South Dakota Perinatal Association 2015 Annual Conference Friday September 11, 2015 Annie L. Siewert, MD MS FACOG

Also known as Venereal Disease Derived from word “Veneris or Venus”. Greek God of Love CDC estimates 333 million new cases of STIs worldwide 65 million people in US are living with an STI Medical costs estimated $13 billion per year in U.S. 50% of sexually active individuals will contract an STI before age 25 A young woman is 4X more likely to contract STI than to become pregnant Sexually Transmitted Infections Venus de Milo

1)Discuss the diagnosis of sexually transmitted diseases 2)Discuss up to date treatment of sexually transmitted infections in obstetrics 3)Discuss up to date management of sexually transmitted infections in obstetrics Objectives

Gynecology Patients USPTF: recommend an annual chlamydia screening All sexually active adolescents Young adult females 24 years of age and younger Pregnant females Females and males at high risk Screening for STDs National Chlamydia Coalition. Developments in STD Screening: Chlamydia Testing

Pregnancy *in high risk populations Screening for STDs STDTiming HIV1 st Prenatal Visit 3 rd trimester* Syphilis1 st Prenatal Visit 3 rd trimester* Delivery* Chlamydia1 st Prenatal Visit 3 rd trimester* If +screen=TOC Gonorrhea*1 st Prenatal Visit 3 rd trimester* If +screen=TOC Hepatitis B1 st Prenatal Visit Hepatitis C*1 st Prenatal Visit

2015 Sexually Transmitted Diseases Treatment Guidelines

CDC STD Treatment App: “There’s an app for that!”

Caused by polymicrobial anaerobic bacteria in vagina G. vaginitis, ureaplasma, mycoplasma Associated with having multiple male or female partners, a new sex partner, douching, lack of condom use, and lack of vaginal lactobacilli Women who have never been sexually active can also be affected NOT thought to be sexually transmitted Bacterial Vaginosis Updated Summary of 2010 CDC Treatment Guidelines

Clinical criteria require three of the following symptoms or signs Homogeneous, thin, white discharge that smoothly coats the vaginal walls clue cells (e.g., vaginal epithelial cells studded with adherent coccoobacilli) on microscopic examination pH of vaginal fluid >4.5; or a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test). Other testing methods: DNA hybridization probe test for high concentrations of G. vaginalis OSOM BV Blue test (Sekisui Diagnostics, Framingham, MA), which detects vaginal fluid sialidase activity Bacterial Vaginosis: Diagnosis

Associated with PROM, PTL, PTD, intramniotic infection, and post partum endometritis Only benefit from treatment is reduction in symptoms Treatment of asymptomatic patients Patients at low risk for PTL USPTF recommends not screening One study did demonstrate a 40% reduction in PTD in patients treated with oral clindamycin at 13-22W gestation Patients at high risk of PTL Data is inconclusive 7 trials have been performed: 1 showed harm, 2 showed no benefit, 4 demonstrated benefit Bacterial Vaginosis in Pregnancy 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Diesease Control

Oral therapy is preferred Metronidazole 500mg po BID for 7 days Metronidazole 250mg po TID for 5 days Clindamycin 300mg po BID for 7 days Treatment in Pregnancy Bacterial Vaginosis **Several trials have demonstrated increase in adverse events when intravaginal clindamycin cream was used**

Infects 4 million people per year in US 75% of women and 50% of men are asymptomatic Greek for “cloak” because early scientists thought it “cloaked” the nucleus of the infected cell Shares a common ancestor with plants Important cause of infertility *CHLAMYDIA* Name that STI…

Treatment in Pregnancy Azithromycin 1g po X1 Alternatives: Amoxicillin 500mg po BID for 7 days Erythromycin base 500 mg orally four times a day for 7 days Erythromycin base 250 mg orally four times a day for 14 days Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days TOC recommended 3-4 weeks after treatment Rescreen in 3 rd trimester Chlamydia Treatment

Infects 718,000 people in US Named by Galen in AD 131 Name means “flow of seed” due to discharge Also known as the *Gonorrhea* Name that STI…

Quinolone resistant strains are dispersed worldwide. Quinolones are not recommended for treatment as of 2007 Increased resistance to cephalosporins noted Gonococcal Isolate Surveillance Project (GISP) CDC supported sentinel surveillance system developed in 1986 Samples 3% of US men with Gonococcal infections Susceptibility testing from Increasing resistance to cefixime No decreased resistance to ceftriaxone Therefore oral cephalosporins are no longer recommended first line treatment Gonorrhea: Antibiotic Resistance Updated Summary of CDC Treatment Guidelines, 2010: Oral Cephalosporins No a Longer Recommended Treatment for Gonococcal Disease

Ceftriaxone 250mg IM X1 PLUS Azithromycin 1g po X1 PCN allergic Potential therapeutic options *Gentamicin 240 mg IM plus Azithromycin 2 g po Spectinomycin for treatment of urogenital and anorectal gonorrhea can be considered when available Pregnancy Gonorrhea: Antibiotic Resistance **TOC should be done 1 week after treatment; preferably by culture** 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Surveillance by physicians critical If ceftriaxone treatment failure is diagnosed: Perform culture and sensitivity Consult specialist for treatment recommendations Report to CDC through state STD/HIV Prevention center CDC telephone Gonorrhea: Antibiotic Resistance Updated Summary of CDC Treatment Guidelines, 2010: Oral Cephalosporins No a Longer Recommended Treatment for Gonococcal Disease

Most prevalent nonviral STI in US Over 180 Million cases world wide 7.4 million new cases yearly Causes “strawberry cervix” Can be a little tricky under the microscope Name that STD… *Trichomoniasis*

Associated with adverse pregnancy outcomes premature rupture of membranes preterm delivery, delivery of a low birthweight infant Perinatal transmission is rare However, treatment may prevent respiratory or genital infection of the newborn Trichomoniasis 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Consideration of Routine Screening in certain populations: high-prevalence settings (e.g., STD clinics and correctional facilities) asymptomatic persons at high risk for infection multiple sex partners exchanging sex for payment illicit drug use history of STI Screening symptomatic pregnant patients is recommended. Symptoms Vaginal discharge Strawberry cervix Trichomoniasis 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Metronidazole 2g po X1 Tinidazole 2g po X1 Alternative Metronidazole 500mg po for 7 days General Treatment and Pregnancy Trichomoniasis 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Infects 1.6 million people yearly in US Nearly 1 in 5 Americans are in infection 50% of patients do not know they have infection Name that STD… *Genital Herpes*

Most recurrent infections are caused from HSV-2 HSV-1 is becoming more prevalent in anogenital infections Genital Herpes Simplex 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

First Clinical Episode Acyclovir 400mg TID for 7-10 days Acyclovir 200mg 5X/day for 7-10 days Famciclovir 250mg TID for 7-10 days Valacyclovir 1g BID for 7-10 days Episodic Treatment for Recurrence Acyclovir 400mg TID for 5 days Acyclovir 800mg BID for 5 days Acyclovir 800mg TID for 2 days Famciclovir 125mg BID for 5 days Famciclovir 1000mg BID for 1 day Famciclovir 500mg once, followed by 250mg BID X2 days Valacyclovir 500mg BID for 3 days Valacyclovir 1g daily for 5days Genital Herpes Simplex 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Acyclovir 400mg TID starting at 36 weeks Valacyclovir 500mg BID starting at 36 weeks Pregnancy Genital Herpes Simplex ACOG Practice Bulletin #

I am the fastest growing STD It is estimated that nearly 98% of strains are asymptomatic Greater than 50% of sexually active people will be infected at some point in their lives Causes 6.2 Million new cases per year 91% of new infections resolve spontaneously within in first two years *Human Papilloma Virus and Genital Warts* Name that STD…

May worsen during pregnancy. May also bleed. Resolution of an exacerbation may not occur until pregnancy is over. HPV types 6 and 11 can cause respiratory papillomatosis in infants and children Cesarean delivery is NOT indicated solely to prevent transmission of HPV infection to the newborn. Cesarean delivery IS INDICATED for women with anogenital warts if obstruction of birth canal is a concern or excessive bleeding is a concern. Pregnant women with anogenital warts should be counseled concerning the low risk for recurrent respiratory papillomatosis Genital Warts 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Genital Warts Treatment in pregnancy Cryotherapy with liquid nitrogen. Surgical removal TCA or BCA 80%–90% solution Podofilox (podophyllotoxin), podophyllin, and sinecatechins should not be used during pregnancy. Imiquimod appears to pose low risk but should be avoided until more data are available Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Named after Greek God who was cursed with terrible disease after insulting Apollo Physicians in the 1400s were so afraid of this that they refused to write its name. Instead they used Greek letter Σ Christopher Columbus may have been responsible for spreading this disease to Europe Up to 1/3 of all patients in mental institutions at the beginning of the 20 th century were suffering from this Notable historical figures who were thought to have this were Al Capone, Adolf Hitler, Benito Mussolini, and Napoleon *Syphilis* Name that STD…

Stages of Infection Primary infection Ulcer or chancre at the infection site Secondary infection skin rash, mucocutaneous lesions, and lymphadenopathy, neurologic infection Latent infection Diagnosed by serologic testing No clinical signs of infection Early Latent Syphilis: acquired within the preceding Late Latent or Unknown Duration: all other cases of latent syphilis Syphilis 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

DiseaseTimingPositive Test Syphilis1 st Prenatal Visit 3 rd trimester Delivery **IUFD >20W Confirmatory testing with Non-treponemal tests with titers Syphilis Screening in Pregnancy 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Benzathine penicillin G 2.4 million U IM +/- additional dose of Benzathine penicillin G 2.4 million U IM 1 week after initial dose Primary or Secondary Benzathine penicillin G 2.4 million units IM in a single dose Early latent Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week interval Late Latent Syphilis or Latent Syphilis of Unknown Duration Primary or Secondary Syphilis: Treatment 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Ultrasound evaluation of fetus Sonographic signs of fetal or placental syphilis indicate a greater risk for fetal treatment failure Increased risk of PTL (esp with Jarisch-Herxheimer reaction to treatment) Screen for HIV Syphilis: Other management considerations 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Team approach is critical Titers should be repeated at 28–32 weeks’ gestation and at delivery Serologic titers can be checked monthly in women at high risk for reinfection or in geographic areas in which the prevalence of syphilis is high Increased risk of inadequate treatment Delivery occurs within 30 days of treatment Clinical signs of infection at delivery Titer at delivery is 4X higher than the pretreatment titer. Syphilis: Treatment Follow-up 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

References Williams Gynecology. First edition. Gynecologic Infection Updated Summary of CDC Treatment Guidelines, 2010: Oral Cephalosporins No a Longer Recommended Treatment for Gonococcal Disease National Chlamydia Coalition. Developments in STD Screening: Chlamydia Testing Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control

Thank You! Questions?