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Gynaecology
Genital Tract Infections
(IV)-Sexual transmitted viral infections:
1-Genital herpes
2-Human papilloma virus (HPV):-
Human papillomavirus (HPV) causes condyloma acuminata (genital warts) which is the most common
sexually transmitted virus in the United States. It infects the epithelial layer (the outer layer) of the skin and
mucous membranes. HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex,
anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to
become infected with HPV by touching a toilet seat.
There are over 100 genotypes of HPV and types 6 and 11 cause over 90% of genital warts that have
little oncogenic potential, while infection with the oncogenic genotypes including types 16 and 18 is
also through sex, but these cause anogenital dysplasia and cancer, not warts. HPV vaccination is
available as a bivalent (against types 16 and 18) or quadrivalent (types 6, 11, 16 and 18) vaccine, and
in cohorts where the latter has been introduced (such as in girls in Australia), a dramatic drop in the
cases of genital warts has been observed
Symptomes:- Rarely, women with genital warts have itching, burning, or tenderness in the genital area,
depending upon the number of warts and their location. However, most women with warts do not have any
symptoms at all. Warts appear skin-colored or pink, and may be smooth and flat or raised with a rough
texture. They are usually located on the labia or at the opening of the vagina.
Treatment :- application of liquid nitrogen or surgical techniques or patient-applied topical
therapies, including podophyllotoxin containing preparations or the local immune modulator
imiquimod. As these are benign lesions treatment is optional. When genital warts are present in
pregnancy treatment is limited to ablative options .Rarely warts may become very large and obstruct
the birth canal, necessitating caesarean delivery. Very rarely the neonate can develop respiratory
papillomatosis, but the risk is extremely small and the benefit of caesarean delivery in preventing this
unproven. Screening for other STIs is required and screening for cervical cancer is as usual.
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3-Molluscum contagiosum:-
This poxvirus produces painless , pearly lesions with a dimple ,up to 5
mm in diameter. These are common in childhood and clear after a few months. Adults may acquire infection
during sexual intercourse, and the lesions can mistaken for genital wart. treatment is by cryotherapy, or
curettage or application of phenol.
3-Human immunodeficiency virus (HIV):-
HIV (human immunodeficiency virus) is a virus that
attacks the immune system, the body's natural defense system. Both the virus and the infection it cause what
is called HIV.
Pathogenesis:-
HIV has several targets including dendritic cells, macrophages, and CD4+ T cells.
Target cells HIV-1 most often enters the host through the genital mucosa. Interstitial dendritic cells are
found in cervicovaginal epithelium as well as tonsillar and adenoidal tissue, which may serve as initial
target cells in infection transmitted via genital-oral sex .
Transmission of HIV during primary infection has been associated with unprotected anal intercourse,
the number of sexual contacts, and high rates of other acute sexually transmitted diseases.Vertical
transmission occurs in 25-40 per cent of pregnancies if there are no interventions to reduce the risk.
Infection with HIV results in an initial acute viral illness followed by a chronic decline in cellular
immunity due to progressive depletion of CD4-positive T-lymphocytes, and eventually resulting in
one or more illnesses defined as the acquired immune deficiency syndrome (AIDS).
Gynaecological complications in HIV-positive women:-
Women with HIV infection are more likely to have infection with HPV 16 or 18 and have a higher
prevalence and incidence of CIN/HSIL. For this reason annual cervical cytology is recommended,
with most guidelines recommending subsequent management as in HIV-negative women. It is worth
noting that other anogenital malignancies resulting from oncogenic HPV infection also occur more
frequently and at a younger age in HIV-positive people.
Contraception and preconception management
Many antiretrovirals interact with hormonal contraceptives, resulting in reduced contraceptive
efficacy.However, this is dependent on the combination of specific medicines, and a holistic
assessment is required assessing the woman’s suitability for, and the availability of, both treatments
3
Non-hormonal contraception such as condoms and IUDs are appropriate in most circumstances
where they would otherwise be offered prior to attempting pregnancy, the health of a HIV-positive
woman and her partner should be optimized. This includes standard health promotion and for
serodiscordant couples advice regarding prevention of HIV transmission. This is achieved by optimal
HIV control as transmission between sexual partners is extremely low when the positive partner has
undetectable HIV ribonucleic acid (RNA) levels termed the ‘viral load’) in the serum. In addition,
screening for and treating coexistent STIs and, where treatment when this is indicated to couples
where one or both are HIV positive, within regulatory frameworks.Most mother-to-child
transmission (MTCT) occurs during birth breastfeeding.Intrauterine infection is unusual and the risk
of this is increased by an intervention that disrupts the placenta (for example, amniocentesis).
Delivery by prelabour caesarean section further reduces MTCT rates when the HIV viral load is
detectable. Obstetric risk factors that increase the risk of transmission include prolonged rupture of
membranes, procedures that breach the infant’s skin (such as fetal scalp electrodes) or increase
maternal blood in the birth canal.
Three interventions have been shown to reduce the risk of vertical transmission of HIV:-
1- Effective antiretroviral therapy, ensuring an undetectable viral load in serum towards the end of
pregnancy, provides excellent protection of the neonate.
2-Elective C\S.
3- Avoidance of breast feeding.
If all three interventions are undertaken the risk of transmission is less than 1 per cent.
References:-
1-Margaret Kingston, Genitourinary problems Gynecology by Ten Teachers, 2 0th Edition ,9,177-
195.
2-Jonathan D.C. Ross, Acute Pelvic Infection,Dewhurst’s Textbook of Obstetrics & Gynaecology
Ninth Edition ,2018;45: 611-620.