Oxford Handbook of Midwifery (19 page)

of 6–8mmol/L before she conceives and during the pregnancy.

Hypertension

Epilepsy

Infections

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Chapter 3

23‌‌

Sexual health

Bacterial vaginosis
24

Candidiasis
26

Chlamydia
28

Genital warts
30

Gonorrhoea
32

Hepatitis B
34

Hepatitis C
36

Herpes simplex virus
38

Syphilis
40

Vaginal infections
42

CHAPTER 3
Sexual health

24‌‌

Bacterial vaginosis

• Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age.
  
• It is caused when the normal lactobacilli of the vaginal flora are replaced with anaerobic flora such as
  Gardnerella vaginalis
  .
  
• It often co-exists with other sexually transmitted infections (STIs), but may occur spontaneously, often repeatedly, in both sexually active and non-sexually active women.
  
• It is often diagnosed in an asymptomatic form, by the detection of ‘clue cells’ when analysing a high vaginal swab taken for an STI screen.
  
• Commonly, women report it to be more of a problem in the perimenstrual period.
  
• It is more common in black women than white, those with an intrauterine device (IUD) and women with pelvic inflammatory disease (PID).
  

  •
  In those who have undergone termination of pregnancy it may cause post-termination endometritis.
  

• On examination the vaginal mucosa is not inflamed.
  
• The main symptom is a malodorous, greyish watery discharge, although 50% of women are asymptomatic. In practice, it is not usually treated unless there are symptoms.
  
• The ‘fishy’ odour is characteristic and more pronounced following sexual intercourse, due to the alkaline semen.
  
• About one-third of women with active BV may also have vulval irritation.
  
• Treatment is usually metronidazole 2g stat or alternatively a course of clindamycin may be given.
  
• All these treatments have been shown to be 70–80% effective in controlled trials, however, recurrence of infection is common.
  
• While undergoing treatment the woman should avoid drinking alcohol for the duration of the treatment and for the next 48h, as it may cause nausea and vomiting.
  
• She should also abstain from sexual intercourse for the duration of the treatment and the next 7 days.
  
• In order to preserve vaginal acidity the woman should be advised to avoid use of shower gel in the vulval area or of bath foam, antiseptic agents, or shampoo in the bath. Similarly, she should avoid vaginal douching.
  

  BV in pregnancy
  

• About 20% of pregnant women have BV in pregnancy, with the majority being asymptomatic.
  
• There is substantial evidence that BV is associated with preterm rupture of the membranes, preterm labour, and birth.
  
• Other evidence suggests an association with late spontaneous abortion, intra-amniotic infection, and postnatal endometritis.
  

  BACTERIAL VAGINOSIS
  

  25
  

Fetal and neonatal infection

CHAPTER 3
Sexual health

26‌‌

Candidiasis

• The causative organism is usually
  Candida albicans
  , normally a commensal organism found in the flora of the mouth, gastrointestinal tract, and vagina, which under certain circumstances become pathogenic and can cause symptoms.
  
• It may be sexually transmitted, but most cases occur spontaneously. Colonization from the lower intestinal tract is common.
  
• Culture from a high vaginal swab is currently the best method of diagnosis for vulval vaginal infection. Similarly, a mouth/throat swab should be taken for oral infection.
  
• The condition is not usually treated unless the woman is symptomatic, which is indicated by a thick, white, discharge and vaginal and vulval irritation.
  
• There is no need to treat the partner unless he is symptomatic.
  
• Common in diabetes mellitus, due to increased glycogen levels in
  uncontrolled diabetes.
  
• Found more commonly in the luteal phase of the menstrual cycle.
  
• There is no evidence that women using the combined oral contraceptive have an increased incidence of colonization. Other contraceptives, such as diaphragms and caps, may carry the infection and cause reinfection, if not cleaned and stored properly.
  
• Impaired immunity, such as that found with human immunodeficiency virus (HIV) infection, will increase the incidence.
  
• Broad spectrum antibiotics increase yeast carriage by 10–30%.
  
• Vaginal deodorants, disinfectants, perfumed shower, and bath gels may exacerbate the problem by increasing irritation and vulval excoriation and dermatitis.
  
• Washing and wiping the vulval area should always be from front to back.
  
• The wearing of tight, synthetic clothing should be avoided.
  
• Application of plain yoghurt may soothe the irritation in the short term, but has not been shown to be effective as treatment. Daily oral ingestion of 8oz of active yoghurt has been shown to decrease
  

  incidence of candidal colonization and infection, but this has not been replicated in other studies.
  

  Candidiasis in pregnancy
  

• Vaginal candidiasis is the most common cause of troublesome vaginal discharge and vulval irritation in pregnancy.
  
• It occurs 2–10 times more frequently in pregnant than in non-pregnant women and is more difficult to eradicate.
  
• The problems are worst in the third trimester, with over 50% having a significant colonization due to increasing vaginal glycogen and the changing pH of the vagina in pregnancy.
  
• A Cochrane review of topical treatments for vaginal candidiasis
  ¹
  concluded that topical imidazole drugs are more effective than clotrimazole and that treatment over 7 days is more effective than single dose or 3–4-day treatment.
  

  CANDIDIASIS
  

  27
  

  Fetal and neonatal infection