Sexually Transmitted Diseases

1. Sexually Transmitted Diseases There Maternal and Fetal Effects

2. HERPES: HSV I & II • TYPE I is usually found ABOVE UMBILICUS (except when transmitted through oral sex to the genitals), non-cancer causing and doesn't return as often as HSVII. • TYPE 11 is usually found BELOW UMBILICUS (unless transmitted from the genitals to the oral cavity). It makes one prone to cancer later • Both types can be transmitted orally or through intercourse. The two can't be differentiated by sight. The virus enters nervous system and the liver. In the case of HSVII, the virus can remain dormant In the ganglia reoccur regularly. HSVI does not usually reoccur as regularly or as frequently as HSBII, and if HSVI is transmitted to the genitalia, may only be responsible for one isolated incident. Precipitating factors (triggers) = stress, excessive sunlight, local trauma, PMS, hormonal changes.

3. Symptoms • With active HIV, small vesicles that rupture in 2-3 days becomes ulcerous. • The genitalia become inflamed with enlarged inguinal nodes, fever and UTI. • Eventually, the vesicles crust over and don't leave scars. • Usually takes 3-6 weeks to heal and crust over. • Dormant- tissues shed virus, although the area appears clear and the patient is asymptomatic. ***BEWARE: Labor is stressful and can activate herpes. Tests should be perfromed throughout labor (test is scraping of cells for shedding of virus)-- if cells are present, C-Section should be performed.

4. Treatment • The condition is self limiting with symptoms subsiding spontaneously, although the virus remains dormant and ready to strike again. • Primarily, the disease is treated withacyclovir (Zovirax) which has been most effective. It is given 200mg po q 4 hours 5 times/day X 10 days or 400mg tid X 10 days. For recurrent or suppressive therapy: 400mg 2 times/day for up to 12 months, then re-evaluate.Herpes zoster (herpes around the waist typically seen in elderly with a history of chickenpox in youth): 800mg 5 times/day X 7-10 daysOr famciclovir(Famvir) 500 mg po q8h for 7 days (in normal renal function), beginning as immediately after diagnosis is made and for recurrent genital herpes: 250: mg tid x 5-10days (in normal renal function), within 6 hours of symptoms. Side effects are minor = headache, nausea, diarrhea, fatigue. • Vidarabine(Vira A, adenine arabinoside and Ara-A ) ophthalmic preparations are effective for acute keratoconjunctivitis and recurrent superficial keratitis caused by HSV-1 and HSV-2. A 3% ophthalmic ointment is instilled 1 cm inside the lower conjunctival sac of the affected eye 5 times/day while awake (q 3 h). Treatment should be continued for 5 to 7 days after complete healing to prevent recurrences. Possible adverse effects include tearing, irritation, pain, photophobia, and superficial punctate keratitis. • If severe or for complications, HSV can be treated with intravenous • Vidarabine (Vira A) - Side effects = gastrointestinal: nausea, vomiting, diarrhea, neurological: = paresthesia, ataxia and seizures) or more commonlywith acyclovir(Zovirax). 5-10mg/kg IV q 8 hours X 7-10 days. Administer at constant rate over 1 hour. Side effects = Renal toxicity: serum creatinine and BUN rise and creatinine clearance decreases, Encephalopathy: lethargy, obtundation, tremors, confusion, hallucinations, agitation, seizures or coma and other: transient elevated creatinine, rash or hives; diaphoresis; hematuria; hypotension; headache and nausea (GI side effects reduced if take with meals); thrombocytosis.

5. Nursing: • Assess for therapeutic and side effects of specific medications used. • Teach appropriate handwashing to parents and precautions mother should take if her lesions are active. • Cultures should be taken from infants throat, conjunctiva, cerebral spinal fluid, blood, urine and any lesions to identify herpes virus II antibodies in serum IgM (cultures positive in 24-48hrs).

6. Implications/Complications

7. HIV and AIDS • The chances of passing HIV to the baby before or during birth are about one in four, or 25 percent, for each pregnancy. A baby can get HIV from an HIV-infected mother in three ways: during pregnancy. during delivery and after delivery through breast feeding (this is still being researched -third world countries are encouraged to breastfeed even in the presence of HIV because of the high morbidity/mortality related to improper nutrition). Most infants acquire AIDS through perinatal transmission (transplacentally)

8. Maternal Implications: • HIV+ mother should be started on AZT (Zidovudine), now referred to as ZDV , during pregnancy (after 1st trimester). • If mothers don't have active AIDS requiring more aggressive therapy, the newest therapy which is elective cesarean section before labor (usually at 36-38 weeks of gestation) plus a short oral course of zidovudine, normally starting at week 32 intravenous zidovudine before cesarean section and later, 10 days of AZT therapy for the neonate have shown that 1/3 less babies get HIV. • AZT does suppress BM = throimbocytopenia, anemia and granulocytopenia which is increased with the administration of acetaminophen (Tylenol), so patients should be advised to avoid this drug ! • Other complications of HIV in pregnancy that should be assessed at every prenatal visit are weight loss in 2nd and 3rd trimester: thrush (candidiasis), pneumonia, enlargement of lymph nodes, liver and spleen and regular visual examinations to watch for toxoplasmosis retinitis. • Serology should also be checked regularly for progression of the disease (absolute CD4 lymphocyte count - if level 200/mm3 or lower, opportunistic infections are more likely). Also, the ration of CD4 (helper cells) to CD8 (suppressor cells) may show changes, usually reversed with active AIDS. • THERE IS ALSO INCREASED RISK OF INTRAPARTAL and POSTPARTAL COMPLICATIONS = intrapartal and postpartal hemorrhage, postpartal infection, poor wound healing and genitourinary infections.

9. Fetal Implications: • Weekly NST begun at 32 weeks and serial ultrasound to check for IUGR. Also Biophysical profiles are checked regularly. AMNIOCENTESIS SHOULD BE AVOIDED DUE TO INCREASED RISK OF TRANSFERRING VIRUS !

10. Nursing Diagnoses • Altered Nutrition • Altered Parenting • Altered Bowel Elimination: diarrhea • Ineffective family coping. (Babies with AIDS die young in childhood. Some babies who have HIV become very sick and die in their first year. Others live longer but may still get sick.) • Risk for Infection

11. NURSING/TREATMENT for Pregnant Mother and fetus • UNIVERSAL PRECAUTIONS, in HIV+ with symptoms • Monitor woman without symptoms for developing S/S of active AIDS/infection/complications (fatigue, anemia, malaise, progressive weight loss, lympadenopathy, diarrhea, fever, neurologic dysfunction, or Karposi's Sarcoma - purplish, reddish-brown lesions either external or internal). • Also if MOM IS HIV+ encourage to check with MD regarding ZDV (AZT) and/or INTERFERON (an immunoglobulin) PROPHYLACTICALLY during pregnancy to prevent AIDS in the infant and also treat mother to prevent progression of disease r/t stress of pregnancy. • Parents of H/R babies experience stress and grieving, and need support. Support groups are available. • Encourage them to help child accomplish the most during lifespan. • Perform Discharge Blood Screening for HIV upon infants discharge (Newborn Screening Tests- filter paper). • Teach parents about implications for newborn.

12. Implications for Newborns born to HIV+ moms • These infants will show +HIV test results up to 15 months of age because they have mom's antibodies. • Only Viral Load test (the approved viral load test is called the Amplicor HIV-1 Monitor test, better known as the PCR DNA test [e.g. RT-PCR called Amplicor by Roche Labs) will accurately show if newborn is HIV+ before 15 months. Infants < 12 months with very high viral loads (>100,000) may be at high risk for disease progression and death (<50,000 is low & undetectable). Two viral load tests should be obtained as baseline.

13. Infants and Children with HIV • This is the 9th leading cause of death among children between 1 and 4 years old. Many children with perinatal transmission die within the first 24 months of age. As of December 2000, more than 1,600 children jave been infected with HIV each day worldwide. • The CDC has defined categories for diagnosis as of 1994. A POSITIVE HIV ANTIBODY TEST IS NOT SUFFICIENT TO DIAGNOSE AIDS. CD4+ lymphocyte counts in healthy children are much higher than in adults. Normal CD4+ counts slowly decline to adult levels by age 6. • Antiretroviral Therapy is recommended for all children with HIV infection who have: Clinical symptoms of HIV infection (Clinical category A, B, or C) or evidence of immune suppression (Immune category 2 or 3 = <25% CD4+ count).

14. CDC Clinical Categtories • CATEGORY N: Not Symptomatic = No signs/symptoms OR one sign/symptom in Category A • CATEGORY A: Mildly Symptomatic = Two or more of the following: Lymphadenopathy; Hepatomegaly; Splenomegaly; Dermatitis; Parotitis; Recurrent/persistent URIs/sinusitis/otits • CATEGORY B: Moderately Symptomatic = HIV-related signs/symptoms not in Category A/C • CATEGORY C: Severely Symptomatic = AIDS-defining disease National Pediatric & Family HIV Resource Center [1998].

15. Clinical manifestations • Early signs are developmental delays or after having achieved normal developments, there is loss of motor milestones (motor dysfunction was especially reduced muscle mass), microcephaly and emotionally exhibit irritable and inconsolable behaviors • Other S/S are lymphadenopathy, hepatosplenomegaly, parotitis (parotid gland inflammation near the ear), opportunistic infections (pnueumocytis carinni pneumonia [PCP], persistent oral candidiasis [thrush] and chronic or recurrent diarrhea. • Progressive/terminal signs = cerebral edema, disorientation, loss of consciousness. Children with the lowest neuropsychological functioning (IQ < 70) at baseline had the highest risk for later HIV disease progression (56%). Neurologic involvement is usually seen as progressive encephalopathy (occurs in 50% of children with HIV)

16. Treatment for child • Therapy usually begins on HIV-infected infants <12 months, as soon as the diagnosis is confirmed, regardless of clinical, immune status, or viral load. Cocktails are preferred (combination of two or more drugs rather than monotherapy). • STRONGLY RECOMMENDED TREATMENT is the use of one highly active protease inhibitor plus 2 NRTIs (Nucleoside Reverse Transcroptase Inhibitors), i.e. Protease Inhibitor = Nelfinavir or ritonavir or indinavir (if children swallow capsules) NRTI = ZDV (zidovudine/Retrovir) + ddI (didanosine / Videx) or ZDV + 3TC (lamivudine/Epivir) • Some children who were treated earlier with monotherapy (usually ZDV or ddI) and have maintained a low viral load (<100) and normal CD4 count before the development of the above guidelines should be maintained on a case by case basis. In such situations monotherapy may be appropriate to continue. • ****Monotherapy and combinations of d4t and ZDV, ddC and ddI, ddC and d4T, ddC and 3TC are NOT RECOMMENDED for those beginning therapy .

17. Nursing Care • Nursing care is primarily supportive. • Physical care is to maintain minimum exposure to infections, nutritional support, comfort measures, assessment and recogniton of changes in status that indicate progression of the disease or complications. • Note FEVER which is the chief sign of infection in all children with AIDS. • If the child has gotten the virus transplacentally, multiple problems related to the mother being infected should be investigated (i.e. Is she is able to care for the child? Does she abuse drugs? Is she sexually promiscuous /prostitute? Is she ill or dying? Is there a father and an extended family who will be able to care for the child?) • If the disease is congenitally acquired, the nurse will have to be prepared for feelings of guilt on the part of the parents, (i.e. hemophiliacs acquiring HIV from past blood transfusions – guilt particularly the mother since it is transmitted from mother to child on the "X" chromosome. Presently, our blood banks are very careful in screening for HIV infected blood). • The last group the nurse may encounter is the adolescent who has acquired the disease as the adult would through sexual activity or drug use. This child needs a great deal of support and teaching to get the appropriate treatment. They may have little family for support.

18. Tips for dealing with HIV+ children • Help the child to make a schedule for medicines and daily eating times that will work him/her • Use a calendar or check-off lis as reminders to check off each dose. • Teach adolescent or paretn to use a special marked dosing cup, them not to use eating spoons to measure liquid medicines as size may vary. • Teach them to work times out so that they will adhere to taking the medicine. Keep in mind that taking medicine in a social situations may cause embarrassment or emotional distress. • Teach parents to be poositive and consistent. • Teach the child to take large pills by practicing with candies. Some of the pills are quite large and difficult to take.

19. VAGINITIS CANDIDA ALBACANS (monilial yeast/fungal infection) • Contributing factors: oral contraceptives, diabetes mellitus, premenstrual factors, douching, use of antibiotic therapy and change in the body's normal hormone balance brought on by pregnancy, recent childbirth, breast feeding or menopause . • This infection is not sexually transmitted. • S/S = thick, curdy discharge, itching, dysuria and dyspareunia. Labia may be swollen and excoriated if the pruritus was severe.

20. Treatment

21. Prevention • Avoid spreading bacteria from the rectum to the vagina. After a bowel movement, wipe from front to back, away from the vagina. • Clean the outer genital area thoroughly and keep it as dry as possible. • Avoid irritating agent such as harsh soaps and scented toilet tissue, deodorant tampons or panty liners. • Avoid feminine hygiene sprays and douches. An offensive odor should not be masked but treated by your physician. • Thoroughly clean diaphragms, cervical caps and spermicide applicators after each use. • Avoid tight jeans or slacks. Wear panties or pantyhose with a cotton crotch and avoid synthetic fabrics that will trap moisture. Wash and thoroughly dry, new pantyhose before wearing them. • Use condoms during sex. • Check with your doctor about preventing yeast infections if you are prescribed antibiotics for another type of infection.

22. Implications/Complications

23. NURSING Care • Assess newborns buccol mucosa, tongue, gums and inside the cheeks for white plaques (usually at 5-7days old noticable - BE SURE TO DIFFERSNCIATE FROM MILK CURDS - Use cotton swab to wipe causes slight bleeding if thrush) and check diaper area for clearly marginated eruptions. • Teach parents to maintain cleanliness of hands, clothing, diapers and feeding items. • If breastfeeding, teach mothers to apply nystatin (Mycostatin) to their nipples. • Teach parents if use gentian violet, to avoid swabbing on normal mucosa because it causes irritation.

24. BACTERIAL VAGINOSIS(Gardnerella vaginalls) • Can be caused by overgrowth of normal flora • S/S = excessive amount of thin, watery, yellow-gray discharge with fishy foul odor.

25. TREATMENT • nonpregnant woman is given metronidazole (Flagyl -can be teratogenic to fetus). • Pregnant woman given 300mg clindamycin 2xday (BID) for 7 days.

26. TRICHOMONIASIS • Caused by trichomonas vaginallis usually acquired through sex. • S/S = yellow-green frothy, odorous, discharge frequently accompanied by inflammation of the vagina and cervix, dysuria and dyspareunia.

27. TREATMENT • metronidazole for nonpregnant woman for 7 days or a single 2g dose for both male andfornale partners. • Avoid intercourse unfil cured. • ***Avoid alcohol while taking Flagyl - similar response to taking alcohol and Antabuse (abdominal pain, flushing, or tremors). • ***Sexual partners must be treated !

28. Implications/Complications

29. Chlamydia • Chlamydia caused by chlamydlal trachomatis is a sexually transmitted bacteria that infects men, women and infants. • Nearly 4 million Americans get chlamydial infections each year making it one of the most common sexually transmitted diseases (STD) in the United States.

30. Symptoms • The symptoms of chlamydial infections may be minimal or severe and usually appear within one week to one month after a person has been exposed to someone with the infection. Untreated, chlamydia can remain in the genital tract for months to years without symptoms. • In many cases, it is very difficult to detect the symptoms of chlamydia. About 80% of the women with chlamydia do not have noticeable symptoms until complications set in. Men are more likely to show symptoms, although most people have no idea they might have a chlamydial infection until a partner is diagnosed and treated, and may people with the disease have it for months or even years without knowing it. Thus, the only sure way to know is to be tested.

32. Transmission • Chlamydial infections are most often spread during vaginal or anal sexual contact. In addition, pregnant women with chlamydia can pass the infection to the baby during birth.

33. Diagnosis • Diagnosis is made by culturing material taken from the cervix in women and the penis in men. A cotton swab is used to collect these samples that are sent to a laboratory for testing. Test results take about one week to obtain. This test is usually not painful and can be done even when there are no symptoms.

34. Nursing Care/Treatment • Chlamydia is curable when promptly and properly treated. Prescribed antibiotic drugs (tetracycline, doxycycline or erythromycin) should be completed as directed to ensure successful treatment. • Pregnant women should be treated with erythromycin ethyl succinate. • For Infant, assess perinatal history of preterm birth, instill opthalmic erthromycin and follow-up for eye complications. • A follow-up appointment will be scheduled three to six weeks after antibiotics are completed for an additional chlamydia culture. Reculture for chlamydia ensures that treatment was successful. • Treatment cannot reverse complications already caused by infection.

35. Implications/Complications

36. Guidelines for preventing chlamydial infections • The best defense is abstinence, or monogamy with a non-infected partner. • Properly used protective barriers such as condoms (rubbers) are the best protection. Spermicidal foams and jellies and diaphragms are less reliable than condoms and should be used along with condoms, not in place of them. • If you think you have been exposed to chlamydia, you and your partner must see a doctor immediately for treatment. Until the infection has been sufficiently treated, sexual activity must be avoided otherwise, partners can infect and reinfect each other.

37. Condyloma – HUMAN PAPILLOMA VIRUS (HPV) • Condylomata Acuminata or Genital Warts are fleshy growths which appear in the genital area. They are caused by Human Papilloma Virus (HPV) typically spread by sexual contact.

38. Symptoms • Genital warts first appear as usually painless, small pink or red bumps on the vulva (lips of the vagina), vagina, cervix, penis shaft, urinary opening or rectum. Sometimes, people complain of itching, burning or slight bleeding from these areas. • The incubation (time between exposure to the virus and the appearance of warts) is not known (several weeks to several years before symptoms), therefore, it is hard to tell when and where the intial exposure took place. • According to a research study, 20% of women with genital warts also had a vaginal infection which may encourage spreading. Warts may grow and spread up inside the vagina and on the cervix and may also cause abnormal Pap smears. Only treatment can cure warts and can prevent spreading or increased growth. During pregnancy women can be treated. In men, warts may spread inside the penis causing problems when they urinate.

39. Diagnosis • The diagnosis of condylomata acuminata is usually made by simple inspection of the genital area. • Occasionally, the health care provider may want to remove a wart to send it for further testing if they are concerned that it may be a type refered to as dysplasia which is pre-cancerous. • Because genital warts are considered a sexually transmitted disease, other tests may be done to rule out other sexually transmitted diseases such as gonorrhea, Chlamydia, syphilis, HIV and hepatitis.

40. Nursing Care/Treatment • Some genital warts will disappear on their own. Others can be frutstrating returning despite vigorous treatment. Treatment is easier when the warts are small and few in number. So nurses should teach parents to keep appointments! • Certain chemicals may be applied to smaller warts on moist areas. The most common drug used is Trichloroacetic Acid (TCA), a clear, watery liquid painted on the warts which turns whitish in color, causing warts to shrink and disappear over a number of weeks. Instruct patients that a burning sensation may occur as it dries. • Podophyllin, a brown liquid that may also cause burning, may also be used. It must be washed off with soap and water 4 to 6 hours after it has been applied. This may also be applied by the patient at home.

41. Nursing Care/Treatment Con’t • If these meds are ineffective, the doctor may try freezing the wart with a treatment called Cryotherapy. A topical cream, 5FU, or laser surgery may be used. When all else fails, Interferon injections may be used. • Even with all these treatments, the warts (HPV) my still return. There may be numerous visits to the doctor and many months of treatment. If the condyloma do not respond to treatment, the patient may be refered to a Colposcopy Clinic where the vulva or cervix can be examined through a special magnifying scope. Tissue samples (biopsies) may be taken and sent for further study.

42. Implications/Complications

43. Prevention Patients whould be instructed: • that the one way to prevent getting warts is abstinence or manogamy with someone who doesn’t have the disease. • to avoid Sexual Contact during treatment. • that if warts are recurrent or the patient has a new sexual partner, they should use condoms during intercourse. • to urge partners to be examined since warts in men may be hard to detect if they are inside the penis. Men may carry HPV even if no condyloma are detected. • to seek treatment early because early detection and treatment makes it easier to get rid of the warts.

44. SYPHILIS • Caused by Treponema pollidum, a spirochete. • Signs and Symptoms: • During early stage, chancre appears, slight fever, loss of weight and malaise which lasts up to 4 weeks. • In 6 weeks to 6 months, secondary S/S appear, skin eruptions called condylomata lata (wart-like stuff) are highly contagious-, acute arthritis, enlargement of the liver and spleen, non-tender enlarged lymph nodes, iritis, and a chronic sore throat with hoarseness. If the newborn is infected in utero, the infant will exhibit secondary stage symptoms. • Tertiary symptoms are encephalopathy and insanity. • Syphillis may cause preterm birth, stillbirth and neonatal morbidity if it crosses placenta.

45. TREATMENT • If less than 1 year duration, 2.4 million units of benzathine penicillin G IM. • If syphilis is longer than 1 year, then give 2.4 million units of benzathine penicillin G IM once a week for 3 weeks. • Doxycycline can be given if woman is allerigic to PCN. • Newborn may show positive test for 3 months. • ***Sexual partners must also be treated !

46. NURSING/TREATMENT • Teach parents and mother about treatment regime, and especially about father also getting treated to prevent re-infection. • Assess infant for elevated cord serum IgM and FTA-ABS IgM, rhinitis (snuffles), fissures on corners of mouth and excoriated upper lip, red rash around mouth and anus, Copper-colored rash over face, plams and soles of feet, irritablity, generalized edema especially over joints, bone lesions and painful extremities, hepatosplenomegaly, jaundice, congenital cateracts, SGA and FTT (failure to thrive). • Isolate infant until on antibiotice 48 hours ! • Administer PCN to infant as ordered. • Provide emotional support to parents because of guilt feelings and long term sequelae possible.

47. Implications/Complications

48. GONNORHEA • Caused by Neisseria gonorrhorae. Non-pregnant woman has a risk of PID. • Pregnant woman will be infected in urethra, cervix, and Bartholin's glands until membranes rupture. This is because mucous plug prevents it from ascending. • Most women are asymptomatic, but most common S/S are purulent, greenish-yellow discharge, dysuria, and urinary frequency. There may be swelling of the vulva. The cervix may appear swollen and secrete foul odor.

49. TREATMENT • Antibiotic Therapy with 250mg ceftriaxone IM once, plus 100mg doxycycline PO 2nd day for 7 days. • ***Sexual partners must be treated !

50. NURSING CARE • Assess for conjunctivitis (ophthalmia neonatorum), purulent discharge and corneal ulcerations, neonatal sepsis with temperature instability, poor feeding response and/or hypotonia, and jaundice. • Administer opthalmic antibiotic solution (usually erythromycin, or tetracycline - old treatment was 1% silver nitrate [needs to be flushed with .9% NS). • Initiate referral for to evaluate for vision loss.