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Clinical Topic #5

Perinatal Loss And Sexually Transmitted Infections

Clinical Topic #4
Objectives:
Discuss the impact on parents and families with the birth of the imperfect infant or an infant that has died. Explore nursing interventions to assist parents and families with their grief. Identify sexually transmitted infections & their potential impact upon pregnancy.

Perinatal Loss
Abortion Fetal Demise Neonatal Demise Loss of the perfect child

GRIEF RESPONSES
Shock & numbness - stunned & disbelief Searching & yearning restless, anger, guilt Disorganization depression, realizes loss Reorganization able to cope with loss and finally move on

Physical Effects of Grief


Exhaustion, fatigue, weakness Loss of appetite Insomnia Weight loss or weight gain Palpitations Aching arms Headaches Restlessness

Psychological/Emotional Effects of Grief


Denial Guilt Anger Resentment Sense of Failure Mood Swings Depression Decreased self esteem Forgetfulness Irritability Sadness Failure to accept reality Time confusion Concentration problems

Social and Spiritual Effects of Grief


Withdrawal from friends and family Emotional and Physical isolation from outside world Questions core belief system Search for meaning of the loss Anger at God or higher power May change religion

Post Delivery Care


Document delivery information Bathe infant Assess infant weight & measurements Complete crib card and footprint sheet Complete memory box Infant photographs Provide family contact if desired Discuss burial arrangements Emotional support for family members

Memory Box

Door Card

Nursing Diagnosis in Relation to Neonatal Loss


Powerlessness r/t: *inability to care for self *lack of knowledge *inability to communicate feelings Altered Family Coping r/t
*loss of family member/baby *inability to talk with others about feelings *inability to make decisions about the funeral *social isolation

Nursing Diagnosis in Relation to Neonatal Loss


Sleep Pattern Disturbance r/t * Grieving process * Anticipatory grief Spiritual Distress r/t * Loss of baby or loss of the perfect child * Loss of self-esteem *Loss of innocence and questioning of faith

Anticipatory Grief
If the parents know that their child will have a deformity or know of an impending loss, such as when an infant is admitted to the NICU, being able to anticipate the loss will give the families an opportunity to feel more in control of their situation and give them time to say good-bye in a special way.

Womens Health: Commonly Occurring Infections

Bacterial Vaginosis (BV)


Most prevalent vaginal infection worldwide Most frequent causative agent: Gardnerella vaginalis Questionable as to whether it is a STI Overgrowth of normal vaginal flora Possible due to changes in vaginal pH Symptoms:
Thin, watery, white-gray discharge Fishy odor

Diagnosis: symptoms and wet mount Treatment: Flagyl

Bacterial Vaginosis (BV) During Pregnancy


BV should be treated with Flagyl during pregnancy If left untreated can increase incidence of preterm labor and preterm birth

Vulvovaginal Candidiasis (VVC)


Fungal or yeast infection Most frequent causitave agent: Candida Albicans Symptoms:
Thick, white, cottage cheese like vaginal discharge Severe itching, Dysuria, and dyspareunia

Diagnosis: symptoms and wet mount Treatment: miconazole cream external or intravaginal

Vulvovaginal Candidiasis (VVC) During Pregnancy


Pregnancy treatment usually limited to external application for 7 days VVC should be treated during pregnancy to prevent transmission during delivery Infants exposed to VVC can develop thrush

Trichomoniasis
Causative agent: Trichomonas vaginalis-An anaerobic flagellated protozoan Sexually transmitted Asymptomatic or mild symptoms:
Yellow-green, frothy, odorous discharge Vulvar itching Possible dysuria or dyspareunia

Diagnosis: symptoms and wet mount Treatment: metronidazole (Flagyl)

Trichomoniasis During Pregnancy


Patient and partner must be treated during pregnancy with Flagyl If left untreated, patient may be at increased risk for premature rupture of membranes or preterm birth

Chlamydia
The most common STI in the US Bacteria organism: Chlamydia trachomatis Sexually transmitted Symptoms
Thin or mucopurulent discharge Friable cervix Burning & frequency with urination

Up to 50% may be asymptomatic. Diagnosis: Chlamydia culture Treatment: azithromycin or doxycycline

Chlamydia During Pregnancy


Patient and partner must be treated during pregnancy with azithromycin or amoxicillin since doxycycline is contraindicated Infants exposed to chlamydia during delivery can develop ophthalmia neonatorum or pneumonia Untreated chlamydia infection can lead to pelvic inflamatory disease and possibly infertility

Gonorrhea
Bacterial organism: Neisseria gonorrhoeae Sexually transmitted Symptoms:
Men are more symptomatic 80% of women are asymptomatic Green-yellowish discharge Urinary frequency and dysuria

Diagnosis: Cervical/vaginal culture Treatment: antibiotics usually Cephalosporin

Gonorrhea During Pregnancy


Patient and partner must be treated with a full course of a cephalosporin Infants exposed to gonorrhea can develop ophthalmia neonatorum which can lead to blindness Untreated gonorrhea can lead to pelvic inflamatory disease and possibly infertility

Herpes Simplex
Viral organism: HSV-1 and HSV-2 Transmission:
Vaginal, anal, or oral sex Skin-to-skin contact with an infected site

Diagnosis:
Clinical appearance of lesions Lesion culture

Herpes Simplex
Symptoms: primary outbreak Single or multiple blister like vesicles Difficult urination and urinary retention Enlargement of inguinal lymph nodes Flu like symptoms, genital pruritus, or tingling Primary lesions heal and the virus lies dormant Recurrences vary from none to regular occurrances Recurrences can be triggered by stress, illness or pregnancy Treatment: oral acyclovir or valacyclovir during outbreaks or suppressive No cure

Herpes Simplex During Pregnancy


Patient should be treated with Acyclovir especially during the third trimester to reduce outbreaks Genital area and cervix should be examined for lesions as term approaches Cesarean birth is recommended if active lesions are present at term Infants exposed to herpes lesions can develop skin rash, fever and CNS symptoms which can lead to mental retardation or death

Syphilis
Bacterial organism:
Treponema pallidum

Transmission:
Sexual contact Exposure to exudate from infected individual Transplacental

Diagnosis: Serologic testing (VDRL or RPR) Treatment: Penicillin G Intramuscularly

Syphilis (contd)
Symptoms: early stage
Chancre appears, lasts for 4weeks then disappears Fever weight loss malaise

Symptoms: secondary stage


Condylomata lata on vulva, acute arthritis Enlargement of liver and spleen, enlarged lymph nodes Chronic sore throat with hoarseness

Syphilis During Pregnancy


Serologic testing for syphillis during pregnancy is state mandated in Illinois Paient and partner must be treated during pregnancy with IM Penicillin G Transplacental transmission can be as high as 95% Congenital syphillis can develop
Intrauterine growth restriction Preterm birth Stillbirth

Condyloma Acuminata (Genital Warts)


Viral organism: human papilloma virus (HPV) Sexually transmitted Symptoms:
Painless genital warts appear as grayish pink cauliflower lesions Pruritus and bleeding may be present

Diagnosed by visual inspection Treatment: Possible surgical removal, cryotherapy or patient applied therapies

Genital Warts During Pregnancy


Genital and vulvar warts do not warrant cesarean birth Surgical removal of warts during pregnancy is safe however patient applied therapies are thought to be teratogenic HPV infection has been linked to cervical cancers and anorectal cancers Gardisil an HPV vaccine against specific types of the virus is available and is now recommended for girls and boys

Pediculosis Pubis (Pubic Lice/Crabs)


Causative agent: Phthirus: a parasitic louse that resembles a crab and lays eggs which attach to hair shafts Transmission: intimate sexual contact, shared towels and bed linens Diagnosis: Microscopic examination of nits Symptoms: Itching in pubic area Treatment: 1% permethrin cream; linens, towels, and clothing should be machine washed and dried on a hot setting

Pubic Lice During Pregnancy


Patient and partner should be treated with 1% permethrin cream

Hepatitis B
Causative agent: Hepatitis B virus Transmission: Blood borne, sexual or perinatal Diagnosis: Serum testing for HBsAg (Hepatitis B Surface Antigen) Hepatitis B is a chronic disease, there is no cure

Hepatitis B During Pregnancy


All pregnant women should be screened for HBsAg Women admitted to L&D who have not been screened should have blood drawn for HBsAg Pregnancy is not a contraindication for vaccination HBV infection does not cause birth defects Risk for fetal/neonatal transmission during delivery or invasive procedures Newborns born to HBV positive mothers should receive hepatitis vaccine AND hepatitis B immune globulin (HBIG) within 12 hours of birth.

HIV
HIV is transmitted via blood/body fluids and sexual contact CDC recommends that all pregnant women be screened for HIV Women who have not been screened should have a rapid HIV drawn upon labor admission HIV transmission to the neonate can occur by
Transplacental Breastfeeding Exposure to contaminated blood

HIV During Pregnancy


All HIV positive pregnant women should be managed with antiretroviral therapy even if asymptomatic to reduce perinatal transmission Recommended method of delivery is Cesarean prior to labor or ROM Breastfeeding is contraindicated since the virus is present in breast milk

HIV During Pregnancy


HIV testing done on the neonate can be done but can not distinguish between maternal and infant antibodies. Absence of HIV can be confirmed with a negative HIV antibody assay result at 12-18 months of age. For exposed infants, AZT is started prophylactically x 6 weeks beginning at 8-12 hours of age

DISEASE

ORGANISM

SYMPTOMS Thin, watery, gray discharge with a fishy smell

TREATMENT Metronidazole or Clindamycin Amoxicillin or Azithromycin Surgical or laser removal of warts Amoxicillin or Azithromycin Acyclovir

PREGNANCY IMPLICATIONS PROM, PTL, amniotic infection & Post partum endometritis PTL, neonatal opthamic infection

Bacterial Vaginosis

Gardnerella Vaginalis Chlamydia Trachomatis Papovavirus Neisseria Gonorrhoeae Herpes Simplex Virus Phthirus Trichomonas Vaginalis Treponema Pallidum Candida Albicans

Chlamydia

May be asymptomatic, or UTI symptoms

Condyloma Acuminata Gonorrhea

Lesions on the vulva, vagina, cervix or anus Vaginal inflammation & purulent vaginal discharge

Link between HPV and cervical cancer Active infection at birth can cause opthalmia neonatorum Vaginal birth possible only if no active lesions. None, if treated during pregnancy Increased risk for PTL & PROM

Herpes Genitalis

Lesions only if active, inactive asymptomatic with elevated herpes titer Profuse perineal itching. Microscopic ID of lice or nits Frothy green vaginal discharge

Permethrin shampoo

Pediculosis Pubis

Metronidazole

Trichomonas

Syphillis

Primary: Chancre Secondary: skin rash. Diagnosed with blood tests Thick, white, curdy discharge. Perineal itching

Benzathine Penicillin G IM

Can be passed transplacentally to the fetus. Risk for stillbirth, abortion, congenital syphilis If present at vaginal birth, infant may contract thrush

Vulvovaginal Candidiasis

Miconazole Cream or Vaginal Inserts

Health Teaching to Decrease STI Transmission


Planning ahead and developing strategies to say no to sex Limiting the number of sexual contacts and practicing monogamy Using a condom and negotiating condom use with a partner Reducing high-risk behaviors such as used of alcohol and recreational drugs

Health Teaching to Decrease STI Transmission


Refraining from oral sex if partner has active sores in mouth, vagina, anus, or on penis Seeking care as soon as symptoms are noticed Understanding that disappearance of symptoms does not mean treatment is unnecessary Taking all prescribed medications completely Having more frequent Pap screening for certain genital infections

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