or orally every 12 hr	Clindamycin, 900 mg IV every 8 hr PLUS Gentamycin, loading dose IV or IM (2 mg/kg of body weight), followed by maintenance dose ( 1.5 mg/kg) every 8 hr. Single daily dosing may be substituted
Oral regimen	Ofloxacin, 400 mg orally twice a day for 14 days or Levofloxacin, 500 mg orally, once a day for 14 days With or Without Metronidazole, 500 mg orally twice a day for 14 days	Ceftriaxone, 250 mg IM in a single dose or Cefoxitin, 2 g IM PLUS Probenecid, I g orally in a single dose, concurrently or Other parenteral third-generation cephalosporin PLUS Doxycycline, 100 mg orally twice a day for 14 days With or Without Metronidazole, 500 mg orally twice a day for 14 days

 

 

VIRAL SEXUALLY TRANSMITTED INFECTIONS

HUMAN PAPILLOMAVIRUS

Human papillomavirus (HPV) infection, previously named genital or venereal warts, is a sexually transmitted infection that was first described in 25 A.D. and is now the most prevalent viral STI seen in ambulatory health care settings. HPV, a double-stranded DNA virus, has more than 40 known serotypes; more than 20 types can infect the genital tract. Most HPV infections are asymptomatic, subclinical, or unrecognized. The visible genital lesions are usually caused by HPV types 6 and 11. Other types (e.g., 16, 18, 31, 33, and 35) have the highest oncogenic potential, with types 16 and 18 associated with the highest mortality from cervical cancer (Thomas, 2001; Workowski et al., 2002). HPV types 31, 33, and 35 have an intermediate oncogenic potential and are commonly associated with squamous cell carcinoma in situ (Canavan & Doshi, 2000).

Because health care providers are not required to report HPV infections, the true incidence of these infections is not known. An estimated 24 million Americans are infected with HPV, and as many as 1 million new infections occur yearly (CDC, 2002b). In addition to the general risk factors for STIs noted earlier, cigarette smoking and use of oral contraceptives for more than 5 years have been found to be risk factors for HPV.

In women, HPV lesions (also called condylomata acuminata) are most frequently seen in the posterior part of the introitus; however, lesions also are found on the buttocks, vulva, vagina, anus, and cervix (Fig. 2). Typically the lesions are small, 2 to 3 mm in diameter and 10 to 15 mm in height, soft, papillary swellings occurring singly or in clusters on the genital and anal-rectal region. Infections of long duration may appear as a cauliflower-like mass. In moist areas such as the vaginal introitus, the lesions may appear to have multiple, fine, fingerlike projections. Vaginal lesions are often multiple. Flat-topped papules, 1 to 4 mm in diameter, are seen most often on the cervix. Often these lesions are visualized only under magnification. Warts are usually flesh colored or slightly darker on Caucasian women, black on African-American women, and brownish on Asian women. Usually painless, the lesions also may be uncomfortable, particularly when very large, inflamed, or ulcerated. Chronic vaginal discharge, pruritis, or dyspareunia can occur.

HPV infections are thought to be more frequent in pregnant than in nonpregnant women, with an increase in incidence from the first trimester to the third. Furthermore, a significant proportion of preexisting HPV lesions enlarge greatly during pregnancy, a proliferation presumably resulting from the relative state of immunosuppression present during pregnancy. Lesions may become so large during pregnancy that they affect urination, defecation, mobility, and fetal descent, although birth by cesarean is rarely necessary (Thomas, 2001). Cesarean birth may be performed when extensive growths are present. Initial observation of large growths can be misleading, suggesting that the entire vagina is involved; however, all of the growth may derive from one stalk, and in such cases, it may be possible to push the large mass to the side, allowing the baby to pass through. HPV infection may be acquired by the neonate during birth; the frequency of such transmission is unknown. The preventive value of cesarean birth is unknown and is not recommended solely to prevent transmission of HPV infection to newborns.

Fig 2 Human papillomavirus infection. Genital warts or condylomata acuminata

 

Screening and Diagnosis

A woman with HPV lesions may complain of symptom such as a profuse, irritating vaginal discharge, itching, dyspareunia, or postcoital bleeding. She also may repon "bumps" on her vulva or labia. History of a known exposure is important; however, because of the potentially long latency period and the possibility of subclinical infections in men, the lack of a history of known exposure cannot be used to exclude a diagnosis of HPV infection.

Physical inspection of the vulva, perineum, anus, vagina, and cervix is essential whenever HPV lesions are suspected or seen in one area. Because speculum examination of the vagina may block some lesions, it is importicn to rotate the speculum blades until all areas are visualized. When lesions are visible, the characteristic appearance previously described is considered diagnostic. However, in many instances, cervical lesions are not visible, and some vaginal or vulvar lesions also may be unobservable to the naked eye. Because of the potential spread of vulvar a vaginal lesions to the anus, gloves should be changed between vaginal and rectal examinations.

Diagnosis is made by colposcopy and direct visualization of the growths or by biopsy. It is imperative that women with vulvar HPV or who have partners with HPV have a cervical examination with a Papanicolaou (Pap) smear. Pap smears of the cervical transformation zone are used as a screening technique; however, because of false negative results, a negative Pap smear does not indicate absence of disease. The severity of any cervical lesion reported on a Pap smear is best determined by colposcopy and biopsy. Vinegar solution may be used to highlight early or flat cervical lesions; however, it is important to note that a positive reaction also may be obtained with any inflammatory reaction, after sexual intercourse, and with vaginal trauma. DNA testing for high risk types or HPV also is recommended for Pap smears showing cervical abnormalities (Wright et al., 2002).

HPV lesions must be differentiated from molluscum contagiosum and condylomata lata. Molluscum contagiosum lesions are half-domed, smooth, flesh-colored to pearly white papules with depressed centers. Condylomata lata are a form of secondary syphilis and generally are flatter and wider than genital warts. A serologic test for syphilis would confirm the diagnosis of secondary syphilis.

 

Management

Treatment of genital warts is often difficult. No therapy has been shown to eradicate HPV. The goal of treatment therefore to removal of warts and relict of signs and symptoms, not the eradication of HPV (CDC, 2002b). The client often must make multiple office visits; frequently, many different treatment modalities will be used. Eradication of the virus is not considered conclusive even after there is no visible evidence of wart tissue because of the high incidence of recurrence.

Treatment of genital warts should be guided by preference of the woman, available resources, and experience of the heath care provider. None of the treatments is superior to all other treatments, and no one treatment is ideal for all warts (CDC. 2002b). Available treatments are outlined in Table 2. Imiquimod, podophyllin, and podofilox should not be used during pregnancy. Because the lesions can proliferate and become friable during pregnancy, many experts recommend their removal by using cryptherapy or various surgical techniques during pregnancy (CDC, 2002b).

Women with discomfort associated with genital warts may find that bathing with an oatmeal solution and drying the area with a cool hair dryer will provide some relief. Keeping the area clean and dry will also decrease growth of the warts. Cotton underwear and loose-fitting clothes that decrease friction and irritation also may decrease discomfort. Women should be advised to maintain a healthy lifestyle to aid the immune system; women can be counseled regarding diet, rest, stress reduction, and exercise.

Client counseling is essential. Women must understand how the virus is transmitted, that no immunity is conferred with infection, and that reacquisition of the infections is likely with repeated contact. Women should know that their partners should be checked even if they are asymptomatic. Because HPV is highly contagious, the majority of women's partners will be infected and should be treated. All sexually active women with multiple partners or history of HPV should be encouraged to use latex condome and a vaginal spermicide for intercourse to decrese acquisition or transmission of condylomata.

Instructions for all medications and treatments must be detailed. Women should be informed before treatment of the posibility of posttreatment pain associated with specific therapies. The importance of thorough treatment of concurrent vaginitis or STI should be emphasized. The link between cervical cancer and HPV infections and the need for close follow-up should be discussed. Annual health examinations are recommended to assess disease recurrencе and screening for cervical cancer. Women should be counseled to have regular Pap screening, as recomended for women without genital warts. The presents of genital warts is not an indication for a change in Pap smear test frequency or for cervical colposcopy (CDC, 2002b).

Women with HPV infection may radically alter their sexual practices both from fear of transmission to and from a partner and from genital discomfort associated with treatment, which may have a negative impact on their sexual relationships. Unless the partner accepts and understands the necessary precautions, it may be difficult for the woman to follow the treatment regimen. The nurse can offer to discuss feelings that the woman may have. When indicated, joint counseling can be suggested.

 

HERPES SIMPLEX VIRUS

Unknown until the middle of the twentieth century, herpes simplex virus (HSV) infection is now widespread in the United States, especially in women. HSV infection results in painful recurrent genital ulcers and is caused by two diferent antigen subtypes oft herpes simplex virus: herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2). HSV-2 is usually transmitted sexually, and HSV-1, nonsexually. Although HSV-1 is more commonly associated with gingivostomatitis and oral labial ulcers (fever blisters) and HSV-2 with genital lesions, neither type is exclusively associated with the respective sites.

Although HSV infection is not a reportable disease, it is estimated that about one in five people in the United States are infected with genital herpes and that up to one million new infections occur each year (CDC, 2002b). Re­current HSV infections are much more common. Most persons infected with HSV-2 have not been diagnosed, and most infections are transmitted by persons unaware that they are infected.

An initial HSV genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks. Women generally have a more severe clinical course than do men. Women with primary genital herpes have many lesions that progress from macules to papules, then forming vesicles, pustules, and ulcers that crust and heal without scarring (Fig. 3). These ulcers are extremely tender, and primary infections may be bilateral. Women also may have itching, inguinal tenderness, and lymphadenopathy. Severe vulvar edema may develop, and women may have difficulty sitting. HSV cervicitis also is common with initial HSV-2 infections. The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. A heavy, watery-to-purulent vaginal discharge is common. Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root.

Women with recurrent episodes of HSV infections commonly have only local symptoms that are usually less severe than those associated with the initial infection. Systemic symptoms are usually absent, although the characteristic prodromal genital tingling is common. Recurrent lesions are unilateral, are less severe, and usually last 5 to 7 days. Lesions begin as vesicles and progress rapidly to ulcers. Few women with recurrent disease have cervicitis.

During pregnancy, maternal infection with HSV-2 can have adverse effects on both the mother and fetus. Viremia occurs during the primary infection, and congenital infection is possible, though rare. Primary infections during the first trimester have been associated with increased miscarriage rates. The most severe complication of HSV infec­tion is neonatal herpes, a potentially fatal or severely disabling disease occurring in 1 in 2000 to 1 in 10,000 live births. Most mothers of infants who contract neonatal herpes lack histories of clinically evident genital herpes. Risk of neonatal infection is highest among women with primary herpes infection who are near term and is low among women with recurrent herpes (CDC, 2002b). A 60% infant mortality rate is associated with infants who contract HSV infection, and about 50% of those who survive have serious neurologic damage (Corder-Mabe, 1998).

An association between cervical cancer and HSV-2 has been observed. It is theorized that genital herpes is a marker for high risk sexual behaviors that could transmit other STIs, including HPV (DiSaia & Creasman, 2002).

FIG. 8-3 Herpes genitalis

 

Screening and Diagnosis

A careful history provides much information when making a diagnosis of herpes. A history of exposure to an infected person is important, although infection from an asymptomatic individual is possible. A history of having viral symptoms such as malaise, headache, fever, or myalgia is suggestive. Local symptoms such as vulvar pain, dysuria, itching or burning at the site of infection, and painful genital lesions that heal spontaneously also are highly suggestive of HSV infections. The nurse should ask about a history of a primary infection, prodromal symptoms, vaginal discharge, and dyspareunia. Pregnant women should be asked whether they or their partner(s) have had genital lesions.

During the physical examination, the nurse should assess for inguinal and generalized lymphadenopathy and elevated temperature. The entire vulvar, perineal, vaginal, and cervical areas should be carefully inspected for vesicles or ulcerated or crusted areas. A speculum examination may be very difficult for the woman because of the extreme tenderness often associated with herpes infections. Any suggestive or recurrent lesions found during pregnancy should be cultured to verify HSV. Although a diagnosis of herpes infection may be suspected from the history and physical, it is confirmed by laboratory studies. A viral culture is obtained by swabbing exudate during the vesicular stage of the disease. In primary HSV infection, viral shedding is prolonged, and HSV is more easily isolated.

 

Management

Genital herpes is a chronic and recurring disease for which there is no known cure. Management is directed toward specific treatment during primary and recurrent infections, prevention, self-help measures, and psychologic support.

Systemic antiviral medications partially control the symptoms and signs of HSV infections when used for the primary or recurrent episodes or when used as daily suppressive therapy. However, these medications do not eradicate the infection, nor do they alter subsequent risk, frequency, or recurrences after the medication is stopper. Three antiviral medications provide clinical benefit: acyclovir, valacyclovir, and famciclovir. Treatment recommendations are given in Table 2. Safety and efficacy have been shown clearly in persons taking acyclovir daily for up to 3 years. The safety of acyclovir, valacyclovir, and famciclovir therapy during pregnancy has not been establisher however, the first clinical episode of genital herpes dunring pregnancy may be treated with oral acyclovir. In the presence of severe maternal HSV infection, acyclovir IV is indicated (CDC, 2002k). Continued investigation of HSV therapy with these medications in pregnancy is needed.

Cleaning lesions twice a day with saline will heir prevent secondary infection. Bacterial infection must be treated with appropriate antibiotics. Measures that may increase comfort for women when lesions are active include warm sitz baths with baking soda; keeping lesions dry by blowing the area dry with a hair dryer set on cool or patting dry with a soft towel; wearing cotton underwear and loose clothing; using drying aids such as hydroger peroxide, Burow's solution, or oatmeal baths; applying cool, wet, black tea bags to lesions; and applying compresses with an infusion of cloves or peppermint oil and clove oil to lesions.

Oral analgesics such as aspirin or ibuprofen may be used to relieve pain and systemic symptoms associated with initial infections. Because the mucous membranes infected by herpes are extremely sensitive, any topical agents. should be used with caution. Nonantiviral ointments, especially those containing cortisone, should be avoided. A thin layer of lidocaine ointment or an antiseptic spray mar be applied to decrease discomfort, especially if walking is difficult.

A diet rich in vitamin C, B-complex vitamins, zinc, and calcium is thought to help prevent recurrences. The amino acide L-lyrsine has been used in doses of 750 to 1000 mg daily wile lesions are active and 500 mg during asymptomatic periods. It is thought that L-lysine has an inhibitory effect on the multiplication of the HSV.

Counseling and education are critical components of the nursing care of women with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. The nurse should explain that each woman is unique in her response to herpes and emphasize the variability of symptoms. Women shuld be helped to understand when viral shedding and thus transmission to a partner is most likely, and that they should refrain from sexual contact from the onset of prodrome until complete healing of lesions. Some authories recommend consistent use of condoms for all persons with genital herpes. Condoms may not prevent transmission, parricularly male-to-female transmission; however, this does not mean that the partners should avoid all intimacy. Women can be encouraged to maintain close contact with their partners while avoiding contact with lesions. Women should be taught how to look for herpetic lesions with a mirror and good light source and a wet cloth or finger covered with a finger cot to rub lightly over the labia. The nurse should ensure that women understand that when lesions are active, sharing intimate articles (e.g., washcloths, wet towel) that come into contact with the lesions should be avoided. Plain soap-and-water is all that is needed to clean hands that have come in contact with herpetic lesions; isolation is not necessary or appropriate.

The nurse should explain the role of precipitating factors in the reactivation of the latent virus and recurrent episodes.Stress, menstruation, trauma, febrile illnesses, chronic illness and ultraviolet light have all been found to trigger genital herpes. Women may wish to keep a diary to identify stressors that seem to be associated with recurrent herpes attacks so that they can then avoid these stressors when possible. The role of exercise in reducing stress can be discussed. Refferal for stress-reduction therapy, yoga, or meditation classes may be indicated. Avoiding excessive heat and sun and hot baths and using a lubricant during sexual intercourse to reduce friction also may be helpful. Women in their chuldbearing years should be counseled regarding the risk of the herpes infection during pregnancy. They should be instructed to use condoms it there is any risk of contracting any STI from a sexual partner. If they are using acyclovir therapy, they should be counseled to use contraception because of the potential teratogenicity of acyclovir. Women who are breastfeeding should use acyclovir with caution because it concentrates in the milk

Because neonatal HSV infection is such a devastating disease, prevention is critical. Current recommendations include carefully examining and questioning all women about symptoms at onset of labor (CDC, 2002b). If visible lesions are not present at onset of labor, vaginal birth is acceptable. Cesarean birth within 4 hours after labor begins or membranes rupture is recommended if visible lesions are present. Infants who are delivered through an infected vagina should be carefully observed and cultured. Some experts recommend presumptive treatment of infants who were exposed to HSV during birth. Because HSV infection may be associated with cervical dysplasia, women must be encouraged to have yearly Pap smears and gynecologic examinations.

The emotional impact of contracting herpes is considerable. Media publicity regarding this disease has made receiving a diagnosis of genital herpes a devastating experience. No cure is available, and most women will experience recurrences. At diagnosis, many emotions may surface—helplessness, anger, denial, guilt, anxiety, shame, or inadequacy. Women need the opportunity to discuss their feelings and help in learning to live with the disease. A woman can be encouraged to think of herself as a person who is not diseased but rather healthy and inconvenienced from time to time. Herpes can affect a woman's sexuality, her sexual practices, and her current and future relationships. She may need help in raising the issue with her partner or with future partners.

VIRAL HEPATITIS

Five different viruses (hepatitis viruses A, B, C, D, and E) account for almost all cases of viral hepatitis in humans. Hepatitis viruses A, B, and C are discussed. Hepatitis D and E viruses, common among users of intravenous drugs and recipients of multiple blood transfusions, are not in­cluded in this discussion.

Hepatitis A

Hepatitis A virus (HAV) infection is acquired primarily through a fecal-oral route by ingestion of contaminated food, particularly milk, shellfish, or polluted water, or person-to-person contact. However, hepatitis A, like other enteric infections, can be transmitted during sexual activity. Women living in the western United States, Native Americans, Alaskan Natives, and children and employees in day care centers are at high risk.

HAV infection is characterized by flulike symptoms with malaise, fatigue, anorexia, nausea, pruritis, fever, and right upper quadrant pain. Serologic testing to detect the immunoglobulin M (IgM) antibody is done to confirm acute infections. The IgM antibody is detectable 5 to 10 days after exposure and can remain positive for up to 6 months. Because HAV infection is self-limited and does not result in chronic infection or chronic liver disease, treatment is usually supportive. Women who become dehydrated from nausea and vomiting or who have fulminat­ing hepatitis A may need to be hospitalized. Medications that might cause liver damage or that are metabolized in the liver (e.g., acetaminophen, ethyl alcohol) should be avoided. A well-balanced diet is recommended. Immune globulin (gamma-globulin) or immune-specific globulin is indicated for any pregnant woman exposed to HAV to provide passive immunity through injected antibodies. All household contacts of" the woman also should receive gamma-globulin. Vaccination is the most effective means of preventing HAV transmission; maintenance of "good personal hygeine" has not been successful in preventing HAV outbreaks (CDC, 2000a).

Hepatitis B

Hepatitis B virus (HBV) is the virus most threatening to the fetus and neonate. It is caused by a large DNA virus and is associated with three antigens and their antibodies: hepatitis B surface antigen (HBsAG), HBV antigen (HBeAG), HBV core antigen (HBcAG), antibody to HBsAG (anti-HBs), antibody to HBeAG (anti-HBe), and antibody to HBcAG (anti-HBc). Screening for active or chronic disease or disease immunity is based on testing for these antigens and their antibodies.

HBV infection can be transmitted parenterally, perinatally, and rarely, orally, as well as through intimate contact. It is 50 to 100 times more contagious than HIV. The hepatitis B carrier state affects 5% of the world's population, with higher percentages found in tropical areas and Southeast Asia. HBsAG has been found in blood, saliva, sweat, tears, vaginal secretions, and semen. Perinatal transmission does occur; however, the fetus is not at risk until it comes in Contact With Contaminated blood during birth. Infants born to mothers who are highly infectious (positive for both HBsAG and HBeAG) have a 10% to 90% chance of acquiring perinatal hepatitis B infection (Thomas, 2001). Approximately 90% of infected infants will become chronic carriers. HBV also has been transmitted by artificial insemination,

Factors considered to place a woman at risk for HBV are those associated with STl risk in general history of multiple sexual partners, multiple STIs, and intravenous drug use; and behaviors that are associated with blood contact (e.g., work or treatment in a dialysis unit, history of multiple blood transfusions, public safety workers exposed to blood in the workplace, health care workers). Although HBV can be transmitted via blood transfusion, the incidence of such infections has decreased significantly since testing of blood for HBsAG became a routine procedure. Drug abusers who share needles are at risk, as are health care workers who are exposed to blood and needle sticks. In addition, women of Asian, Pacific Islander (Polynesian, Micronesian, and Melanesian), or Alaskan Eskimo descent and of Haitian or sub-Saharan Africa birth are considered to be at risk.

HBV infection is a disease of the liver and is often a silent infection. In the adult, the course of the infection can be fulminating, and the outcome, fatal. Symptoms of HBV infection are similar to those of hepatitis A: arthral­gias, arthritis, lassitude, anorexia, nausea, vomiting, headache, fever, and mild abdominal pain. Later the woman may have clay-colored stools, dark urine, increased abdominal pain, and jaundice. Between 5% and \ individuals with HBV have persistence of HBsAG ai come chronic hepatitis B carriers. Twenty-five percent of chronic carriers die of primary hepatocellular carcinoma cirrhosis of the liver.

 

Screening and Diagnosis.

All women at high risk for contracting HBV should be screened on a regular basis. Screening only individuals at high risk may not identify up to 50% of HBsAG-positive women; therefore current CDC guidelines recommend screening for the present of  HBsAG on all women at the first prenatal visit, regardless of whether they have been tested previously, and repeated later in pregnancy for women with high risk behaviors (CDC, 2002b).

Testing for HBV is complex. Clients with acute hepatitis B generally have detectable serum HBsAG levels in the late incubation phase of the disease, 2 to 5 weeks before symptoms appear. Anti-HBs with a negative HBsAG test signals immunity. Anti-HBs with a positive antigen denotes a chronic carrier state; during this time, the disease can be transmitted. During the recovery phase, the client may continue to be infectious even though HBsAG cannot be detected. This is called the "window phase" and is identified by anti-HBc in the absence of anti-Hbs. Women should be prepared for repeated testing because HBV screening tests also may be used to monitor the progression of the disease.

Components of the history to be obtained when hepatitis B is suspected include the inquiry about the symptoms of the disease and risk factors outlined earlier. Physical examination includes inspection of the skin for rashes, inspection of the skin and conjunctiva for jaundice, and palpation ot the liver for enlargement and tenderness. Weight loss, fever, and general debilitation should be noted. If the HBsAG is positive, further laboratory studies may be ordered (anti-HBe, anti-HBc, serum glutamic-oxaloacetic transaminase (SGOTJ, alkaline phosphatase, and liver panel). It the HBsAG is negative in early pregnancy and the woman could be in the window phase or if high risk behaviors continue during pregnancy, a repeated HBsAG should be ordered in the third trimester.

 

Management. There is no specific treatment for hepatitis B. Recovery is usually spontaneous in 3 to 16 weeks. Pregnancies complicated by acute viral hepatitis are managed on an outpatient basis. Women should be advised to increase bed rest; eat a high-protein, low-fat diet; and increase their fluid intake. They should avoid medications metabolized in the liver, drugs, and alcohol. Pregnant women with a definite exposure to HBV should be given hepatitis B immune globulin and should begin the hepatitis B vaccine series within 14 days of the most recent contact to prevent infection (CDC, 2002b). Vaccination during pregnancy is not thought to pose risks to the fetus.

All nonimmune women at high or moderate risk of hepatitis should be informed of the availability of hepatitis B vaccine. Vaccination is recommended for all individuals who had multiple sex partners within the past 6 months (CDC, 2002b). In addition, intravenous drug users, residents of correctional or long-term care facilities, personsis seeking care for an STI, prostitutes, women whose partners are intravenous drug users or bisexual, and women whose occupation exposes them to high risk should be vaccinated. The vaccine is given in a series of three (four if rapid protection is needed) doses over a 6-month period, with the first two doses given at least 1 month apart. The vaccine is given in the deltoid muscle (CDC, 2002b).

Client education includes explaining the meaning of B infection, including transmission, state of infectivity, and sequelae. The nurse also should explain the need for immunoprophylaxis for household members and sexual contacts. To decrease transmission of the virus, women with hepatitis B or who test positive for HBV should be advised to maintain a high level of personal hygiene (e.g. wash hands after using the toilet; carefully dispose of tampons, pads, bandages in plastic bags; do not share razor blades, toothbrushes, needles, manicure implements; have male partner use a condom if unvaccinated and with hepatitis; avoid sharing saliva through kissing, or sharing of silverware or dishes; wipe up blood spills immediately with soap and water). They should inform all health care providers of their carrier state. Postpartum women should be reassured that breastfeeding is not contraindicated if their infants received prophylaxis at birth currently on the immunization schedule.

Hepatitis C

Hepatitis C virus (HCV) infection, the most common blood-borne infection in the United States, has become an important health problem as increasing numbers of persons acquire the disease. Fourteen percent of the U.S. population is infected with HCV (Hunt, Carson, & Sharara, 1997). Because up to 70% of clients with HCV infection progress to chronic hepatitis, hepatitis C represents nearly 50% of chronic viral hepatitis. The most common risk factor for pregnant women is a history of injecting intravenous drugs. Other risk factors include STIs such as hepatitis B and HIV, multiple sexual partners, and a history of •ransmissions. Hepatitis C is readily transmitted through exposure to blood and much less efficiently through semen, saliva, or urine.

Most clients with hepatitis C are asymptomatic or have general flulike symptoms similar to hepatitis A. About 10% have fatigue, nausea, and anorexia (Hunt et al., 1997). HCV infection is confirmed by the presence of anti-C antibody during laboratory testing. Routine HCV testing is recomended for women who have ever injected drugs; women who received a blood transfusion prior to July 1992; children of HCV-positive women; health care, emergency, medical, and public safety workers; and women with chronic liver disease (CDC, 2002b).

Inteferon alfa-2b is the main therapy for HCV infection, although effectiveness of this treatment varies. In addition, drug-abuse treatment is an important adjunct for many persons with HCV (CDC, 2002b). Currently there is no vaccine to prevent hepatitis C. Transmission of HCV through breastfeeding has not been reported.

 

HUMAN IMMUNODEFICIENCY VIRUS

Although HIV has traditionally been thought to be a homosexual or gay disease, heterosexual transmission is now the most common means of transmission in women. Furthermore, women are now the fastest-growing population of individuals with HIV infection and acquired immunodeficiency syndrome (AIDS). Between 1985 and 1997, the proportion of women with AIDS tripled. HIV/AIDS infections are seen disproportionately in women of color (African-American and Hispanic).

Transmission of HIV, a retrovirus, occurs primarily through exchange of body fluids (semen, blood, or less commonly, vaginal secretions). Severe depression of the cellular immune system associated with HIV infection characterizes AIDS. For both men and women, the most frequently reported opportunistic diseases are Pneumocystis carinii pneumonia (PCP), candida esophagitis, and wasting syndrome. Other viral infections such as HSV and cytomegalovirus infections seem to be more prevalent in women than men. PID may be more severe in HIV-infected women, and rates of HPV and cervical dysplasia may be higher. The clinical course of HPV infection in women with HIV infection is accelerated, and recurrence is more frequent.

Once HIV enters the body, seroconversion to HIV positivity usually occurs within 6 to 12 weeks. Although HIV seroconversion may be totally asymptomatic, it usually is accompanied by a viremic, influenza-like response. Symptoms include fever, headache, night sweats, malaise, generalized lymphadenopathy, myalgias, nausea, diarrhea, weight loss, sore throat, and rash.

Laboratory studies may reveal leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. HIV has a strong affinity for surface-marker proteins on T lymphocytes. This affinity leads to significant T-cell destruction. Both clinical and epidemiologic studies have shown that declining CD4 levels are strongly associated with increased incidence of AIDS-related diseases and death in many different groups of HIV-infected persons.

Screening and Diagnosis

Screening, teaching, and counseling regarding HIV risk factors, indications for being tested, and testing are major roles for nurses caring for women today. A number of behaviors place women at risk for HIV infection, including intravenous drug use, high risk sexual partners, multiple sex partners, and a previous history of multiple STIs. HIV infection is usually diagnosed by using HIV-1 and HIV-2 antibody tests. Antibody testing is first done with a sensitive screening test such as the enzyme immunoassay (EIA). Reactive screening tests must be confirmed by an additional test, such as the Western blot or an immunofluorescence assay. If a positive antibody test is confirmed by a supplemental test, it means that a woman is infected with HIV and is capable of infecting others. HIV antibodies are detectable in at least 95% of clients within 3 months after infection. Al­though a negative antibody test usually indicates that a person is not infected, antibody tests cannot exclude recent in­fection. Because HIV antibody crosses the placenta, definite diagnosis of HIV in children younger than 18 months is based on laboratory evidence of HIV in blood or tissues by culture, nucleic acid, or antigen detection (CDC, 2002b).

CDC guidelines recommend offering HIV testing to all women whose behavior places them at risk for HIV infection (CDC, 2002b). It may be useful to allow women to self-select for HIV testing. On entry to the health care system, a woman can be handed written information about the risk factors for the AIDS virus and asked to inform the nurse if she believes she is at risk. She should be told that she does not have to say why she may be at risk, only that she thinks she might be.

Counseling for HIV Testing

Counseling before and after HIV testing is standard nursing practice today. It is a nursing responsibility to assess a woman's understanding of the information such a test would provide and to be sure the client thoroughly understands the emotional, legal, and medical implications of a positive or negative test before she is ready to take an HIV test. One's life is profoundly altered by knowledge of HIV seropositivity. A unique stigma associated with HIV infection can have a profound impact on the quality of life of those infected. This stigma extends to those who are asymptomatic but seropositive (see Research box).

Pregnant women should be counseled about their options and contraceptive counseling offered to HIV-positive women who do not desire pregnancy. HIV-infected women should be informed specifically about the risks for perinatal infection. Current evidence indicates that 15% to 25% of infants born to untreated HIV-infected women are infected with HIV; an additional 12% to 14% are infected when breastfeeding continues after age 1 year (CDC, 2002b).

All pregnant women should be offered voluntary counseling and HIV testing as early in pregnancy as possible (Allen et al., 2001; CDC, 2002b). This recommendation is essential because of the available treatments that can reduce the likelihood of perinatal transmission and maintain the health of the woman.

Perinatal transmission of HIV has decreased significantly in the past decade because of the prophylactic adinistration of antiretroviral prophylaxis (zidovudine [ZDV, AZT, Retrovir]) to pregnant women in the prenatal and perinatal period. Oral ZDV is initiated between 14 and 34 weeks of pregnancy and continued until labor. During labor, intravenous ZDV is administered. The newborn infant then receives oral ZDV for 6 weeks after birth. The transmission rate of HIV to the newborn with this protocol demonstrated a 66% decrease in the Pediatric AIDS Clinical Trials Group (PACTG protocol 076) in the early 1990s (Allen et al., 2001). The suspected means of protection for the fetus is preexposure prophylaxis. With this standart of care, rates of perinatal transmission to the fetus have been reported as low as 4% (Perinatal HIV Guidelines Working Group, 2001).

Other factors identified as potentially influencing perinatal transmission of HIV to the fetus include length of time membranes are ruptured before birth, mode of birth, during of labour, especially prolonged second stage expulsion effort, increased maternal viral load levels, and multiple birth. Exposure to cervical and vaginal secretions is the likely mechanism of transmission to the newborn, rather than in utero exposure (Klirsfeld, 1998). Cesarean birth has been shown to be of undisputed benefit for preventing vertical transmission of HIV; however, complications after cesarean birth are more common in HIV-positive women than in uninfected women, and it is unknown whether postpartum morbidity is higher in HIV-infected than in women (Grubert et al., 1999; Perinatal HIV Guidelines Working Group, 2001). The American College of Obstetricians and Gynecologists (2001) issued recommendations on the use of cesarean birth as an intervention for prevention of HIV perinatal transmission.

Given strong social stigma attached to HIV infection, nurses must consider the issue of confidentiality and documentation before providing counseling and offering HIV testing to clients.

 

LEGAL TIP   HIV Testing

* If test results are placed in the woman's chart—the appropriate place for all health information—they are avaible to all who have access to the chart. The woman must be informed of this before testing. Informed consent must be obtained before an HIV test is performed. In some states, written consent is mandated.

* Counseling associated with HIV testing has two components: pretest and posttest counseling. During pretest counseling, nurses conduct a personalized risk assessment, explain the meaning of positive and negative test results, obtain informed consent for HIV testing, and help women develop a realistic plan for reducing risk and preventing infection. Posttest counseling includes informing the woman of the test results, reviewing the meaning of the results, and reinforcing infection prevention messages. All pretest and posttest counseling should be documented.

 

There is generally a 1-week to 3-week waiting period after testing HIV, which can be a very anxious time for the woman. It is helpful if the nurse informs her that this time period between blood drawing and test results is routine. Test results, whatever they are, always must be communicated in person and women informed in advance that such the procedure. Whenever possible, the person who provided the pretest counseling also should tell the woman her test results. Some women, when informed of negative results, may escalate their risk behaviors because of an equating of negativity with immunity. Others may belive that negative means "bad" and positive means “good”. Women’s reactions to a negative test should be explored, asking, "How do you feel?" HIV-negative result counseling sessions are another opportunity to provide education. Emphasis can be placed on ways in which a woman can remain HIV free. She should be reminded that if she has been exposed to HIV in the past 6 months, she should be retested, and that if she continues high risk be­haviors, she should have ongoing testing.

In posttest counseling to an HIV-positive woman, privacy with no interruptions is essential. Adequate time for the counseling sessions also should be provided. The nurse should make sure that the woman understands what a positive test means and review the reliability of the test results. Safer sex guidelines should be reemphasized. Referral for appropriate medical evaluation and follow-up should be made, and the need or desire for psychosocial or psychiatric referrals should be assessed.

The importance of early medical evaluation so that a baseline assessment can be made and prophylactic medication begun should be stressed. If possible, the nurse should make a referral or appointment for the woman at the posttest counseling session.

As the number of HIV-infected women escalates, prevention, education, and counseling activities must be di­rected toward all women. It is very difficult to keep abreast of the ever-changing picture of AIDS. Important sources of information are listed in the Resources at the end of the chapter.

Management

During the initial contact with an HIV-infected woman, the nurse should establish what the woman knows about HIV infection and that she is being cared for by a medical practitioner or facility with expertise in caring for persons with HIV infections, including AIDS. Psychologic referral also may be indicated. Resources such as counseling for death and dying, suicide prevention, financial assistance, and legal advocacy may be appropriate. All women who are drug users should be referred to a substance-abuse pro­gram. A major focus of counseling is prevention of transmission of HIV to partners.

Nurses counseling seropositive women wishing contraceptive information may recommend oral contraceptives and latex condoms or tubal sterilization or vasectomy and latex condoms. The IUD is not an ideal choice for the HIV-infected woman because of increased risk of infection. Insertion in a woman who is immunocompromised should be avoided (World Health Organization, 2000). Female condoms or abstinence can be offered to women whose partners refuse to use condoms.

No cure is available for HIV infection. Rare and unusual diseases are characteristic of HIV infection. Opportunistic infections and concurrent diseases should be managed vig­orously with treatment specific to the infection or disease. Discussion of the medical care of HIV-positive women and women with AIDS is beyond the scope of this chapter. The reader is referred to the Centers for Disease Control and Prevention AIDS hotlines and Internet websites for the current information and recommendations.

Routine gynecologic care for HIV-positive women should include a pelvic examination every 6 months. Careful Pap screening is essential because of the greatly in­creased incidence of abnormal findings. In addition, HIV-positive women should be screened for syphilis, gonor­rhea, chlamydia, and other vaginal infections.

Coinfection with syphilis is common in HIV-infected women, and unusual serologic responses have been docu­mented among HIV-infected persons who have syphilis (CDC, 2002b). Because treatment failures with benzathine penicillin are common, follow-up and evaluation must be done at 3, 6, 9, 12, and 24 months after therapy. Further­more, HIV infection increases susceptibility to neu­rosyphilis, which is difficult to differentiate clinically from HIV dementia.

 

VAGINAL INFECTIONS

Vaginal discharge and itching of the vulva and vagina are among the most frequent reasons a woman seeks help from a health care provider; more women complain of vaginal discharge than of any other gynecologic symptom. Vaginal discharge resulting from infection must be distinguished from normal secretions. Women who have adequate en­dogenous or exogenous estrogen will have vaginal secre­tions. Normal vaginal secretions, or leukorrhea, are clear to cloudy in appearance and may turn yellow after drying; the discharge is slightly slimy, is nonirritating, and has a mild, inoffensive odor. Normal vaginal secretions are acidic, with a pH range of 4 to 5. The amount of leukorrhea differs with phases of the menstrual cycle, with greater amounts occur­ring at ovulation and just before menses. Leukorrhea also is increased during pregnancy. Normal vaginal secretions contain lactobacilli and epithelial cells.

Vaginitis, or abnormal vaginal discharge, is an infection caused by a microorganism. The most common vaginal in­fections are bacterial vaginosis, candidiasis, and trichomo­niasis. Vulvovaginitis, or inflammation of the vulva and vagina, may be caused by vaginal infection; copious leuk­orrhea, which can cause maceration of tissues; and chemi­cal irritants, allergens, and foreign bodies, which may pro­duce inflammatory reactions.

BACTERIAL VAGINOSIS

Bacterial vaginosis (BV), formerly called nonspecific vaginitis, Haemophilus vaginitis, or Gardnerella, is the most common type of vaginitis (Plourd, 1997). BV is associated with preterm labor and birth. The exact etiology of BV is unknown. It is a syndrome in which normal H2O2 producing lactobacilli are replaced with high concentrations of anaerobic bacteria (Gardnerella and  Mobiluncus). With the proliferation of anaerobes,  the level of vaginal amines is increased, and the normal acidic pH of vagina is altered. Epithelial cells slough, and numerous bacteria attach to their surfaces (clue cells). When the amines are volatilized, the characteristic odor of BV occurs.

Screening and Diagnosis

A careful history may help distinguish BV from other vaginal infections if the woman is symptomatic. Women with previous occurrence of similar symptoms, diagnosis, and treatment should be queried, because women with BV often have been treated incorrectly because of misdiagnosis.

Most women with BV complain of a characteristic "fishy odor"; however, not all note it. The odor may be noticed by the woman or her partner after hete» heterosexual intercourse because semen releases the vaginal amines. When present, the BV discharge is usually profuse; thin; and white, gray, or milky in appearance. Some women also may have mild irritation or pruritis.

Microscopic examination of vaginal secretions is always done (Table 4). Both normal saline and 10% potassium hydroxide smears should be made. The presence of clue cells (vaginal epithelial cells coated with bacteria) by wet smear is highly diagnostic because the phenomenon is specific to BV (USPSTF, 2001b). Vaginal secretions should be tested for pH and amine odor. Nitrazine paper is sensitive enough to detect a pH of 4.5 or greater. The fishy odor of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum.

table 4 Wet Smear Tests for Vaginal Infections
INFECTION	TEST	POSITIVE FINDINGS
Trichomoniasis	Saline wet smear (vaginal secretions mixed with normal saline on a glass slide)	Presence of many white blood cell protozoa
Candidiasis	Potassium hydroxide (KOH) prep (vaginal secre­tions mixed with KOH on a glass slide)	Presence of hyphae and pseudohyphae (buds and branches of yeast cells)
Bacterial vaginosis	Normal saline smear Whiff test (vaginal secretions mixed with KOH)	Presence of clue cells (vaginal epithelian cells coated with bacteria) Release of fishy odor

 

Management

Treatment of bacterial vaginosis with oral metronidazole (Flagyl) is most effective (CDC, 2002b). Table 5 outlines treatment guidelines.

 

 

Table 5 Vaginal Infections and Drug Therapies for Women
DISEASE	NONPREGNANT WOMEN 13-17 YEARS OF AGE	NONPREGNANT WOMEN >I8 YEARS OF AGE	PREGNANT WOMEN	LACTATING WOMEN
Bacnerial vaginosis	Recommended: Metronidazole. 500 mg bid for 7 days (no alcohol) or Metronidazole gel 0.75%, 5 g per vagina bid for 7 days or Clindamycin cream 2%, 5 g per vagina for 7 days (less effective) or Alternatives: Metronidazole, 2 g orally once or Clindamycin, 300 mg orally bid for 7 days (less effective)	Recommended Metronidazole, 500 mg bid for 7 days (no alcohol) or Metronidazole gel 0.75%, 5 g per vagina bid for 7 days or Clindamycin cream 2%, 5 g per vagina for 7 days (less effective) or Alternatives: Metronidazole, 2 g orally once or Clindamycin, 300 mg orally bid for 7 days (less effective)	High risk asymptomatic or symptomatic women Recommended: Metronidazole, 250 mg orally tid for 7 days Alternatives: Metronidazole, 2 g orally once or Clindamycin, 300 mg orally bid for 7 days Low risk symptomatic women Recommended: Metronidazole, 250 mg orally tid for 7 days Alternatives: Metronidazole. 2 g orally once or Clindamycin, 300 mg orally bid for 7 days or Metronidazole gel 0.75%, 5 g per vagina bid for 5 days	Recommended: Clindamycin cream
Trichomoniasis	Recommended: Metronidazole, 2 g orally once Alternative: Metronidazole, 500 mg bid for 7 days	Recommended: Metronidazole. 2 g orally once Alternative: Metronidazole, 500 mg bid for 7 days	Recommended: Metronidazole, 2 g orally once	Not recommended during lactation; stop lactation, treat, resume in 48 hr after drug completed
Candidiasis	Numerous over-the-counter topical intravaginal agents: butoconazole, clotrimazole, miconazole, tioconazole, terconazole; treatment with azole drugs more effective than nystatin Dose varies by agent from a single dose to 3 days to 7 to 14 days Oral agent Fluconazole 150 mg oral tablet once	Numerous over-the-counter topical intravaginal agents: butoconazole, clotrimazole, miconazole, tioconazole, terconazole; treatment with azole drugs more effective than nystatin Dose varies by agent from a single dose to 3 days to 7 to 14 days Oral agent Fluconazole 150 mg oral tablet once	Over-the-counter topical azole intra-vaginal agents: butoconazole, clotrimazole, miconazole, terconazole. Use for 7 days. Oral agents not recommended	Over-the-counter topical azole intravaginal agents: butoconazole, clotrimazole, miconazole, terconazole Use for 7 days

 

Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent. Metronidazole was formerly contraindicated in the first trimester of pregnancy; however, because of the increased risk of preterm birth, current CDC guidelines recommend treatment of all asymptomatic pregnant women at high risk, as well as all symptomatic pregnant women (CDC, 2002). The medication is contraindicated if the woman is breastfeeding because high concentrations have been found in infants. If it is necessary to prescribe metronidazole for the lactating woman, she can suspend breastfeeding temporarily (pump and discard milk to maintain supply), and resume it 48 to 72 hours after taking the last dose. Metronidazole is contraindicated in clients with blood dyscrasia or central nervous system disease because in rare cases Flagyl may affect the hematopoietic or central nervous system.

Side effects of metronidazole are numerous, including sharp, unpleasant metallic taste in the mouth; furry tongue; central nervous system reactions; and urinary tract disturbances. When oral metronidazole is taken, the client is advised not to drink alcoholic beverages, or she will have the severe side effects of abdominal distress, nausea, vomiting, and headache. Gastrointestinal symptoms are common whether alcohol is consumed or not. Treatment of sexual partners is not recommended because sexual transmission of BV has not been proven (CDC, 2002b).

 

CANDIDIASIS

Vulvovaginal candidiasis, or yeast infection, is the second most common type of vaginal infection in the United States. Although vaginal candidiasis infections are com­mon in healthy women, those seen in women with HIV infection are often more severe and persistent. Genital candidiasis lesions may be painful, coalescing ulcerations necessitating continuous prophylactic therapy.

The most common organism is Candida albicans; it is estimated that 80% to 95% of the yeast infections in women are caused by this organism. However, in the past 10 years, the incidence of non-C. albicans infections has increased steadily. Women with chronic or recurrent infec­tions often are infected with a higher percentage of non-C. albicans species than are women with their first in­fection or are those who have few recurrences.

Numerous factors have been identified as predisposing a woman to yeast infections, including antibiotic therapy, particularly broad-spectrum antibiotics such as ampicillin, tetracycline, cephalosporins, and metronidazole; diabetes, especially when uncontrolled; pregnancy; obesity; diets high in refined sugars or artificial sweeteners; use of cor­ticosteroids and exogenous hormones; and immunosuppressed states. Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials create an envi­ronment in which a vaginal fungus can grow.

The most common symptom of yeast infections is vulvar and possibly vaginal pruritis. The itching may be mild or intense, interfere with rest and activities and occur during or after intercourse. Some women report a feeling of dryness. Other may have painful urination as the urine flows over the vulva; this usually occurs in women who have excoriations resulting from scrathing. Most often the discharge is thick, white, lumpy, and cottage cheese-like. The discharge may be found in patches on the vaginal walls, cervix, and labia. Commonly the vulva are red and the swollen, as are the labial folds, vagina, and cervix. Although there is no characteristic odor with yeast infections, sometimes a yeasty or musty smell occurs.

Screening and Diagnosis

In addition to a careful history of the woman's symptoms, their onset, and course, the history is a valuable screening tool for identifying predisposing risk factors. Physical examination should include a thorough inspection of the vulva and vagina. A speculum examination is always done. Commonly saline and KOH wet smear and vaginal pH are obtained. Vaginal pH is normal with a yeast infectiction; if the pH is greater than 4.5, trichomoniasis or BV should be suspected. The characteristic pseudohyphae (bud or branching of a fungus) may be seen on a wet smear done with normal saline; however, they may be confused with other cells and artifacts.

Management

A number of antifungal preparations are available for the treatment of C. albicans (see Table 5). In 1990, many of these medications (e.g., miconazole [Monistat] and clotrimazole [Gyne-Lotrimin]) were made available as over-the-counter (OTC) agents. The first time a woman suspects that she may have a yeast infection, she should see a health care provider for confirmation of the diagnosis and treatment recommendation. If she has another infection, she may wish to purchase an OTC preparation and self-treat. If she elects to do this, she should always be counseled regarding seeking care for numerous recurrent or chronic yeast infections. If vaginal discharge is extremely thick and copious, vaginal debridement with a cotton swab followed by application of vaginal medication may be useful.

Women who have extensive irritation, swelling, and discomfort of the labia and vulva may find sitz baths helpful in decreasing inflammation and increasing comfort Adding Aveeno powder to the bath also may increase the woman's comfort. Not wearing underpants to bed may help decrease symptoms and prevent recurrences. Completing the full course of treatment prescribed is essential to removing the pathogen, and women are instructed to continue medication even during menstruation. They should be counseled not to use tampons during menses because the medication will be absorbed by the tampon. If possible, intercourse is avoided during treatment; if this is not feasible, the woman's partner should use a condom to prevent introduction of more organisms. Suggested measures to prevent genital tract infections are outlined in the Teaching for Self-Care box.

 

TRICHOMONIASIS

Trichomoniasis is almost always a sexually transmitted infection. It also is a common cause of vaginal infection (up to 25% of all vaginitis) and discharge and thus is discussed in the section.

Trichomoniasis is caused by Trichomonas vaginalis, an anaerobic one-celled protozoan with characteristic tlagellae. Although trichomoniasis may be asymptomatic, commonly women have characteristically yellowish to greenish, frothy, mucopurulent, copious, malodorous discharge. Inflamation of the vulva, vagina, or both may be present, and the woman may complain of irritation and pruritis. Disuria and dyspareunia arc often present. Typically, the discharge worsens during and after menstruation. Often the cervix and vaginal walls will demonstrate the characteristic "strawberry spots" or tiny petechiae, and the cervix may bleed on contact. In severe infections, the vaginal walls, cervix, and occasionally the vulva may be acutely inflamed.

Screening and Diagnosis

In addition to obtaining a history of current symptoms, a careful sexual history should be obtained. Any history of similar symptoms in the past and treatment used should be noted. The nurse should determine whether the client's parent(s) were treated and if she has had subsequent relations with new partners.

A speculum examination is always done, even though it may be very uncomfortable for the woman; relaxation techniques and breathing exercises may help the woman with the procedure. Any of the classic signs may be present on physical examination. The typical one-celled flagellate trichomonads are easily distinguished on a normal saline wet prep. Trichomoniasis also may be identified on Pap smears. Because trichomoniasis is an STI, once diagnosis is confirmed, appropriate laboratory studies for other STIs should be carried out.

Management

The recommended treatment is metronidazole, 2 g orally in a single dose (CDC, 2002b) (see Table 5). Although the male partner is usually asymptomatic, it is recommended that he receive treatment also, because he often harbors the trichomonads in the urethra or prostate. It is important that nurses discuss the importance of partner treatment with their clients because if they are not treated, it is likely that the infection will recur.

Women with trichomoniasis need to understand the sexual transmission of this disease. The client must know that the organism may be present without symptoms being present, perhaps for several months, and that it is not possible to determine when she became infected. Women should be informed of the necessity for treating all sexual partners and helped with ways to raise the issue with their partners).

 

GROUP B STREPTOCOCCUS

Group B streptococcus (GBS) may be considered a part of the normal vaginal flora in a woman who is not pregnant, and it is present in 9% to 23% of healthy pregnant women. GBS infection is associated with poor pregnancy outcomes (Guise, 2001). Furthermore, GBS infections are an important factor in neonatal morbidity and mortality, usu­ally resulting from vertical transmission from the birth canal of the infected mother to the infant during birth (Lieu et al., 1998).

Risk factors for neonatal GBS infection include positive prenatal culture for GBS in the current pregnancy; preterm birth of less than 37 weeks of gestation; premature rupture of membranes for longer than 18 hours; intrapartum maternal fever higher than 38° C; and a positive history for early-onset neonatal GBS.

To decrease the risk of neonatal GBS infection, it is recommended that all women be screened at 35 to 37 weeks' gestation for GBS using a rectovaginal culture and intravenous antibiotic prophylaxis (LAP) be offered to all who test positive. If a culture is not available at onset of labor or if risk factor present, LAP is also offered. IAP is not recommended before a cesarean birth if labor or rupture of membranes has not occurred. The recommended treatment is penicillin G, 5 million units IV loading dose, and then 2.5 million units IV every 4 hours during labor. Ampicillin, 2 g loading dose IV, followed by 1 g IV every 4 hours, is an alternative therapy.

EFFECTS OF SEXUALLY TRANSMITTED INFECTIONS ON PREGNANCY AND THE FETUS

Sexually transmitted infections in pregnancy are responsible for significant morbidity and mortality. Some consequences of maternal infection, such as infertility and sterility, last a lifetime. Congenitally acquired infection may affect a child's length and quality of life. Table 6 describes the effects of several common STIs on pregnancy and the fetus. It is difficult to predict these effects with certainty. Factors such as coinfection with other STIs and when in pregnancy the infection was treated can affect outcomes.

 

 

Table 6 Pregnancy and Fetal Effects of Common Sexually Transmitted Infections
INFECTION	PREGNANCY EFFECTS	FETAL EFFECTS
Chlamydia	Premature rupture of membranes Preterm labor	Preterm birth Conjunctivitis Pneumonia
Gonorrhea	Intraamniotic infection Preterm labor Premature rupture of membranes Postpartum endometritis Miscarriage	Preterm birth Sepsis Conjunctivitis
Group B streptococcus	Preterm labor Premature rupture of membranes Chorioamnionitis Postpartum sepsis Urinary tract infections	Preterm birth Early-onset sepsis
Herpes simplex	Rare: infection	Systemic infection
Human papillomavirus (HPV)	Dystocia from large lesions Excessive bleeding from lesions after birth trauma	Respiratory papillomatosis (rare)
Syphilis	Preterm labor Miscarriage	Preterm birth Stillbirth Congenital infection

 

TORCH Infections

TORCH infections can affect a pregnant woman and her fetus. Toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus (CMV), and herpes simplex virus, known collectively as TORCH infections, form a group of organisms capable of crossing the placenta and adversely affecting the development of the ferns. Generally, all TORCH infections produce influenza-like symptoms in the mother, but fetal and neonatal effects are more serious. TORCH infections and their maternal and fetal effects are shown in Table 7.

 

Table 7 Maternal Infection: TORCH
INFECTION	MATERNAL EFFECTS	FETAL EFFECTS	COUNSELING: PREVENTION, IDENTIFICATION, AND MANAGEMENT
Toxoplasmosis (protozoa	Acute infection similar to influenza, lymphadenopathy Woman immune after first episode (except in immunocompromised clients)	With maternal acute infetion, parasitemia Less likely to occur with maternal chronic infection Miscarriage likely with acute infection early in pregnancy	Use good handwashing technique Avoid eating raw meat and exposure to litter used by infected cats; if cats in house, have toxoplasma titer checked If titer is rising during early pregnancy, abortion may be considered an option
Other Hepatitis A (infectious hepatitis (virus)	Miscarriage, cause of liver failure during pregnancy Fever, malaise, nausea, and abdominal discomfort	Exposure during first trimester, fetal anom­alies, fetal or neonatal hepatitis, preterm birth, intrauterine fetal death	Usually spread by droplet or hand contact especially by culinary workers; gamma-globulin can be given as prophylaxis for hepatitis A; vaccine is available for populations at risk
Hepatitis B (serum hepatitis (virus)	Symptoms variable: fever, rash, arthralgia, depressed appe­tite, dyspepsia, abdominal pain, generalized aching, malaise, weakness, jaundice, tender and enlarged liver	Infection occurs during birth Maternal vaccination during pregnancy presents no risk for fetus	Generally passed by contaminated needles, syringes, or blood transfusions or sexually; also can be transmitted orally (but incubation period is longer); hepatitis B immune globulin can be given prophylactically after exposure Hepatitis B vaccinations recommendations: universal infant immunizations, universal immunizations of previously unvaccinated adolescents age 11-12 yr, adolescents and adults at increased risk Populations at risk are women from Asia, Pacific Islands, Indochina, Haiti, South Africa, Alaska (women of Eskimo descent); other women at risk include health care providers, users of intravenous drugs, those sexually active with multiple partners or single partner with multiple risks
Rubella (3-day German measles) (virus)	Joint pain, muscle aches, rash, fever, mild symptoms; suboccipital lymph nodes may be swollen; some photophobia Occasionally arthritis or encephalitis Miscarriage	Incidence of congenital anomalies: first trimester 50°/o-90% Exposure during first 2 mo: malformations of heart, eyes, ears, or brain; abnormal dermatoglyphics Exposure after fourth mo: hearing loss, psychomotor retardation, systemic infection, hepatosplenomegaly, intrauterine growth restriction, rash, heart disease, cataracts	Vaccination of pregnant women contraindícate-pregnancy should be prevented for 3 mo after vaccination; pregnant women non reactive to hemagglutinin-inhibition antigen can be safely vaccinated after birth
Cytomegalovirus (CMV) (a herpesvirus)	Respiratory or sexually transmitted asymptomatic illness or mononucleosis-like syndrome, may have cervical discharge No immunity develops	Fetal death or severe, generalized disease: hemolytic anemia and jaundice, hydrocephaly or microcephaly, pneumonitis, hepatosplenomegaly, deafness, mental retardation	Virus may be reactivated and cause disease in utero or during birth in subsequent pregnancies; fetal infection may occur during passage through infected birth canal; disease is commonly progressive through infancy and childhood
Herpes genitalis (herpes simplex virus, type 2 [HSV-2])	Primary blisters, rash, fever, malaise, nausea, headache; pregnancy risks include miscarriage, preterm labor, stillbirths	Transmission occurs after rupture of membranes; congenital effects include skin lesions and scarring, IUGR, mental retardation, microcephaly Active HSV in first trimester, there is 20%-50% miscarriage/stillbirth rate	Risk of transmission is greatest during vaginal birth if woman has active lesions Acyclovir not recommended in pregnancy treat symptomatically

 

Toxoplasmosis

Toxoplasmosis is a protozoan infection associated with the consumption of infested raw or undercooked meat and with poor handwashing aftei handling infected cat litter.

Pregnant women with HIV antibodies are at higher risk because toxoplasmosis is a common accompanying opportunistic infection. The presence of toxoplasmosis can be determined through blood studies, although laboratory diagnosis is difficult. Women at risk for infection should have toxoplasmosis titers evaluated. Acute infection in pregnancy produces influenza-like symptoms and lymphadenopathy in some women but no symptoms in others. Miscarriage may occur.

The treatment of choice for toxoplasmosis is spramycin, sulfadine, or a combination of pyrimethamine and sulfadiazine. Although pyrimethamine may be potentially harmful to the fetus, treatment of the parasitemia is essential (Lopez, Dietz, Wilson, Navin, & Jones, 2000).

 

Other Infections

The primary infection included in the category of other infections is hepatitis, which was discussed previously. Infections other than hepatitis also may be identified as “other” TORCH infections. These include GBS, varicella, and HIV

 

Rubella

Rubella, also called German measles or 3-day measles, is a viral infection transmitted by droplets (such as from an infected person's sneeze). Rash, muscle aches, joint pain, and mild lymphedema are usually seen in the infected mother. Consequences for the fetus are much more serious and include miscarriage, congenital anomalies (referred as congenital rubella syndrome), and death. Vaccination of pregnant women is contraindicated because a rubella infection may develop after the live vaccine is administered. Rubella vaccine is given to women who are not immune as part of preconception counseling or in the postpartum period prior to discharge, with instructions to use contraception for at least 3 months after vaccination.

 

Cytomegalovirus

Maternal infection with CMV may begin as a mononucleosis-like syndrome. In most adults the onset of CMV infection is uncertain and asymptomatic; however, the disease may become a chronic persistent infection. Approximately 60% of the adult population have antibodies to CMV. This virus is primarily transmitted by close contacts but also has been isolated from semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces and banked blood. Maternal CMV infection may be diagnosed by presence of CMV in urine or in serum, because many women have evidence of CMV infection. Women who show CMV infection in pregnancy (by positive viral titers) usually have chronic or recurrent infections (Cowles & Gonik, 2002).

Women at risk for infection include those who work in or have children in day care centers, institutions for the mentally retarded, or certain health care settings (such as nursery, dialysis, laboratory, and oncology).

In the United States, 1% to 2% of infants have genital CMV infection. Fetal infection can cause microcephaly; eye, ear, and dental defects; and mental retardation. No treatment is available during pregnancy.

 

Herpes Simplex Virus

The potensial pregnancy effects of primary genital herpes include miscarriage, preterm labor, and intrauterine growth restriction. The main route of HSV transmission from mother to neonate is through an infected birth canal. The risk of maternal-infant transmission is greater during a primary HSV-2 infection than during recurrent episode. Cesarean birth is not recommended for all mother with HSV; only mothers with clinical evidence of active lesions during labor should have cesarean birth. Prenatal HSV cultures do not predict the presence of a live virus at time of birth. Cultures in women with HSV lesion at or near term may be done to determine the absence of the virus at time of birth and increase likelihood of a vaginal birth (see Table 2 for treatment guidelines).

CARE  MANAGEMENT

Women may delay seeking care tor STIs and other infections because they fear social stigma, have little accessibility to health care services, are asymptomatic, or are unaware that they have an infection.

Assessment and Nursing Diagnoses

A comprehensive assessment focuses on lifestyle issues that are often personal or sensitive. A culturally sensitive, non-judgental approach is essential to facilitate accurate data collection. Specific areas to address are listed in Box 3. A history that is accurate, comprehensive, and specific is diagnosis.

 

BOX 3 Essential Areas of Assessment for a Woman at Risk for or Who Has a Sexually Transmitted Infection CURRENT PROBLEM What symptoms are present? Vaginal discharge Lesions Rash Dysuria Fever Itching, Burning, Dyspareunia, Malaise MEDICAL HISTORY History of STIs Allergies, especially to medications MENSTRUAL HISTORY Last menstrual period (possibility of pregnancy) PERSONAL AND SOCIAL HISTORY Sexual History Sexual preference Number of partners (past, present) Types of sexual activity Frequency of sexual activity LIFESTYLE BEHAVIORS Intravenous drug use (or use by partner) Smoking Alcohol use Inadequate/poor nutrition High levels of stress, fatigue

 

History

Because many women are embarrassed or anxious, the history would be taken first, with the woman dressed. Information should be collected in a nonjudgmental manner by using open-ended questions and avoiding assumptions of sexual preference. All partners should be reffered to as partners and not by gender. A complete history is essential in identifying possible STIs. Factors that may influence the development and management of STIs in women include history of STI or PID, number of past or current sexual partners, and types of sexual activity. Women should be queried for specific lifestyle behaviors that place them at risk for STIs. Among these are intravenous drug use or partner intravenous drug use, smoking, alcohol use, inadequate or poor nutrition, and high levels of stress or fatigue.

 

Physical Examination

Before the actual physical examination is performed, the nurse should discuss the examination with the woman so she is prepared for it. A thorough assessment of symptoms including a comprehensive physical examination is essential to diagnosing STIs. Because the speculum usually is not lubricated before insertion into the vagina (cultures of vaginal secretions may have to be obtained), insertion may be more uncomfortable than usual. Women should be informed of this and reassured that every effort will be made to make the speculum examination as comfortable as possible.

 

Laboratory Tests

Appropriate laboratory studies will be suggested, in part, by the history and physical examination results. Bacterial STIs are easily determined from genital tract, urine, and blood studies. Viral agents also can be cultured, but less successfully. Because women often are infected with more than one STI simultaneously, and many are asympto­matic, additional laboratory studies may be done, including Pap smear, wet mounts, gonococcal culture, and VDRL or RPR test for syphilis. Cultures for HSV are obtained when indicated by history or physical examination. The woman should be offered the HIV-antibody test. When indicated, a complete blood count, sedimentation rate, urinalysis, or urine culture and sensitivity should be obtained.

Nursing diagnoses are derived after carefully analyzing assessment findings, medical management, and health care provider directives. The following nursing diagnoses are representative of those used in a plan of care for women with STIs and other vaginal infections:

Axiety/situational low self-esteem/disturbed body image related to

- erceived effects on sexual relationships and family processes -possible effects on pregnancy/fetus -long-term sequelae of infection

Deficient knowledge related to

-transmission/prevention of infection/reinfection

-safer sex behaviors

-management of infection

Acute pain/impaired tissue integrity related to

-effects of infection process -scratching (excoriation) of pruritic areas

-hygiene practices

Sexual dysfunction related to

-effects of infection process

Social isolation and impaired social interaction related to

-perceived effects on relationships with others if STI status is unknown

 

Expected Outcomes of Care

Care of the woman with an STI focuses on physical and psychologic needs. Avoidance of reinfection and harmful sequelae is critical. Measurable expected outcomes are mutually derived with the woman's input. Outcomes for the woman include that she will do the following:

•    Be free of infection or, in the case of viral infection, have remission or stabilization of the infection.

•    Identify and be able to discuss the etiology, management, and expected course of the infection and its prevention.

•    Be able to identify her risky behaviors and discuss plans for decreasing her risk for infection.

 

Plan of Care and Interventions

The woman with an STI will need encouragement to seek care at the earliest stage of symptoms. Counseling women about STIs is essential for (1) preventing new infections or reinfection; (2) increasing compliance with treatment and follow-up; (3) providing support during treatment; and (4) assisting women in discussions with their partner(s). Women must be made aware of the serious poten­tial consequences of STIs and the behaviors that increase the likelihood of infection.

The nurse must make sure that the woman understands what infection she has, how it is transmitted, and why it must be treated (see Teaching for Self-Care box). Women should be given a brief description of the infection in language that they can understand. This description should include modes of transmission, incubation period, symptoms, infectious period, and potential complications. Effective treatment of STIs necessitates careful, thorough explanation of the treatment regimen and follow-up procedures. Thorough, careful instructions about medications must be provided, both verbally and in writing. Side effects, benefits, and risks of the medication should be discussed. Unpleasant side effects or early relief of symptom may discourage women from completing their medication course. Clients should be strongly urged to take all the medication and not stop even if their symptoms diminish or disappear in a few days. Comfort measures to decrease symptoms such as pain, itching, or nausea should be suggested. Providing written information is a useful strategy because this is a time of high anxiety for many women, and they may not be able to hear or remember what they were told. A number of booklets on STIs are available, or the nurse may wish to develop literature that is specific to the practice setting and clients.

In general, women will be advised to refrain from intercourse until all treatment is finished and a repeat culture, if appropriate, is done. After the infection is cured, women should be urged to continue using condoms to prevent repeat infections, especially if they have had one episode of PID or continue to have intercourse with new partners. Women may wish to avoid having sex with partners who have many other sexual partners. All women who have contracted an STI should be taught safer sex practices, if this has not been done already. Follow-up appointments should be made as needed.

Addressing the psychosocial component of STIs is essential. A woman may be afraid or embarrassed to tell her partner or to ask her partner to seek treatment. She may be embarrassed to admit her sexual practices, or she may be concerned about confidentiality. The nurse may need to help the woman deal with the impact of a diagnosis of an STI on a committed relationship, for the woman is now faced with the necessity of dealing with "uncertain monogamy."

In many instances, sexual partners should be treated; thus the infected woman is asked to identify and notify all partners who might have been exposed. Often she will find this difficult to do. Empathizing with the client's feelings and suggesting specific ways of talking with partners will help decrease anxiety and assist in efforts to control infection. For example, the nurse might suggest that the woman say “I care about you and I'm concerned about you. That’s why I’m calling to tell you that I have a sexually transmitted infection. My clinician is ____ and she will be happy to talk with you if you would like." Offering literature and role playing situations with the client also may be assistance. It is often helpful to remind the woman that although this is an embarrassing situation, most person would rather know than not know that they have been exposed. Health professionals who take time to counsel their clients on how to talk with their partner(s) can improve compliance and case finding.

Interrupting the transmission of infection is crucial to STI control. For treatable and vaccine-preventable STIs, further transmission and reinfection can be prevented with referral of sex partners. Many STIs are reportable; all states require that the five traditional venereal diseases-gonorrhea, syphilis, chancroid, lymphogranuloma ven­ereum, and granuloma inguinale-be reported to public health officials. Many other states require that other STIs such as chlamydial infections, genital herpes, and genital warts be reported. In addition, all states require that AIDS cases be reported; 35 states require that HIV infection be reported. The nurse is legally responsible for reporting all cases of those diseases identified as reportable and should know what the requirements are in the state in which she or he practices. The woman must be informed when a case will be reported and told why. Failure to inform the woman that the case will be reported is a serious breech of professional ethics. Confidentiality is a crucial issue for many clients. When an STI is reportable, women must be told that they may be contacted by a health department epidemiologist. They should be assured that the information reported to and collected by health authorities is not available to anyone without their permission. Every effort, within the limits of one's public health responsibilities, should be made to reassure clients (see Plan of Care).

Management During Pregnancy

Treatment of specific STIs may he different tor the pregnant womam and may even be different at different stages of pregnancy. Tables 2 and 5 describe treatment of common STIs and vaginal infections during pregnancy

 

Infection Control

Infection Control measures are essential to protect care providers and to prevent nosocomial infection of clients, regardless of the infectious agent. The risk for occupational transmission varies with the disease. Even when the risk is low, as with HIV, the existence of any risk warrants reasonable precautions. Precautions against airborne disease transmission are available in all health care agencies. Standard Precautions (precautions to use in care of all persons for infection control) and additional precautions for labor and birth settings are listed in Box 4.

Evaluation

Evaluation is a continuous process. To be effective, evalu­ation is based on client-centered outcomes identified dur­ing the planning stage of nursing care. The nurse can be reasonably assured that care was effective to the extent that expected outcomes have been met.

 

Plan of Care Sexually Transmitted Infections Nursing Diagnosis Ineffective health maintenance related to prevention of sexually transmitted infections evidenced client positive diagnosis of sexually transmitted infection Expected Outcome Woman will verbalize which health practices directly led to positive diagnosis of o sexually transmitted infection. Nursing Interventions/Rationafes Inquire about woman's sexual history and sexual health practices to provide database for current problem. Use the therapeutic communication for private, nonjudgmental discussion to facilitate  learning and promote self-esteem. Provide emotional support to indicate awareness of woman's feelings about this sensitive topic. Provide information about transmission of disease, including cause, symptoms, and treatment for both partners to enhance woman's knowledge base and correct any misinformation. Discuss the use and importance of safe sexual practices to raise woman’s awareness and motivation to avoid future risk-taking behaviors. Instruct woman and sexual partner to complete medication regiment completely eradicate transmitted organism.   Nursing Diagnosis Impaired social Interaction related to diagnosis of sexually transmitted disease as evidenced by client verbal report Expected Outcome Woman will report increased incidences of social interraction Nursing Interventions/Rationafes Provide nonjudgmental, confidential therapeutic communication to increase woman's feelings of self-worth. Refer to support groups to provide group interaction, discussion, and information   Nursing Diagnosis Impaired tissue integrity related to effects of disease process as evidenced by client report of itching and vaginal discharge Expected Outcome Woman's tissue integrity will be restored. Nursing Interventions/Raltionales Assess, monitor, and document characteristics of the damaged skin area, including color, lesions, drainage, and edema to provide database. Instruct woman in correct genital hygiene practices to prevent further infection of damaged tissues with other organisms. Provide warm soaks or sin baths to promote comfort, circulation, and healing. Administer prescribed medications to promote comfort and eradication of organism. Provide written self-help materials and pamphlets to prevent further skin integrity loss. Teach woman to perform self-vulvar examination to encourage participation in self-care.   Nursing Diagnosis Anxiety related to diagnosis of STI Expected Outcome Woman will report decreased level of anxiety. Nursing Interventions/Raotionales Provide opportunity for therapeutic communication to promote trust and expression of feelings. Assist woman to identify effective coping mechanisms to decrease anxiety. Refer to support groups to share feelings and common effective strategies.

 

 

 

box 8-4 Standard Precautions Medical history and examination cannot reliably identify all persons infected with HIV or other blood-borne pathogens. Standard Precautions should therefore be used consistently in the care of all persons. These precautions apply to blood, body fluids, and all secretions and excretions, except sweat, nonintact skin, and mucous membranes. Standard Precautions are recommended to reduce the risk of transmission of microorganisms from known and unknown sources of infection (Bolyard, E. et al., 1998; CDC, 2001 b). 1. Prompt and thorough handwashing is recommended between client contacts. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed. 2. In addition to handwashing, all health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any person is anticipated. Latex gloves should be worn for touching blood and body fluids, mucous membranes, or nonintact skin of all persons; for handling items or surfaces soiled with blood or body fluids; and for performing venipuncture and other vascular access procedures. Gloves should be changed after contact with each client. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids. Leg coverings, boots, or shoe covers also can be worn to provide protection against splashes and may be recommended for certain procedures such as surgery. 3. All health care workers should take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needle-stick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be immediately placed in a puncture-resistant container for disposal; puncture-resistant containers should be located as close as is practical to the use area. 4. Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. 5. Health care workers who have exudative lesions or weeping dermatitis should refrain from all direct client care and from handling client care equipment until the condition resolves.   PRECAUTIONS FOR INVASIVE PROCEDURES An invasive procedure is surgical entry into tissues, cavities, or organs; or repair of major traumatic injuries (I) in an operating or birthing room, emergency department, or out-of-hospital setting, including both physicians' and dentists' offices; and (2) a vaginal or cesarean birth or other invasive obstetric procedure during which bleeding may occur. Standard Precautions, combined with the following precautions, should serve as minimum precautions for all such invasive procedures: 1. All health care workers who participate in invasive procedures must routinely use appropriate barrier precautions to prevent skin and mucous membrane contact with blood and other body fluids of all clients. Gloves and surgical masks must be worn for all invasive procedures. Protective eyewear or face shields should be worn for procedures that commonly result in the generation of droplets, splashing of blood or other body fluids, or the generation of bone chips. Gowns or aprons made of materials that provide an effective barrier should be worn during invasive procedures that are likely to result in the splashing of blood or other body fluids. All health care workers who perform or assist in vaginal or cesarean births should wear gloves and gowns when handling the placenta or the infant until blood and amniotic fluid have been removed from the infant's skin. Gloves should be worn during infant eye prophylaxis, care of the umbilical cord, circumcision site, parenteral procedures, diaper changes, contact with colostrum, and postpartum assessments. 2. If a glove is torn or a needle stick or other injury occurs, the glove should be removed and a new glove used as promptly as client safety permits; the needle or instrument involved in the incident also should be removed from the sterile field. 3. Any needle stick or other injury should be reported and appropriate treatment obtained as specified by the health care facility.

 

 

 

TEACHING FOR SELF-CARE Prevention of Genital Tract Infections * Practice genital hygiene * Choose underwear or hosiery with a cotton crotch. * Avoid tight-fitting clothing (especially tight jeans). * Select cloth car seat covers instead of vinyl. * Limit time spent in damp exercise clothes (especially swimsuits, leotards, and tights). * Limit exposure to bath salts or bubble bath, colored or scented toilet tissue. * If sensitive, discontinue use of feminine hygiene deodorant spray. * Use condomes * Void before and after intercourse. * Decrease dietary sugar. * Drink yeast-active milk and eat yogurt (with lactobacilli). * Do not douche. Sexually Transmitted Infections Take your medication as directed. Use comfort measures for symptom relief as suggested by your health care provider. Keep your appointment for repeat cultures or checkups after your treatment to make sure your infection is cured. Inform your sexual partner(s) to be tested and treated, if necessary. Abstain from sexual intercourse until your treatment is completed or for as long as you are advised by your health care provider. Use safer sex practices when sexual intercourse is resumed. Call your health care provider immediately if you notice bumps, sores, rashes, or discharges. Keep all future appointments with your health care provider, even if things appear normal

.
NEONATAL TORCH Infections

The occurrence of certain maternal infections during early pregnancy is known to be associated with various congenital malformations and disorders. The most common and best understood infections are TORCH infections (TORCH is an acronym for toxoplasmosis, other [gonorrhea, syphilis, varicella, hepatitis B virus, and human immunodeficiency virus (HIV)], rubella, cytomegalovirus, and herpes simplex virus) (Box 2). HSV may result in a severe, often fatal systemic illness in neonates. Survivors of herpetic infection may have residual neurologic defects and chorioretinitis. The other congenital infections also may result in encephalopathy with various anomalies, including microcephaly, chorioretinitis, intracranial calcifications, microphthalmos, and cataracts. To a certain extent the varied clinical manifestations of these infections overlap, but a specific diagnosis can be made by the clustering of clinical findings, as well as specific antibody studies (Fanaroff & Martin, 1997).

 

BOX 2 TORCH Infections Affecting Newborns T       Toxoplasmosis O       Other: gonorrhea, syphilis, varicella, hepatitis B virus (HBV), human immunodeficiency virus (HIV) R       Rubella C        Cytomegalovirus (CMV) infections or cytomegalic inclusion disease (CMID) H        Herpes simplex virus (HSV) infection

 

 

Toxoplasmosis

Toxoplasmosis is a multisystem disease caused by the protozoan Toxoplasma gondii. Eating cured, raw, or under-cooked meat puts women at high risk for contracting toxoplasmosis. Other significant risk factors are contact with soil and travel outside the United States, Europe, and Canada (Cook et al., 2000.) Hand-to-mouth contact after disposal of cat litter is less of a risk factor (Cook et al., 2000). Approximately 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring (Lynfield & Guerina, 1997). Fetal infection occurs in 0.07% to 0.11% of all pregnancies (Beazley & Egerman, 1998; Boyer, 1996). The diagnosis of toxoplasmosis in the neonate is supported by elevated levels of cord blood serum IgM.

More than 70% of affected infants are free of symptoms. The clinical features of toxoplasmosis resemble cytomegalic inclusion disease (CMID) in the infant. Both diseases are responsible for significant perinatal mortality and morbidity rates: 10% to 15% die, 50% have visual problems by age 1 year, and 85% have severe psychomo-tor problems or mental retardation by age 2 to 4 years.

Severe toxoplasmosis is associated with preterm birth, growth restriction, microcephaly or hydrocephaly, microphthalmos, chorioretinitis, CNS calcification, thrombocytopenia, jaundice, and fever. Petechiae or a maculopapular rash may also be evident. Some clinical manifestations do not develop until later in life. The affected infant may be treated with pyrimethamine, as well as oral sulfadiazine, but folk acid supplement will be required to prevent anemia.

 

Gonorrhea

The incidence of gonococcal infection in pregnant women ranges from 2.5% to 7.3% (Fanaroff & Martin, 1997); neonatal infection with Neisseria gonorrhoeae occurs frequently. After rupture of membranes, ascending infec­tion can result in orogastric contamination of the fetus. The organism also may invade mucosal surfaces such as the conjunctiva (ophthalmia neonatorum), rectal mucosa, and pharynx. Contamination may occur as the infant passes through the birth canal, or it may occur postnatally from an infected adult. Neonatal gonococcal arthritis, septicemia, meningitis, vaginitis, and scalp abscesses can also develop.

Eye prophylaxis (e.g., with 0.5% erythromycin oint­ment) is administered at or shortly after birth to prevent ophthalmia neonatorum. The infant with a mild infection often recovers completely with appropriate treatment, such as neonatal ceftriaxone. Occasionally, infants die of overwhelming infection in the early neonatal period.

 

Syphilis

Congenital and neonatal syphilis have reemerged in recent years as significant health problems. It is estimated that for every 100 women diagnosed with primary or secondary disease, 2 to 5 infants will contract congenital syphilis. If syphilis during pregnancy is untreated, 40% to 50% of neonates born to these women will have symptomatic congenital syphilis. Treatment failure can occur, particularly when treatment is given in the third trimester; therefore infants born to women treated after 20 weeks of gestation should be investigated for congenital syphilis. The following factors have been identified as placing the neonate at high risk for exposure to syphilis: inadequate prenatal care, single or teenage mother, substance abuse in mother or partner, multiple sexual partners or partner with known sexually transmitted infection (STI), past history of STI, poverty, homelessness, and HIV infection (Cloherty, 1998).

Fetal infestation with the spirochete Treponema pallidum is blocked by Langhans' layer in the chorion until this layer begins to atrophy between 16 and 18 weeks of gestation. If spirochetemia is untreated, it will result in fetal death by midtrimester miscarriage or stillbirth in one in four cases. All neonates in whom the infection occurs before 7 months of gestation are affected. Only 60% are affected if the infection occurs late in pregnancy. If maternal infection is treated adequately before the eighteenth week, neonates seldom demonstrate signs of the disease. Although treatment after the eighteenth week may cure fetal spirochetemia, pathologic changes may not be prevented completely.

Because the fetus becomes infected after the period of organogenesis (first trimester), maldevelopment of organs does not result. Congenital syphilis may stimulate preterm labor, but no evidence indicates that it causes IUGR. Stigmas of congenital syphilis may include inflammatory and destructive changes in the placenta; in organs such as the liver, spleen, kidneys, and adrenal glands; and in bone cov­ering and marrow. Disorders of the CNS, teeth, and cornea may not become evident until several months after birth.

The most severely affected infants may be hydropic (edematous) and anemic, with enlarged liver and spleen. Hepatosplenomegaly probably results from extramedullary hematopoietic activity stimulated by the severe anemia. In some infants, signs of congenital syphilis do not appear until late in the neonatal period. In these newborns, early signs, such as poor feeding, slight hyperthermia, and snuffles, may be nonspecific. Snuffles refers to the copious, clear, serosanguineous mucous discharge from the obstructed nose. A mucopurulent discharge indicates secondary infection, usually by streptococci or staphylococci.

By the end of the first week of life, a copper-colored maculopapular dermal rash appears in untreated newborn cases. The rash is characteristically first noticeable on the palms of the hands, the soles of the feet, the diaper area, and around the mouth and anus. The maculopapular le­sions may become vesicular and confluent and extend over the trunk and extremities. Condylomata (elevated wartlike lesions) may be seen around the anus. Rough, cracked, mucocutaneous lesions of the lips heal to form circumoral radiating scars termed rhagades.

If the mother was adequately treated before giving birth and serologic testing of the infant does not show syphilis, generally the infant is not treated with antibiotics. The in­fant is checked for antibody titer (received from the mother through the placenta) every 2 weeks for 3 months, at which time the test result should be negative. Some physicians recommend antibiotic therapy for asympto­matic or inconclusive cases.

Penicillin is the usual treatment (Hollier & Cox, 1998). Erythromycin is the substitute antibiotic of choice for infants sensitive to penicillin.

 

NURSE ALERT The infant is contagious until treated. Care providers should use Standard Precautions (contact isolation) in caring for the infant until the infant has been on antibiotics for 12 to 24 hours.

In general, treatment of syphilis is more effective if it is begun early rather than late in the course of the disease. However, a recurrence rate of 5% can be expected. Even adequate treatment of congenital syphilis after birth does not always prevent late (5 to 15 years after initial infection) complications. Potential complications include neu-rosyphilis, deafness, Hutchinson teeth (notched incisors), saber shins, joint involvement, saddle nose (depressed bridge), gummas (soft, gummy tumors) over the skin and other organs, and interstitial keratitis (inflammation of the cornea).

 

Va ricella -zos ter

The varicella-zoster virus responsible for chickenpox and shingles is a member of the herpes family. Approximately 90% of women in the childbearing years are immune; therefore the risk of infection in pregnancy is low, 0.7 to 3 per 1000 births (Birthhistle & Carrington, 1998; Chapman, 1998).

Varicella transmission to the fetus may occur across the placenta when the disease is contracted in the first half of pregnancy, but this is relatively infrequent. When transmission to the fetus does occur in the early part of pregnancy, the effects on the fetus include limb atrophy, neurologic abnormalities, eye abnormalities, and IUGR.

When maternal infection occurs in the last 3 weeks of pregnancy, 25% of infants born to these mothers will develop clinical varicella (Nathwani et al, 1998). The severity of the infant's illness increases greatly if maternal infection occurred within 5 days before or 2 days after birth. The mortality rate in severe illness is 30% (Chapman, 1998).

Seroimmune pregnant women exposed to active chickenpox can be given varicella-zoster immune globulin (VZIG), which does not reduce the incidence of infection but should decrease the effects of the virus on the fetus. To be effective, the immunoglobulin must be given within 12 hours of exposure.

Infants born to mothers who develop chickenpox between 5 days before birth and 48 hours after should be given VZIG at birth because of the risk of severe disease. Acyclovir can be used to treat infants with generalized involvement and pneumonia (Chapman, 1998; Nathwani et al., 1998).

Term infants exposed to chickenpox after birth will have a mild or no infection if they are born to immune moth­ers. Those born to nonimmune mothers may develop chickenpox, but the course is not usually severe. Experts are divided as to whether this group of infants should receive VZIG. Infants less than 28 weeks are at risk regardless of their mother's status and probably benefit from VZIG if exposed to chickenpox.

 

Hepatitis B virus

Hepatitis B virus (HBV) infection during pregnancy is not associated with an increase in malformations, still­births, or IUGR; however, approximately a 32% increase in risk exists for preterm birth (Fanaroff & Martin, 1997). The transmission rate of HBV to the newborn is as high as 90% when the mother is seropositive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) (Duff, 1998). Transmission occurs transplacentally, serum to serum, and by contact with contaminated urine, feces, saliva, semen, or vaginal secretions during birth. Infants are most frequently infected during birth or in the first few days of life. The rate of transmission is highest when the mother contracts the virus immediately before birth. These mothers will be positive for HBsAg. Transmission may occur through breast milk, but antigens also develop in formula-fed infants at the same or higher rate. Diagnosis is made by viral culture of amniotic fluid, as well as the presence of HBsAg and IgM in the cord or baby's serum.

Neonatal and fetal effects are serious. Preterm birth exposes the neonate to the problems of prematurity. Infants may be symptom free at birth or show evidence of acute hepatitis with changes in liver function. The mortality rate for full-blown hepatitis is 75%. Infants who become carriers are at high risk for chronic hepatitis, cirrhosis of the liver, or liver cancer even years later (Fanaroff & Martin, 1997).

Infants whose mothers have antibodies for HBsAg or who have developed hepatitis during pregnancy or the postpartum period should be treated with hepatitis B im­munoglobulin (HBIG), 0.5 ml intramuscularly, as soon as possible after birth-within the first 12 hours of life. Concurrently, but at a different site, the vaccine also should be given (Fanaroff & Martin, 1997). The second dose of vaccine is given at 1 month and the third dose at 6 months. The vaccine should protect the child for up to 9 years. After the infant has been cleansed thoroughly and has received the vaccine, breastfeeding may be initiated. Vaccination for infants not exposed to HBV is recommended before discharge; breastfeeding for these infants may begin before the vaccine is given (Corrarino, 1998).

 

Human immunodeficiency virus and acquired immunodeficiency syndrome

It is estimated that globally, more than 1 million children born to HIV-infected women acquire the virus each year (Mofenson, 1997). Since 1994, when research demonstrated that prenatal treatment of HIV-positive women reduced the vertical transmission of HIV to the fetus, there has been an almost 70% drop in the risk of transmission, from 25% to 8% (Minkoff, 1998). Most cases of pediatric acquired immunodeficiency syndrome (AIDS) result from maternal-to-fetal transmission. Universal counseling and screening of pregnant women is recommended in the United States and Canada (American College of Obstetricians and Gynecologists, 1997; Centers for Disease Control and Prevention, 1998).

Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmis­sion close to or at the time of birth is thought to account for 50% to 80% of cases (Franck & Johnson, 1998; Mofenson, 1997). Breastfeeding is contraindicated because postnatal transmission through breastfeeding may also occur.

Diagnosis of HIV infection in the neonate is complicated by the presence of maternal IgG antibodies, which cross the placenta after 32 weeks of gestation. The accuracy of all HIV tests varies according to the infant's age and is dependent on the viral load in the blood. The Centers for Disease Control and Prevention (CDC) recommends that at least two polymerase chain reaction assays or viral cultures be done before a definitive diagnosis is made (Franck & Johnson, 1998). Testing should be done in the first 48 hours of life, at age 1 to 2 months, and at age 3 to 6 months (CDC, 1998).

Typically, the HIV-infected neonate is asymptomatic at birth. These infants tend to be of lower birth weight than those born to noninfected mothers. Some have physical stigma from concurrent exposure to injectable drugs or other STIs. Early-onset HIV disease (virus detected within 48 hours of birth) is attributed to prenatal infection and occurs in 10% to 15% of infected infants (Franck & Johnson, 1998). These babies develop opportunistic infections (caused by an organism that does not usually cause illness) and rapid progression of immunodeficiency, which progresses to death in the first 1 to 2 years of life (Franck & Johnson, 1998).

The remainder of infants develop AIDS more slowly. From 80% to 90% of perinatally infected infants show signs by 1 year of life. Some children infected at birth show no signs of disease 8 to 10 years later (Scarlatti, 1996). The age of onset of symptoms predicts the length of survival. Children with late-onset infection receiving treatment may live into adolescence.

The signs and symptoms of HIV infection vary from severe immunodeficiency to nonspecific findings such as failure to thrive, parotitis, and recurrent or persistent upper respiratory infections. In the first year of life, lymphadenopathy and hepatosplenomegaly are common (Scarlatti, 1996). The infant may have fever, chronic diarrhea, chronic dermatitis, interstitial pneumonitis, persistent thrush, and AIDS-defining secondary infections. Common secondary infections include Pneumocystis carinii pneumonia, candidiasis, CMV infection, cryptosporidiosis, herpes simplex or herpes zoster, and disseminated varicella.

Although it is rare for an infant to be born with symptoms of HIV infection, all infants born to seropositive mothers should be presumed to be HIV positive. Management begins by implementing Standard Precautions. Measures should also be undertaken to protect the infant from further exposure to maternal blood and body fluids. The infant's skin should be cleansed with soap and water and alcohol before invasive procedures such as vitamin K administration or heel punctures. Umbilical cord stumps are cleaned meticulously every day until healing is complete. Isolation is not required, and the infant can usually be cared for in the normal nursery. The use of gloves is not required for care activities such as dressing or feeding the infant.

Regimens for the prevention of HIV transmission include treatment of the neonate with zidovudine for 6 weeks following birth or until the infant's HIV status is determined (CDC, 1998). If the infant is diagnosed with HIV infection, the family should be counseled about conventional and investigational treatment options.

Counseling regarding the care of the mothers themselves, the family's care of the infant, and future pregnancies challenges the caregiver. Some parents opt to place infected infants in foster homes despite the low risk for transmission among members of the same household. Social services are required in these cases. If the parent chooses to keep the infant, home health care may be arranged.

The family must be counseled about vaccinations. Children with symptomatic or asymptomatic HIV infection should receive all routine vaccines except oral poliovirus and varicella vaccines. The family should be advised that household contacts should not receive oral polio vaccine because the virus can be transmitted to the immunocompromised child. Inactivated poliomyelitis vaccine can be given (Franck & Johnson, 1998; Wong, 1999).

 

Rubella infection

Since rubella vaccination was begun in 1969, cases of congenital rubella infection have been reduced dramatically; however, it is still seen occasionally in the newborn. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella, also known as German measles or 3-day measles.

The risk for congenital anomalies varies with the gestational age of the fetus when maternal infection occurs. Abnormalities are most severe if the mother contracts the virus during the first trimester.

More than two thirds of infected infants have no symptoms apparent at birth, but sequelae may develop years later. Hearing loss, the most common result, appears to be progressive after birth. Congenital rubella syndrome comprises cataracts or glaucoma, hearing loss, and cardiac defects (pulmonary artery stenosis, patent ductus arteriosus, or coarctation of the aorta) (Rosa, 1998). Multiple other abnormalities may also be present, including IUGR, microphthalmia, hy-potonia, hepatosplenomegaly, thrombocytopenic purpura, dermatoglyphic abnormalities, bony radiolucencies, and brain wave abnormalities (Burchett, 1998). Severe infection may result in fetal death. Delayed effects of infection manifest as thyroid dysfunction, diabetes mellitus, growth hormone deficiency, myocarditis, glaucoma, microcephaly, and polycystic kidney disease (Fanaroff & Martin, 1997).

The rubella virus has been cultured in infants for up to 18 months after their birth. These infants are a serious source of infection to susceptible individuals, particularly women in the childbearing years. Extended pediatric isola­tion is mandatory until the noncontagious stage of rubella has been reached. (The infant should be isolated until pha-ryngeal mucus and urine are free of virus.)

 

Cytornegalovirus infection

CMV infection during pregnancy may result in miscarriage, stillbirth, or congenital or neonatal CMID. It is the most common cause of congenital viral infections in humans, occurring in 1% of all newborns (Fanaroff & Martin, 1997). Most (90% to 95%) of the affected infants are asymptomatic at birth; however, hearing loss and learning disabilities have been reported in previously asymptomatic infants (Brown & Abernathy, 1998).

The neonate with classic, full-blown CMID displays IUGR and has microcephaly. The neonate also has a rash, jaundice, and hepatosplenomegaly (Fig. 5). Anemia, thrombocytopenia, and hyperbilirubinemia are to be ex­pected. Intracranial, periventricular calcification often is noted on x-ray films. Inclusion bodies ("owl's eye" figures) in cells sedimented from freshly voided urine or in liver biopsy specimens are typical.

Fig. 5 Neonatal cytomegalovirus (CMV) infection. Typical rash seen in a severely affected infant. (Courtesy David A. Clarke, Philadelphia, PA.)

 

Elevated levels of cord blood IgM are suggestive of disease. The virus may be isolated from urine or saliva of the newborn. Differential diagnosis includes other causes of jaundice, syphilis (positive Venereal Disease Research Laboratories [VDRL] findings), toxoplasmosis (positive Sabin-Feldman dye test result), hemolytic disease of the newborn (positive Coombs' test reaction), or coxsackievirus infection (positive culture).

Despite the extensive, endemic nature of the disease in women and men and its potential for havoc in perinatal life, critically affected newborns are born only occasionally. Milder forms of the disease often result when the fetus is affected late in pregnancy. CMV can be transmitted through breast milk while the mother is experiencing acute CMV syndrome. CMV infections acquired after birth are often asymptomatic and have no sequelae. Exceptions to this occur in preterm infants, in whom postnatal acquisition of CMV can result in pneumonia, hepatitis, thrombocytopenia, and long-term neurologic sequelae.

Antenatally infected infants who are asymptomatic at birth are at risk for late sequelae. Hearing loss may not be apparent until after the first year of life. Chorioretinitis, microcephaly, mental retardation, and neuromuscular deficits may occur by 2 years of age. Some children are at risk for a defect in tooth enamel, resulting in severe caries.

 

Herpes simplex virus

HSV infections among newborns are being diagnosed more frequently. HSV infection is estimated to occur in as many as 1 in 2000 to 1 in 5000 births (Fanaroff & Martin, 1997).

The neonate may acquire the virus by any of four modes of transmission (Riley, 1998):

* Transplacental infection

* Ascending infection by way of the birth canal

* Direct contamination during passage through an infected birth canal

* Direct transmission from infected personnel or family

Congenital infection is rare and characterized by in utero destruction of normally formed organs. Affected in­fants are growth restricted. They have severe psychomotor restriction, with intracranial calcifications, microcephaly, hypertonicity, and seizures. They suffer eye involvement, including microphthalmos, cataracts, chorioretinitis, blindness, and retinal dysplasia. Some infants have patent ductus arteriosus, limb anomalies, and recurrent skin vesi­cles, with a short life expectancy.

Most infants are infected directly during passage through the birth canal. The risk of infection during vaginal birth in the presence of genital herpes has not been clearly delineated. It may be as high as 40% to 60%, with active primary infection at term. Primary maternal infections after 32 weeks of gestation carry a higher risk for the fetus and newborn than do recurrent infections (Fanaroff & Martin, 1997). The transmission rate of chronic vaginal herpes from the pregnant woman to her newborn is low. Passive intrauterine immunity to herpes may be responsible.

Postnatal acquisition of the virus and spread within a nursery have been documented by DNA analysis. Both mother and father, as well as maternal breast lesions, have been implicated in neonatal infections. There also is concern regarding symptomatic and asymptomatic shedding among hospital personnel. Nursery personnel with cold sores should practice strict handwashing and wear a mask, but no evidence indicates they should be removed from the nursery unless they have a herpetic whitlow (primary HSV infection of the terminal segment of a finger) (Fanaroff & Martin, 1997).

Clinically, neonatal HSV infections are classified as diseminated infection; encephalitis; or localized infection of the skin, eye, or mouth. Disseminated infections may involve virtually every organ system, but the liver, adrenal glands, and lungs are primarily involved. Affected infants exhibit initial symptoms usually in the first week of life but sometimes in the second week, with signs of bacterial sep­sis or shock. Clinical manifestations include skin vesicles in approximately 50% of infants (Fig. 6). Death results from progression of CNS involvement, respiratory distress and pneumonitis, shock, disseminated intravascular coagulation (DIC), and bleeding. Overall, the mortality rate without antiviral therapy is 57% (Riley, 1998).

 

Fig. 6 Neonatal herpes simplex virus (HSV) skin infection. (From Behrmann, R. [1973]. Neonatology: Diseases of the fetus and infant. St. Louis: Mosby.)

Gloves should be worn when caregivers are in contact with these infants. The neonate's eyes, oral cavity, and skin are inspected carefully for the presence of any lesions (Fig. 7). Cultures are obtained from the mouth, eyes, and any possible lesions. Circumcision, if performed, is delayed until the infant is ready to be discharged. The infant may be discharged with the mother if the infant's cultures are negative for the virus. As long as no suspicious lesions are on the mother's breasts, breastfeeding is allowed. For the infant at risk, prophylactic topical eye ointment (vidarabine) is administered for 5 days to prevent keratocon-junctivitis. No current recommendations exist for prophylactic systemic therapy; each case should be considered individually. Blood, urine, and CSF specimens should be cultured when indicated clinically. If herpetic lesions first occur after 6 weeks of life, the risk of dissemination and severe illness is very low (Fanaroff & Martin, 1997).

 

Fig. 7 Neonatal HSV oral lesions. (Courtesy David A. Clarke, Philadelphia, PA.)

 

Therapy includes general supportive measures, as well as treatment with vidarabine or acyclovir. Acyclovir is the most frequently used drug. It is considered safe because only viral replication is inhibited, although long-term sequelae are not yet known. Acyclovir is easier to administer; there is no difference between vidarabine and acyclovir for treatment of HSV (Jacobs, 1998). Continuing therapy may be required in recurrences. Ophthalmic ointment should be administered simultaneously (Fanaroff & Martin, 1997).

 

Bacterial Infections

Group B streptococci

Group B streptococci (GBS) are the most common cause of neonatal sepsis and meningitis in the United States (Lieu et al., 1998). The incidence of early-onset GBS infection is 0.7 to 4 per 1000 live births (Guerina, 1998). Early-onset GBS infection in the neonate occurs in the first 7 days after birth but most commonly manifests in the first 24 hours following birth. Risk factors for the development of early-onset GBS include low birth weight, preterm birth, rupture of membranes of more than 18 hours, maternal fever, previous GBS infant, maternal GBS bacteriuria, and multiple gestation (Guerina, 1998). Usually resulting from vertical transmission from the birth canal, early-onset disease results in a respiratory illness that mimics the symptoms of severe respiratory distress. The infant may rapidly develop septic shock, which has a significant mortality rate. Prophylactic antibiotics given to mothers with risk factors during labor significantly reduce the incidence and severity of early-onset GBS infection in the newborn (Lieu et al., 1998).

Late-onset GBS infection manifests between 1 week and 3 months of age with an average age of onset of 24 days. Eighty-five percent of infants with late-onset GBS have meningitis, with a mortality rate of 0% to 23%. Fifty percent of the survivors develop neurologic damage (Adriaanse et al., 1996).

 

Escherichia coli

E. coli is the second most common cause of neonatal sepsis and meningitis in the United States (Guerina, 1998). E. coli is found in the GI tract soon after birth and makes up the bulk of human fecal flora. In addition to meningitis, E. coli can cause infections in other body systems, including the urinary tract. There is concern that increasing the use of ampicillin in labor as prophylaxis against GBS infection will result in more virulent E. coli infection resulting from ampicillin-resistant organisms (Joseph, Pyati, & Jacobs, 1998).

 

Tuberculosis

The incidence of tuberculosis (TB), caused by Mycobacterium tuberculosis, is increasing in Canada and the United States. Congenitally acquired TB, although rare, can cause otitis media, pneumonia, hepatosplenomegaly, enlarged lymph glands, or disseminated disease. After birth, exposed infants contract TB through droplets expelled by in­fected individuals, which results in pneumonia and necro­sis of lung tissue. Untreated neonatal tuberculosis is almost always fatal.

 

Chlamydia infections

Chlamydia trachomatis is an intracellular bacterium that causes neonatal conjunctivitis and pneumonia. The con­junctivitis (congestion and edema), with minimal discharge, develops 5 days to 2 weeks after birth. Inclusion conjunctivitis is usually self-limiting, but, if untreated, chronic follicular conjunctivitis with conjunctival scarring and corneal microgranulations has been reported (Schachter & Grossman, 1995)

The neonate is treated with oral erythromycin for 2 to 3 weeks. Silver nitrate is not effective against C. trachoma-tis, but erythromycin or tetracycline ointment may prevent ophthalmic infection (Fanaroff & Martin, 1997). Eye pro­phylaxis is not sufficient to prevent the development of chlamydial pneumonia; therefore infants at risk should also be treated with systemic antibiotics such as oral eryth­romycin syrup.

 

Fungal infections

Candidiasis. Candida infections, formerly known as moniliasis, may occur in the newborn. Candida albicans, the organism usually responsible, may cause disease in any organ system. It is a yeastlike fungus (producing yeast cells and spores) that can be acquired from a maternal vaginal infection during birth; by person-to-person transmission; or from contaminated hands, bottles, nipples, or other articles. It usually is a benign disorder in the neonate, often confined to the oral and diaper regions (Wong, 1999).

Candidal diaper dermatitis appears on the perianal area, inguinal folds, and lower portion of the abdomen. The affected area is intensely erythematous, with a sharply demarcated, scalloped edge, frequently with numerous satellite lesions that extend beyond the larger lesion. The source of the infection is through the GI tract. Treatment is with applications of an anticandidal ointment, such as nystatin (Mycostatin) or miconazole 2% (Monistat), with each diaper change. The infant also may be given an oral antifungal preparation to eliminate any GI source of infection (Wong, 1999).

Oral candidiasis (thrush, or mycotic stomatitis) is characterized by the appearance of white plaques on the oral mucosa, gums, and tongue. The white patches are easily differentiated from milk curds; the patches cannot be removed and tend to bleed when touched. In most cases the infant does not seem to be in discomfort from the infection. A few infants seem to have difficulty swallowing.

Infants who are sick, debilitated, or receiving antibiotic therapy are more susceptible to thrush. Those with conditions such as cleft lip or palate, neoplasms, and hy-perparathyroidism seem to be more vulnerable to mycotic infection.

The objectives of management are to eradicate the causative organism, to control exposure to C. albicans, and to improve the infant's resistance. Interventions include maintenance of scrupulous cleanliness to prevent reinfection (nursing personnel, parents, others). Good handwashing technique is always essential. Clean surfaces should be provided for neonates. Proper cleanliness of the equip­ment and environment is ensured. If the infant is breastfeeding, the mother is also treated with topical nystatin.

Medications are administered as ordered. Nystatin is instilled into the newborn's mouth with a medicine dropper after the infant is given sterile water to wash out any residual milk. Nystatin may also be swabbed over mucosa, gums, or tongue. Less frequently, an aqueous solution of gentian violet (1% to 2%) is applied with a swab to oral mucosa, gums, and tongue. The nurse should guard against staining the skin, clothes, and equipment and should warn parents about the purple staining of the baby's mouth.