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妇产科学 第 19 章 性传播疾病

妇产科学 第 19 章 性传播疾病. 王自能教授主讲 暨南大学第一临床医学院妇产科. 【 教学目标 】 了解淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径、临床表现及诊断治疗和预防措施。 【 教学重点 】 淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的传播途径、临床表现及诊断治疗和预防措施。 【 教学难点 】 淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径。. Sexually Transmitted Diseases. Bacterial infections: Chlamydia trachomatis

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妇产科学 第 19 章 性传播疾病

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  1. 妇产科学第19章 性传播疾病 王自能教授主讲 暨南大学第一临床医学院妇产科

  2. 【教学目标】了解淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径、临床表现及诊断治疗和预防措施。【教学目标】了解淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径、临床表现及诊断治疗和预防措施。 【教学重点】淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的传播途径、临床表现及诊断治疗和预防措施。 【教学难点】淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径。

  3. Sexually Transmitted Diseases Bacterial infections: Chlamydia trachomatis Neisseria gonorrhoeae (GO) Syphilis Viral infections: Herpes genitalis Human papillomavirus (HPV) Human immunodeficency virus (HIV)

  4. Chlamydia vaginitis [E] Chlamydia trachomatis Salpingitis (Peritonitis, infertility, etopic pregnancy , premature labor , stillbirth possible) [S] Often symptom free,associated with other pathogens of vaginitis (GO, vaginosis), Dysuria, pollakisuria, white glassing discharge. Chlamydia should be suspected in any patient with acute PID, possible GO or trichomonas vaginitis [D] Intracelluar inclusion, immunology with monoclonal antibody. [T] Azithromycin 1g oral, single dose Doxycycline 100mg bid for 7 d, Minocine?

  5. Ofloxacin 100 mg tid for 7 d Erythromycin 500 mg qid for 7 d. for pregnant patients

  6. Gonorrhea (GO) [E] Gramnegative gonococci (Diplococci ), Optimal pH 7.2 , incubation time :ca.1 w. [S] 50-80% women with GO are asyptomatic. Acute infection in urethra, cervix, Skne’s glands, Bartholin’s glands, evtl rectum. Confined in the mucosa only Profuse purulent urethral and vaginal discharge,urethral burning, dysuria, bladder irritability, inflammation of urethra, cervix, Skene’s and Bartholin’s glands.

  7. Co-infection with other STD is common. Causing recurrent PID, chronic pelvic pain or infertility due to tubal damage or hydrosalpinx formation. Women with a history of salpingitis  7~10 X ectopic pregnancy

  8. If treatment of the acute phase delayed or inadequate, GO via ascending surface spreading usually toward the end or after the next menstrual period  Acute salpingitis and pelvic peritonitis. Accompany symptom: Condylomata acuminata. [D] History of exposure, microscopy, culture, PCR ELISA. .

  9. [T] Ceftriaxone 1g iv + Doxycycline 100 mg bid for 7 d. Failure is rare and a follow up culture is not necessary. For pregnant patients. Ceftriaxone 250 mg i.m. as single dose + Erythromycine 500 mg qid oral. for 7 d.

  10. Syphilis [E] Treponema pallidum by direct genital or oral- genital contact with an actively infected sexual partner . Following transfusion with blood from an infected donor Transplacental spread : Mother fetus. Primary stage of the disease in the reproductive tract. [S] Prim. Stage : Incubation time 2~3 w.  Ulcus durum with indolent swelling of regional LN in genital area. 6~8 w. healing up.

  11. [S] Sec.stage: Otherwise 6~12 w. after formation of prim. affection Lymphogen or hematogen spreading Generalization of LN swelling, macular, later mixed with popular exanthema,together with condylomata lata in genital area,alopecia and tonsillitis. Tert. Stage: Latent time 10-20 years, Serotest: positive,without syndrome and sign. Mostly affected in CNS,cardiovascular system, gumma in face ,body and extremities. Lesions of the reproductive tract are uncommon.

  12. [D] Darkfield examination ,Serologic test (Cardiolipin, TPHA, FTA),RPR(rapid plasma reagin). [T] Benzathine（苄星） penicillin G 2~4 million u. i.m. or aqueous procaine penicillin G 600 000 u./di.m. for 8 d.

  13. Erythromycin 500 mg oral qid for 15 d in pregnant patients. Patients should be followed by quatitative VDRL titers and examination at 3, 4, 12 months after treatment. A 4x decline at 6. month or 8 x decrease by 12 months should be anticipated, if the disease has been cured.

  14. Herpes genitalis Neonatal HSV infection in the US incidence of app. 11~33 cases / 100 000 live birth HSV  30 % spontaneous abortions. Babies born to mothers with active herpes virus  infected.> 50 % with disseminated disease die, even with antiviral therapy. Among neonates with encephalitis > 50% of survivors are left with severe neurologic impairment.

  15. App. 85 % of early neonatal herpes infections are aquired during delivery from virion contaminated maternal vaginal secretions, therefore C-section for women with active genital lesions at time of labor. 40 ~70% of all neonates with herpes are born to asymptomatic mothers. Incubation period about 6 d with first episodes lasting for 10 ~ 12 d.

  16. Location: Vulva, vagina, cervix, perineal and perianal skin, often extending to the buttocks. Prim. infection with symptoms such as malaise, low grade fever and inguinal adenopathy. Aseptic meningitis with fever, headache and menigismus can be found in some patients 5 ~ 7 d after genital lesions. 60 ~ 90 % of patients with recurrence of herpetic lesions in the first 6 m. after initial infection.

  17. Recurrences are similar in character, but milder in severity and shorter in duration. [D] 1. Suspicion and clinical findings. 2. Viral culture. 3. Immunofluorescence techniques to detect viral particles. [T] 1. Sitz baths, followed by drying with a heat lamp or warm hair dryer. 2. Topical anesthetic ( 2% lidocaine jelly) 3. Local antibacterial cream.

  18. 4. Acyclovir ointment or oral acyclovir (200 mg tid) for patients having frequent recurrence. Acyclovir prophylaxis for herpes infction during pregnancy: At 36 w of gestation to(1) women who have experienced symptomatic HSV during their pregnancy  Effective of reducing both symptomatic recurrence and asyptomatic shedding or to (2) women with history of HSV but no recurrence during pregnancy.

  19. Human Papillomavirus (HPV) • The most common viral STD in the USA. found in 2.5 ~ 4 % of women, presenting as condylomata acuminata. • Subtypes 16, 18, 31, 33, 35  Cervical neoplasia. 90 % of pateints with cervical squamous cell carcinomas are HPV(+). • Incubation period 1 ~ 6 m. • Often accompanied by trichomonasis or bacterial vaginosis.

  20. [T] 1.Podophyllin ( not be used during pregnancy). 2. Laser ablation, cryotharapy or electrodessication. 3. 5 FU cream as an adjunct for cervical vaginal lesions.

  21. HIV and AIDS HIV (gp 120)  APC (i.e DC) via gp120 + DC SIGN (dendritic cell specific ICAM-grabbing non-integrin) + CD4R  CD4+ T cells via CCR5. HIV (gp 120)  Endothelial cells via DC-SIGNR  CD4 + T cells via CCR5.

  22. Infected via blood transfusion, pregnancy or drug associated use of contaminated needles, but sexual transmission is a major mode of spread. • In 90 % of patients, infection by HIV produces only nonspecific symptoms, often mimicking mononucleosis, febrile pharyngitis

  23. with fever, sweat, lethary嗜睡, arthralgia, myalgia, headache, photophobia and lymphadenopathy seen soon after infection. Following the initial infection  carrier state without symptoms but viral shedding occurs. Immune dysfunction becomes apparent roughly 10 years after the initial infection. [D] : Immunoassay, Western blot or immunofluorescence assays. [T] : Azidovudine or combination multidrug therapy to delay the progress of HIV .

  24. Puerperal and postabortal pelvic inflammatory diseases [E] Pathogen organisms: 2/3 gram negative bacteria (E. Coli, Pseudomonas假单胞菌, Proteus变形杆菌, Klebsiella, Occasionally Clostridium )Endotoxin↑  Septic shock, if untreated  50% †

  25. Pathogenesis of septic shock: Endotoxin ( Lipopolysaccharide or lipoprotein=carbon-hydrate-complex ) 1.Releasing of catecholamines  Vasoconstriction, initially microcirculation  Peripheral vascular resistance↑Tissue perfusion↓a.Skin pale, cold and clammy, fever. b.Stagnant anoxia Tissue damage, metabolic acidosisEdema  Pulmonary edema. Hypovolemic stage  Renal function↓, Liver jaundice In irreversible phase (Vasomotor collapse)  Generalized vasodilatation  Final state.

  26. 2. Neurotoxic effectMental confusion or semicoma!! Risk factors: a.Anemia, malnutrition, chronic disease. b.Coitus immediately before delivery. c.PROM( Premature rapture of membranes) d.Chorioamnionitis. e.Intern CTG . f. Sectio. g.Forceps and trauma of birth canal. h.Postpartal bleeding.

  27. [S] Fever↑↑↑, Pulse↑, Shaking chills, Pelvic pain+++,Tenderness+++, Purulent discharge+, Leukocytosis+, Later onOligouria, Hypotension, Pulseless, Subnormal temperature with pale, cold, clammy skin, Dyspneic and cyanotic, Metal confusionnear moribund, Anuric, semicomatose †

  28. [T] For simple, uncomplicated case, initially bacteriogram or blood culture, broad spectrum antibiotics, i.e. Penicillin 10-20 million units i.v. After 6-12 hrs, afebrile, fluid and electrolyte balance, Emptying all retained infected and necrosis tissue. For early endotoxic shock ,massive antibiotic therapy i.v. Penicillin 40 ~ 60 million units/d, or Cephalosporin +Gentamycin 60~80 mg tid i.m.,if urine output o.k. (Nephrotoxic and ototxic !!)

  29. i.v. fluid therapy (CVP! urin output!) • Corticosteroid for all patients i.v. vasospasm, cardiac output.e.g hydrocortisone 2.0~5.0 g/d Removal the source of infection. Tetracycline 2g/d Metronidazole

  30. THE END

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