Sexually Transmitted Infections

Abnormal vaginal discharge

Genital ulcers

Genital warts

Syphilis & postitive RPR tests

ABNORMAL VAGINAL DISCHARGE

Perform a vaginal speculum examination to observe the discharge & inspect the cervix. If no speculum is available, simple digital vaginal examination can be done.

• If vaginal candidiasis (thrush) is observed, give clotrimazole single-dose pessary 500 mg to be inserted in the vagina that evening. Advise the woman to avoid washing with soap or antiseptics
• If a nonspecific yellow/green or offensive discharge is observed, give metronidazole 2 g orally as a single dose (for trichomoniasis or bacterial vaginosis). In the first trimester, give clotrimazole pessary 500 mg instead of metronidazole
• If a mucopurulent discharge from the cervical os is observed on speculum examination, add ceftriaxone 250 mg IM (mixed with 0.9 mL lidocaine 1%), & azithromycin 1 g orally as a stat dose. Do not use ciprofloxacin or doxycycline in pregnant women

GENITAL ULCERS

• Give benzathine penicillin 2.4 million units IM (mixed with 6 mL lidocaine 1%) as a single dose (for syphilis) & azithromycin 1 g oral single dose (for chancroid)
• For pregnant women who are allergic to penicillin, consider penicillin desensitization & then give penicillin (page 128)
• Check or repeat RPR (if initially negative)
• Encourage the woman to send her partner for examination & treatment
• Follow up in 1-2 weeks to assess response
• For ulcers that appear to be caused by genital herpes, give acyclovir 400 mg 8 hourly for 7 days
• Further details on syphilis treatment are given below

GENITAL WARTS

These are caused by the human papillomavirus & are sexually transmitted.

• Do not attempt to treat the warts
• Podophyllin is contraindicated in pregnancy
• For large foul-smelling & infected warts, try metronidazole 400 mg 3 times daily orally for 7 days, or local applications with crushed metronidazole powder, vinegar, &/or honey or golden syrup
• Reassure the woman that the warts may resolve after the pregnancy & can be treated postnatally if they persist
• Surgical excision of warts may be considered in exceptional cases – discuss with an experienced consultant
• Consider elective caesarean section when warts are so large as to obstruct vaginal delivery

SYPHILIS & POSITIVE RPR TESTS

Treat all women with positive RPR, irrespective of titre values

• Do not do specific treponemal tests (FTA-ABS, TPHA, TPAB) unless there is a strong suspicion of a false positive RPR, & follow up is guaranteed
• Give benzathine penicillin 2.4 million units IM (mixed with 6 mL lidocaine 1%) once weekly for 3 doses
• Repeat RPR 3 months after the last dose of penicillin to exclude reinfection.  Retreatment is only necessary if the titre has increased. Give one injection only
• Penicillin desensitisation is recommended if the RPR titre is ≥1:16 for women who are allergic to penicillin. If a macrolide was used, the baby should be treated with penicillin after delivery
• Notify partner to go for examination & treatment

Penicillin desensitization

This is done for pregnant women who are allergic to penicillin & who have a high RPR titre (≥1:16). This is necessary because oral erythromycin may not transfer adequately to the fetus.

Penicillin desensitisation takes about 4 hours, & is followed by close observation until the following day. Use oral penicillin V, with a starting dose of 100 units, doubling every 15 minutes. Give the benzathine penicillin injection 30 minutes after the last oral dose. Second & third doses are given at weekly intervals one hour after a 400 000 unit dose of oral penicillin V, with similar precautions as described below.

Oral desensitization regimen

Precautions with desensitization

• Admit to a high care area
• Get informed consent
• Place an IV line
• Measure 4 hourly temperature, hourly BP & ½ hourly heart and respiratory rate
• Treat mild allergic reactions with promethazine 25 mg IV, & continue with the regimen