NU 330 - Exam 1 - PP 5 (STIs and Infectious Diseases)

Infection occurring during pregnancy

Increases risk for spontaneous abortion (SAB) (before 20 weeks), preterm labor (PTL), and preterm premature rupture of membranes (PPROM)

Most likely to cause harm in first trimester

-Due to interference with organ development

Infections later in pregnancy can cause

-Intrauterine growth restriction, Neurologic disturbance

Lower Genital Tract Infection (Vaginitis) -

-Most common reason women seek gynecologic care

-Bacterial vaginosis (BV)

▪ Most prevalent vaginal infection in United States

• Overgrowth of bacteria (gardnerella) within vaginal flora

• Thin, watery, white-gray discharge with odor

• Test: Wet mount

• Treatment: Metronidazole (Flagyl) PO or Clindamycin PO

-Candidiasis (fungal/yeast infection)

▪ Candida albicans is the most common cause

• Thick, white vaginal discharge

• Itching, dysuria, and dyspareunia (genital pain r/t intercourse)

• Exam and test: Speculum exam and wet mount

• Treatment: Fluconazole cream or Clotrimazole cream

*Clue cells seen in Bacterial Vaginosis

Sexually Transmitted Infections (STIs)

-Prevention based on:

▪ Education and counseling on safe sex behavior

▪ Effective diagnosis and treatment

▪ If diagnosed, avoid intercourse until fully treated (at least 7 days) and partner(s) should be tested and treated as well

▪ If left untreated (especially chlamydia and gonorrhea), can lead to pelvic inflammatory disease (PID) = possible risk of ectopic pregnancy (scarring of fallopian tubes), and infertility

-Implications for and risks to pregnancy:

• Anomalies in organ development (1st trimester)

• Preterm premature rupture of membranes (PPROM)

• Preterm labor (PTL)

• Chorioamnionitis, postpartum sepsis (endometritis), neonatal sepsis

• In 2020, a nationwide total of 1,579,885 cases of chlamydia and 677,769 cases of gonorrhea were reported to CDC. The number of reported cases is lower than the estimated total number because infected people may misinterpret or be unaware of symptoms and not seek treatment

STI - Chlamydia

-Caused by bacteria Chlamydia trachomatis

-Symptoms

• Up to half of women asymptomatic

• Thin, mucupurulent discharge, especially from penis

• Friable cervix, spotting

-Screening: Urine sample

-Treatment

• Azithromycin or Amoxicillin PO

STI - Gonorrhea

-Caused by bacteria Neisseria gonorrhoeae

-Symptoms

• Up to half of women are asymptomatic

• Thin, mucupurulent discharge, especially from penis

• Dysuria, low abdominal pain

• Friable cervix, spotting

-Screening: Urine sample

-Treatment

• Azithromycin PO AND Ceftriaxone (Rocephin) IM

STI - Syphilis

-Caused by bacteria Treponema pallidum

- Symptoms

• Chancre appears, then possibly rash, fever, weight loss, malaise, neurological affects,

vision loss

-Trans-placental transmission

▪ Can cause anomalies, fetal demise, neurological effects

-Screening: Blood test (RPR or VDRL)

-Treatment

• Penicillin PO

• If not pregnant and allergic to Penicillin-- Doxycycline or Tetracycline PO

STI - Human Papilloma Virus (HPV)

-Caused by viral organisms (over 100 subtypes)

• Types 16 and 18 are high risk for cervical, anorectal cancers

• Types types 6 and 11 are commonly low risk, still sent for

biopsy these cause condylomas

-Vaccines: Gardasil (quadrivalent), Cervarix (bivalent), 9- valent

-Diagnosis and Symptoms

• Pap smear

• Visual inspection of genital warts (condylomas)

• Pruritus, dyspareunia, spotting

-Treatment

• Cryotherapy to cervix (freeze the cells)

• Medicines applied to wart

• Surgical removal of war

STI - HIV

-HIV screening is part of all routine prenatal blood work, patient has the right to refuse

-Antiretroviral therapy (ART) started as soon as diagnosis is made

decreases risk for transmission to fetus

-Fetal implications

• Transmission can occur through placenta, blood exposure during birth, breast milk

• Antiretroviral therapy is administered to the newborn and continued the first 6 weeks of life

STI - Herpes Simplex

-Viral organisms herpes simplex virus (HSV-1) and herpes genitalis (HSV-2)

• Recurrent lifelong infection; dormant vs. active

-Transmission

• Sexual contact as well as

• Skin-to-skin contact with an infected site

-Diagnosis: Clinical appearance, obtain culture of vesicles

-Implications for pregnancy

• Acyclovir or Valtrex PO given prophylactically started at 36 weeks

• Prevent neonatal transmission/infection

• Deliver by c/section if active lesions within/near perineum

-If newborn is exposed during birth; risk for rash, sepsis, encephalitis

The primary outbreak:

• Single or multiple painful blister-like vesicles

• Genital pruritus, tingling

• Difficult urination, urinary retention

• Enlargement of inguinal lymph nodes

• Possible flu-like symptoms

• If in 1st trimester: Increased risk for spontaneous abortion (SAB)

• If in 2nd or 3rd trimester: IUGR (intrauterine growth restriction), preterm labor, neonatal infection

-The dormant phase: (no symptoms) Active outbreaks brought on by illness, stress

STI - Trichomoniasis

-Caused by protozoa Trichomonas vaginalis

-Asymptomatic or mild symptoms

• Yellow-green, frothy, odorous discharge

• Vulvar itching

• Dysuria, dyspareunia (painful intercourse)

-Screening: Wet mount

• Treatment

-Metronidazole PO

-Implications in pregnancy

• PPROM (preterm premature rupture of membranes)

• PTL (preterm labor)

Diagnosing Pelvic Inflammatory Disease (PID)

-Symptoms:

• Bilateral sharp, cramping pain in lower quadrants

• Fever greater than 101°F, chills

• Mucopurulent cervical or vaginal discharge

-Diagnosis:

• Clinical assessment

• STI testing, ultrasound

• Inflammation of upper genital tract (uterus,

fallopian tubes, ovaries)

-Treatment:

• Broad-spectrum antibiotic

Nursing Care and Management

-For the individual with a sexually transmitted infection

• Nursing assessment and diagnosis

▪ Cultural considerations

▪ Awareness of symptoms/provide education

▪ Anticipate testing at first prenatal visit

▪ May retest again in third trimester if high risk behaviors

-Nursing diagnosis

• Interrupted Family Processes

• May carry stigma, be emotionally devastating to patient

-Nursing plan and implementation

▪ Address in nonjudgmental, supportive way

▪ Health promotion education

▪ Take all prescribed medications completely

TORCH Infections (Additional Perinatal Infections with Risk to the Fetus)

-Toxoplasmosis

-Other infections

• Syphilis

• Varicella

• Parvovirus B19 (Fifths disease)

• HIV

-Rubella

-Cytomegalovirus

-Herpes simplex virus (HSV

Additional Perinatal Infections with Risk to the Fetus - Toxoplasmosis

-Protozoa Toxoplasma gondii

• Eating raw or undercooked meat

• Can be present in cat feces

• Education on prevention (no handling used cat litter)

• Asymptomatic or flu-like symptoms

-Fetal-neonatal risks

• Can cause severe fetal damage, at risk for spontaneous abortion

-Clinical therapy

• Goal is to identify at-risk women, provide education

• Test and treat positives with medications to reduce transmission to fetus

Perinatal Infections - Hepatitis A and B

-Route of transmission:

• Hepatitis A: Fecal-oral, contaminated food/water

• Hepatitis B: Blood/body fluids

-Screening: Hepatitis B (HBsAg) is included in routine prenatal testing

-If the mother is Hepatitis B positive:

• The neonate should receive both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours after birth to reduce risk of neonatal infection.

• The neonate should then complete the full series of Hepatitis B vaccinations

Perinatal Infections - Human B19 Parvovirus

• Causes erythema infectiosum (fifths disease) in children

• About half of women are immune (had it as a child)

• Most resolve the viral infection without issue

• Risk for spontaneous abortion, stillbirth, fetal anemia, fetal hydrops

• Monitor per prenatal visits, bloodwork, ultrasound

• Child with “slapped cheek” rash-

Perinatal Infections - Zika Virus

-Caused by Aedes mosquito bite

-Also transmitted through blood, intercourse, and to fetus by mother

-No transmission of Zika in the continental U.S. since 2017

-Check CDC website for travel guidance re; areas with Zika

-Fetal risk for neurodevelopmental abnormalities

• Brain and eye defects

• Hearing loss

• Seizures

Perinatal Infections - Rubella

-Mild illness or asymptomatic in children, adults

• Muscle aches, malaise, flu-like symptoms

-Rare occurrence because of MMR vaccinations (immunity)

-Rubella titer included in routine prenatal testing

• Measles, mumps, rubella (MMR) vaccine postpartum if titer reveals nonimmune or equivocal

• Avoid pregnancy for 4 weeks after vaccination

-Fetal-neonatal risks

• First trimester poses greatest risk for occurrence of fetal anomaly

• Congenital cataracts, deafness, heart defects

• Mental retardation, cerebral palsy

• Risk for spontaneous abortion, fetal demis

Perinatal Infections - Cytomegalovirus (CMV

-Belongs to herpes simplex virus family

• Can be transmitted through urine, saliva, cervical mucus, semen, breast milk

• Mother can be asymptomatic or have mono-like symptoms

-Has active and latent phases

-Fetal-neonatal risks

• Intellectual disability, hearing loss

• If contracted in first half of pregnancy

• Extensive intrauterine tissue damage leading to fetal deat

Urinary Tract Infection

-Bacteriuria with symptoms

• Dysuria

• Urgency, frequency

• Suprapubic and/or low back discomfort, “cramping”

• Low grade fever possible

• Hematuria

-Causes and risk factors

• Escherichia coli most common pathogen

• Shortness of woman’s urethra

• Delayed postcoital micturition

• Pregnancy (structure and hormones)

• Catheterizations (CAUTI)

-Treatment: Antibiotic (PO or IV depending on severity/risks)

-Risks to pregnancy (if untreated)

• PPROM (preterm premature rupture of membranes)

• IUGR (intrauterine growth restriction)

• Chorioamnionitis

• Febrile, Flank pain, Costovertebral angle (CVA), tenderness, Nausea/vomiting, Malaise

-Upper Urinary Tract Infection (Pyelonephritis)

-Lower Urinary Tract Infection (Cystitis and Urethritis

Foodborne Illness - Listeriosis

-Listeria monocytogenes is bacteria that can be present in:

• Unpasteurized milk and dairy products

• Improperly stored or prepared meat, poultry, or seafood

*Also, maternal salmonella Infection can lead to neonatal sepsis

*soft cheeses is common for listeria / 24x more likely to get it = pregnant Hispanic women

Group B Streptococcus (GBS)

-Bacteria present in the vaginal flora of some women

-Vaginal and rectal culture obtained between 36.0-37.6 weeks gestation

-If positive or unknown GBS treat during labor: Penicillin 5 million units IV x 1 then 2.5 million units IV every 4 hours until delivery

- Less than 4 hours or no treatment with appropriate antibiotics increases the risk for neonatal pneumonia, respiratory distress syndrome (RDS), sepsis, and meningitis.

• Blood cultures drawn from umbilical cord or newborn immediately after delivery

• Neonate must be observed for at least 48 hours if asymptomatic and negative cultures. IF symptomatic, blood cultures drawn from neonate as well.

• If + blood culture, NICU admission and 10 day regimen of IV antibiotics given

-Newborn can also be at risk for infection if mother has prolonged rupture of membranes (> 18 hours), or is febrile (T > 100.4°F) in labor