婦產(chǎn)科之性傳播疾病

婦產(chǎn)科學(xué)

第19章性傳播疾病

【教學(xué)目標(biāo)】了解淋病、梅毒及病毒和沙眼衣原體感染的生殖道炎癥的發(fā)病原因、傳播途徑、臨床表現(xiàn)及診斷治療和預(yù)防措施。【教學(xué)重點(diǎn)】淋病、梅毒及病毒和沙眼衣原體感染的生殖道炎癥的傳播途徑、臨床表現(xiàn)及診斷治療和預(yù)防措施。【教學(xué)難點(diǎn)】淋病、梅毒及病毒和沙眼衣原體感染的生殖道炎癥的發(fā)病原因、傳播途徑。SexuallyTransmittedDiseasesBacterialinfections:ChlamydiatrachomatisNeisseriagonorrhoeae(GO)SyphilisViralinfections:HerpesgenitalisHumanpapillomavirus(HPV)Humanimmunodeficencyvirus(HIV)Chlamydiavaginitis

[E]Chlamydiatrachomatis

Salpingitis(Peritonitis,infertility,etopicpregnancy,prematurelabor,stillbirthpossible)[S]Oftensymptomfree,associatedwithotherpathogensofvaginitis(GO,vaginosis),Dysuria,pollakisuria,whiteglassingdischarge.ChlamydiashouldbesuspectedinanypatientwithacutePID,possibleGOortrichomonasvaginitis[D]Intracelluarinclusion,immunologywithmonoclonalantibody.[T]Azithromycin1goral,singledoseDoxycycline100mgbidfor7d,Minocine?Ofloxacin100mgtidfor7dErythromycin500mgqidfor7d.forpregnantpatientsGonorrhea(GO)

[E]Gramnegativegonococci(Diplococci),OptimalpH7.2,incubationtime:ca.1w.[S]50-80%womenwithGOareasyptomatic.Acuteinfectioninurethra,cervix,Skne’sglands,Bartholin’sglands,evtlrectum.ConfinedinthemucosaonlyProfusepurulenturethralandvaginaldischarge,urethralburning,dysuria,bladderirritability,inflammationofurethra,cervix,Skene’sandBartholin’sglands.Co-infectionwithotherSTDiscommon.CausingrecurrentPID,chronicpelvicpainorinfertilityduetotubaldamageorhydrosalpinxformation.Womenwithahistoryofsalpingitis7~10XectopicpregnancyIftreatmentoftheacutephasedelayedorinadequate,GOviaascendingsurfacespreadingusuallytowardtheendorafterthenextmenstrualperiod

Acutesalpingitisandpelvicperitonitis.Accompanysymptom:Condylomataacuminata.[D]Historyofexposure,microscopy,culture,PCRELISA..[T]Ceftriaxone1giv+Doxycycline100mgbidfor7d.Failureisrareandafollowupcultureisnotnecessary.Forpregnantpatients.Ceftriaxone250mgi.m.assingledose+Erythromycine500mgqidoral.for7d.

Syphilis[E]Treponemapallidumbydirectgenitalororal-genitalcontactwithanactivelyinfectedsexualpartner.FollowingtransfusionwithbloodfromaninfecteddonorTransplacentalspread:Mother

fetus.Primarystageofthediseaseinthereproductivetract.[S]Prim.Stage:Incubationtime2~3w.

UlcusdurumwithindolentswellingofregionalLNingenitalarea.6~8w.healingup.[S]Sec.stage:Otherwise6~12w.afterformationofprim.affection

Lymphogenorhematogenspreading

GeneralizationofLNswelling,macular,latermixedwithpopularexanthema,togetherwithcondylomatalataingenitalarea,alopeciaandtonsillitis.Tert.Stage:Latenttime10-20years,Serotest:positive,withoutsyndromeandsign.MostlyaffectedinCNS,cardiovascularsystem,gummainface,bodyandextremities.Lesionsofthereproductivetractareuncommon.[D]Darkfieldexamination,Serologictest(Cardiolipin,TPHA,FTA),RPR(rapidplasmareagin).[T]Benzathine〔芐星〕penicillinG2~4millionu.i.m.oraqueousprocainepenicillinG600000u./di.m.for8d.Erythromycin500mgoralqidfor15dinpregnantpatients.PatientsshouldbefollowedbyquatitativeVDRLtitersandexaminationat3,4,12monthsaftertreatment.A4xdeclineat6.monthor8xdecreaseby12monthsshouldbeanticipated,ifthediseasehasbeencured.

HerpesgenitalisNeonatalHSVinfectionintheUSincidenceofapp.11~33cases/100000livebirthHSV30%spontaneousabortions.Babiesborntomotherswithactiveherpesvirusinfected.>50%withdisseminateddiseasedie,evenwithantiviraltherapy.Amongneonateswithencephalitis>50%ofsurvivorsareleftwithsevereneurologicimpairment.App.85%ofearlyneonatalherpesinfectionsareaquiredduringdeliveryfromvirioncontaminatedmaternalvaginalsecretions,thereforeC-sectionforwomenwithactivegenitallesionsattimeoflabor.40~70%ofallneonateswithherpesareborntoasymptomaticmothers.Incubationperiodabout6dwithfirstepisodeslastingfor10~12d.Location:Vulva,vagina,cervix,perinealandperianalskin,oftenextendingtothebuttocks.Prim.infectionwithsymptomssuchasmalaise,lowgradefeverandinguinaladenopathy.Asepticmeningitiswithfever,headacheandmenigismuscanbefoundinsomepatients5~7daftergenitallesions.60~90%ofpatientswithrecurrenceofherpeticlesionsinthefirst6m.afterinitialinfection.Recurrencesaresimilarincharacter,butmilderinseverityandshorterinduration.[D]1.Suspicionandclinicalfindings.2.Viralculture.3.Immunofluorescencetechniquestodetectviralparticles.[T]1.Sitzbaths,followedbydryingwithaheatlamporwarmhairdryer.2.Topicalanesthetic(2%lidocainejelly)3.Localantibacterialcream.4.Acyclovirointmentororalacyclovir(200mgtid)forpatientshavingfrequentrecurrence.

Acyclovirprophylaxisforherpesinfctionduringpregnancy:At36wofgestationto(1)womenwhohaveexperiencedsymptomaticHSVduringtheirpregnancyEffectiveofreducingbothsymptomaticrecurrenceandasyptomaticsheddingorto(2)womenwithhistoryofHSVbutnorecurrenceduringpregnancy.

HumanPapillomavirus(HPV)ThemostcommonviralSTDintheUSA.foundin2.5~4%ofwomen,presentingascondylomata

acuminata.Subtypes16,18,31,33,35Cervical

neoplasia.90%ofpateintswithcervical

squamouscellcarcinomasareHPV(+).Incubationperiod1~6m.Oftenaccompaniedbytrichomonasisorbacterialvaginosis.[T]1.Podophyllin(notbeusedduringpregnancy).2.Laserablation,cryotharapyorelectrodessication.

3.5FUcreamasanadjunctforcervicalvaginallesions.

HIVandAIDSHIV(gp120)APC(i.eDC)viagp120+DCSIGN(dendriticcellspecificICAM-grabbingnon-integrin)+CD4RCD4+TcellsviaCCR5.HIV(gp120)EndothelialcellsviaDC-SIGNRCD4+TcellsviaCCR5.Infectedviabloodtransfusion,pregnancyordrugassociateduseofcontaminatedneedles,butsexualtransmissionisamajormodeofspread.In90%ofpatients,infectionbyHIVproducesonlynonspecificsymptoms,oftenmimickingmononucleosis,febrilepharyngitiswithfever,sweat,lethary嗜睡,arthralgia,myalgia,headache,photophobiaandlymphadenopathyseensoonafterinfection.Followingtheinitialinfectioncarrierstatewithoutsymptomsbutviralsheddingoccurs.Immunedysfunctionbecomesapparentroughly10yearsaftertheinitialinfection.[D]:Immunoassay,Westernblotorimmunofluorescenceassays.[T]:AzidovudineorcombinationmultidrugtherapytodelaytheprogressofHIV.[E]Pathogenorganisms:2/3gramnegativebacteria(E.Coli,Pseudomonas假單胞菌,Proteus變形桿菌,Klebsiella,OccasionallyClostridium)

Endotoxin↑

Septicshock,ifuntreated

50%?PuerperalandpostabortalpelvicinflammatorydiseasesPathogenesisofsepticshock:

Endotoxin(Lipopolysaccharideorlipoprotein=carbon-hydrate-complex)1.

Releasingofcatecholamines

Vasoconstriction,initiallymicrocirculation

Peripheralvascularresistance↑

Tissueperfusion↓a.Skinpale,coldandclammy,fever.b.Stagnantanoxia

Tissuedamage,metabolicacidosis

Edema

Pulmonaryedema.Hypovolemicstage

Renalfunction↓,LiverjaundiceInirreversiblephase(Vasomotorcollapse)

Generalizedvasodilatation

Finalstate.2.Neurotoxiceffect

Mentalconfusionorsemicoma!!Riskfactors:

a.

Anemia,malnutrition,chronicdisease.

b.

Coitusimmediatelybeforedelivery.

c.

PROM(Prematureraptureofmembranes)

d.

Chorioamnionitis.

e.

InternCTG.f.

Sectio.

g.

Forcepsandtraumaofbirthcanal.

h.

Postpartalbleeding.[S]Fever↑↑↑,Pulse↑,Shakingchills,Pelvicpain+++,Tenderness+++,Purulentdischar