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Chapter 7
Sexually Transmitted
and Other Infections
Copyright © 2016 by Elsevier Inc. All rights reserved.
Learning Objectives
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Describe prevention of sexually transmitted infections
in women, including risk reduction measures.
Differentiate signs, symptoms, diagnosis, and
management of nonpregnant and pregnant women
with selected sexually transmitted bacterial infections
(chlamydia, gonorrhea, syphilis).
Examine the care of nonpregnant and pregnant
women with selected sexually transmitted viral
infections (human immunodeficiency virus [HIV];
hepatitis A, B, and C; human papillomavirus; genital
herpes).
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Learning Objectives (Cont.)
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Compare and contrast signs, symptoms, and
management of selected vaginal infections in
nonpregnant and pregnant women.
Discuss the effect of group B streptococci (GBS) on
pregnancy and management of pregnant women with
GBS.
Identify the effects of TORCH infections on
pregnancy and the fetus.
Describe the health consequences (e.g., ectopic
pregnancy, infertility) for women who are infected
with reproductive tract infections.
Review principles of infection control for HIV and
blood-borne pathogens.
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Prevention
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Primary prevention
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Primary prevention the most effective way of
reducing STIs in women
Secondary prevention
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Prompt diagnosis and treatment can prevent
personal complications and transmission to others
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Prevention (Cont.)
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Risk reduction measures
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Knowledge of partner
Reduction of the number of partners
Low-risk sex
Avoiding exchange of body fluids
Vaccination
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Prevention (Cont.)
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Risk reduction measures
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Physical barriers
• Condoms
Chemical barriers
• Nonoxynol-9
Communication
• Expressing feelings and fears
• Attention to partner’s response
• Nurses must suggest strategies to enhance a woman’s
condom negotiation and communication skills.

Vaccination
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Bacterial Sexually Transmitted
Infections
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Chlamydia trachomatis
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Most common and fastest spreading STI
• Infections often silent and highly destructive
• Difficult to diagnose
• Sexually active women ages 15 to 24 years have the
highest rates of infection, with women ages 18 to 20
years having the highest rates (CDC, 2012e).
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Screening and diagnosis
• Asymptomatic and pregnant women
• Comparisons of diagnostic procedures
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Bacterial Sexually Transmitted
Infections (Cont.)
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Chlamydia
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Management
• Doxycycline
• Azithromycin
• All exposed sexual partners should be treated.
 Perinatal transmission
• Antibiotic ointment
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Bacterial Sexually Transmitted
Infections (Cont.)
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Gonorrhea
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Aerobic gram-negative diplococcus
Oldest communicable disease in the United States
Second to chlamydia in reported cases
Highest rates among teenagers, young adults, and
African-Americans
Women often asymptomatic
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Bacterial Sexually Transmitted
Infections (Cont.)
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Gonorrhea
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Screening and diagnosis
• CDC recommends screening all women at risk.
• Testing performed during first trimester and at 36 weeks
of pregnancy
• Is a reportable disease
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Management
• Antibiotic therapy: cefixime or ceftriaxone
• Concomitant treatment for chlamydia
• Perinatal complications of gonococcal infection
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Bacterial Sexually Transmitted
Infections (Cont.)
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Syphilis
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Treponema pallidum, a motile spirochete
• Earliest described STI
• Transmission by entry into subcutaneous tissue through
microscopic abrasions that can occur during sexual
intercourse
• Also transmitted through kissing, biting, or oral-genital
sex
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Transplacental transmission may occur at any
time during pregnancy.
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Bacterial Sexually Transmitted Infections
(Cont.)
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Syphilis
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Can lead to serious systemic disease and even
death when untreated
Infection manifests in distinct stages
• Primary: 5 to 90 days after exposure
• Secondary: 6 weeks to 6 months
• Tertiary: develops in one third of women infected
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Bacterial Sexually Transmitted
Infections (Cont.)
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Syphilis
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Screening and
diagnosis
• Pregnant women
• Serologic tests
• False-positive results
Management
• Penicillin
• Sexual abstinence
during treatment
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Bacterial Sexually Transmitted
Infections (Cont.)
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Pelvic inflammatory disease (PID)
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An infectious process that most commonly
involves the fallopian tubes, uterus, and
occasionally the ovaries and peritoneal surfaces
Multiple organisms have been found to cause PID.
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Bacterial Sexually Transmitted
Infections (Cont.)
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Pelvic inflammatory disease (PID)
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Risk factors for acquiring PID
• Young age
• Nulliparity
• Multiple partners
• High rate of new partners
• History of STIs and PID
Those with PID are at increased risk for
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
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Bacterial Sexually Transmitted
Infections (Cont.)
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Pelvic inflammatory disease (PID) (Cont.)
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Symptoms
• Depend on type of infection
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Acute
Subacute
Chronic
Screening and diagnosis
• History
• CDC routine criteria
Management
• Prevention
• Hospitalization
• Education
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Viral Sexually Transmitted Infections
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Human papillomavirus
(HPV)
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Condylomata acuminata
Affects 20 million
Americans
Most prevalent viral STI
seen in ambulatory
health care settings
Previously named genital
or venereal warts
More frequent in
pregnant women
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Viral Sexually Transmitted Infections
(Cont.)
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Human papillomavirus (HPV) (Cont.)
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Screening and diagnosis
• History of known exposure
• Physical inspection
• Pap test
• Viral screening and typing for HPV are available but not
standard practice.
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Management
• Removal
• Medications
• Counseling
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Viral Sexually Transmitted Infections
(Cont.)
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Herpes simplex virus (HSV)
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Herpes simplex virus 1 (HSV-1)
• Transmitted nonsexually
Herpes simplex virus 2 (HSV-2)
• Transmitted sexually
Initial infection characterized by multiple painful lesions,
fever, chills, malaise, and severe dysuria
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Viral Sexually Transmitted Infections
(Cont.)
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Herpes simplex virus (HSV) (Cont.)
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Chronic and recurring disease for which there is
no known cure
Systemic antiviral medications partially control the
symptoms
● Maternal infection with HSV-2 can have adverse effects
on mother and fetus
● Neonatal herpes
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Most severe complication of HSV
Most mothers lack history of HSV
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Viral Sexually Transmitted Infections
(Cont.)
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Viral hepatitis
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Hepatitis A virus (HAV)
• Acquired primarily through a fecal-oral route
• Vaccination the most effective means of preventing HAV
transmission
• Characterized by flulike symptoms with malaise, fatigue,
anorexia, nausea, pruritus, fever, and right upper
quadrant pain
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Viral Sexually Transmitted Infections
(Cont.)
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Viral hepatitis (Cont.)
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Hepatitis B virus (HBV)
• Most threatening to the fetus and neonate
• Disease of the liver and often a silent infection
• Transmitted parenterally, perinatally, and, rarely, orally
as well as through intimate contact
• Vaccination series available
• No specific treatment; recovery is usually spontaneous
within 3-16 weeks
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Viral Sexually Transmitted Infections
(Cont.)
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Viral hepatitis (Cont.)
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Hepatitis C virus (HCV)
• Most common blood-borne infection in the United States
• Important health problem as increasing numbers acquire
disease
• Risk factor for pregnant women is history of injecting IV
drugs
• Interferon-alfa or ribavirin is main therapy for HCV
infection
• Effectiveness of treatment varies
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Viral Sexually Transmitted Infections
(Cont.)
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Human immunodeficiency virus (HIV)
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47,500 new HIV infections occur in United States
each year
Heterosexual transmission now the most common
means of transmission in women
20% of these new infections occur in women
Transmission of HIV occurs primarily through
exchange of body fluids
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Viral Sexually Transmitted Infections
(Cont.)
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Human immunodeficiency virus (HIV) (Cont.)
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Severe depression of the cellular immune system
associated with HIV infection characterizes AIDS
Symptoms: fever, headache, night sweats,
malaise, generalized lymphadenopathy, myalgias,
nausea, diarrhea, weight loss, sore throat, and
rash
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Viral Sexually Transmitted Infections
(Cont.)
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Human immunodeficiency virus (HIV) (Cont.)
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Screening and diagnosis
• Antibody testing
• Detection
Counseling for HIV testing
• Counseling before and after HIV testing is standard
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nursing practice today
HIV testing offered early in pregnancy
Perinatal transmission decreases
Consider confidentiality and documentation
Pretest and posttest counseling
Notification of results
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Viral Sexually Transmitted Infections
(Cont.)
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Human immunodeficiency virus (HIV) (Cont.)
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Management
• Resources
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Death and dying
Suicide prevention
Financial assistance
Legal advocacy
• Prevention of transmission
• No cure available yet
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Viral Sexually Transmitted Infections
(Cont.)
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Human immunodeficiency virus (HIV) (Cont.)
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HIV and pregnancy
• HIV counseling and testing should be offered to all
women at their initial entry into prenatal care as part of
routine prenatal testing unless the woman opts out of the
screening (CDC, 2010c).
• Perinatal transmission has decreased because of
antiretroviral prophylaxis.
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Decreases transmission to 1% to 2%
• Intrapartum zidovudine
• Cesarean birth is recommended.
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Case Study
Your patient is a 20-year-old, single, G0P0 who
presents to the clinic as a walk-in. She appears upset.
After you bring her to an examination room and take her
vital signs, you ask her what the reason is for her visit
today.
She replies, “A couple of days ago, I noticed some
painful, pimple-like bumps on the outside of my vagina.
I don’t know what to do.”
While you take her health history, what are some
especially important questions to include?
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Case Study (Cont.)
After the physical exam, you explain to the
patient that a diagnosis of herpes simplex virus
is suspected and will be confirmed with the lab
culture.
The patient asks, “Can the doctor prescribe me
some antibiotics to get rid of the infection?”
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As the nurse, what is your best response?
What other patient teaching is important
to include before the patient departs?
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Case Study (Cont.)
The patient states that she is heterosexual and
is currently sexually active with one partner, her
boyfriend. She has a history of 2 past sexual
partners. She denies any previous history of
STIs.
As a nurse, you may perform part of the
examination or you may be present to assist the
provider with the exam.
What is important to include in the focused
physical examination?
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Vaginal Infections
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Vulvovaginitis
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Inflammation of the vulva and vagina
Many different causes
Bacterial vaginosis (BV)
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Syndrome in which normal H2O2-producing
lactobacilli are replaced with high concentrations
of anaerobic bacteria
Associated with preterm labor and birth
Treatment with metronidazole orally
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Vaginal Infections (Cont.)
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Candidiasis
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Candida albicans or non–C. albicans infection
Vulvovaginal candidiasis, or yeast infection, is
second most common type of vaginal infection
Numerous factors have been identified as
predisposing a woman to yeast infections.
In women with HIV, symptoms are more severe
and persistent.
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Vaginal Infections (Cont.)
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Candidiasis (Cont.)
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Predisposing factors
• Antibiotic therapy
• Diabetes
• Pregnancy
• Obesity
• Diets high in refined sugars
• Use of corticosteroids and hormones
• Immunosuppressed states
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Vaginal Infections (Cont.)
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Candidiasis (Cont.)
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Common symptoms
• Vulvar pruritus
• Vaginal pruritus
Screening and diagnosis
• Physical examination
• Vaginal pH
Management
• Over-the-counter agents
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Intravaginal treatment or oral agent
Full course of treatment must be completed
Other comfort measures
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Vaginal Infections (Cont.)
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Trichomoniasis
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Caused by Trichomonas vaginalis
Often considered an STI
Common cause of vaginal infection
Inflammation of the vagina and/or vulva
Screening and diagnosis
• Speculum examination
• Pap test
Management
• Metronidazole
• The risk for sexual transmission must be communicated
to infected women.
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Vaginal Infections (Cont.)
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Group B streptococci (GBS)
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A part of the normal vaginal flora, present in 20%
to 30% of healthy women
Associated with poor pregnancy outcomes
Important factor in neonatal morbidity and
mortality
Screening at 36-37 weeks of gestation
Intrapartum intravenous prophylaxis
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Maternal and Fetal Effects of
Sexually Transmitted Infections
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STIs in pregnancy are responsible for
significant morbidity and mortality
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Pregnancy effects
• Premature rupture of membranes
• Premature labor
• Postpartum sepsis
• Dystocia
• Miscarriage
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Maternal and Fetal Effects of Sexually
Transmitted Infections (Cont.)
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STIs in pregnancy are responsible for
significant morbidity and mortality.
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Fetal effects
• Preterm birth
• Pneumonia
• Systemic infection
• Congenital infection
• Stillbirth
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Maternal and Fetal Effects of Sexually
Transmitted Infections (Cont.)
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TORCH infections
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Form group of infections capable of crossing the
placenta and adversely affecting the fetus
• Toxoplasmosis
• Other infections (e.g., hepatitis, HIV)
• Rubella virus
• Cytomegalovirus
• Herpes simplex virus (HSV)
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Maternal and Fetal Effects of Sexually
Transmitted Infections: Care Management
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Assessment and nursing diagnoses
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History
• Ask about lifestyle behaviors that place clients at risk for
STIs
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Physical examination
• Ensure comfort during examination
Laboratory tests
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Maternal and Fetal Effects of Sexually Transmitted
Infections: Care Management (Cont.)
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Expected outcomes of care
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Plan of care and interventions
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Focus on physical and psychologic needs with
emphasis on avoidance of reinfection and harmful
sequelae
Infection control
Management during pregnancy
Evaluation
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Infection Control
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Interrupting the transmission of infection is
crucial to STI control
Many STIs are reportable; all states require
that these STIs be reported to public health
officials
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Gonorrhea
Syphilis
Chancroid
 Lymphogranuloma venereum
 Granuloma inguinale
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Key Points
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Reproductive tract infections include STIs and
common genital tract infections.
Risk-reduction sexual practices are key STIprevention strategies.
HIV is transmitted through body fluids,
primarily blood, semen, and vaginal
secretions.
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Key Points (Cont.)
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Prevention of mother-to-newborn HIV
transmission is most effective when the
woman receives antiretroviral drugs during
pregnancy and labor and birth, and the infant
receives the drugs after birth.
HPV is the most common viral STI.
Syphilis has reemerged as a common STI,
affecting African-American women more than
any other ethnic or racial group.
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Key Points (Cont.)
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Chlamydia is the most common STI in women
in the United States and the most common
cause of PID.
Viral hepatitis has several forms of
transmission; HBV infections carry the
greatest risk.
Young, sexually active women who do not
practice risk-reducing sexual behaviors and
have multiple partners are at greatest risk for
STIs and HIV.
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Key Points (Cont.)
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STIs are responsible for substantial mortality
and morbidity, great personal suffering, and
heavy economic burden in the United States.
STIs and vaginitis are biologic events for
which all individuals have a right to expect
objective, compassionate, and effective
health care.
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47
Key Points (Cont.)
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Pregnancy confers no immunity against
infection, and both mother and fetus must be
considered when the pregnant woman
contracts an infection.
Because history and examination cannot
reliably identify everyone with HIV or other
blood-borne pathogens, blood and body-fluid
precautions should be used consistently for
everyone all the time.
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48
Question
1. A nurse is providing discharge instructions to
a client who has just been diagnosed with
human papillomavirus (HPV) on her cervix.
What is the most important discharge
instruction for this client?
a. Take a multivitamin every day.
b. Check for external lesions around the vagina
every month.
c. Have Pap tests done as recommended by her
provider.
d. Avoid using an intrauterine device (IUD).
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49