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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

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The baby may become colonized from an infected birth canal, but is more likely to become infected from poor hand washing hygiene by those caring for or handling the baby, including visitors, or inadequately sterilized or contaminated feeding bottles.
A breastfeeding baby may become infected from a sore nipple that becomes infected.
1
Young GL, Jewell D (2001). Topical treatment for vaginal candidiasis in pregnancy. (Cochrane review). In:
Cochrane Library
, Issue 3. Oxford: Update Software.
CHAPTER 3
Sexual health
28‌‌
Chlamydia
- Chlamydia trachomatis
  is the most common cause of bacterial STI in the UK, affecting both men and women, and a leading cause of PID.
- Prevalence is highest, but not exclusive, in young sexually active adults, especially those under 25, hence the introduction of the current National Chlamydia Screening Programme in England for the 16–25-year age group.
- 80% of women and 50% of men have no symptoms and, left untreated, chlamydia can, in women, lead to infertility, ectopic pregnancy, and chronic pelvic pain. In men it may cause urethritis and epididymitis. In both sexes it can cause arthritis—Reiter’s syndrome.
- In the symptomatic woman it may cause mucopurulent cervicitis, postcoital and/or intermenstrual bleeding.
- Because of the prevalence of chlamydia in the sexually active population and lack of symptoms,
  it is good midwifery practice to
  routinely offer a chlamydia screening test
  , using a ‘first catch’ urine sample, both at the beginning of pregnancy and again by 36 weeks, to
  detect and treat affected women. The newer nucleic acid amplification test (NAAT) is 95% sensitive.
- Alternatively, an endocervical swab can be taken.
- It is also good practice to screen the male partner(s) and to refer both partners to the local sexual health service for further STI screening, contact tracing, and follow-up.
- Antibiotic treatment in pregnancy is usually with a course of erythromycin 500mg twice daily for 14 days, but exact treatment will be decided by the doctor or nurse with prescribing rights. Azithromycin should be used with caution in pregnancy and breastfeeding.
  ¹
  Chlamydia in pregnancy
- In the pregnant woman the increased vascularity of the cervix may lead to postcoital or irregular spotting or bleeding per vaginam and any woman with such bleeding should be screened for chlamydia.
- Chlamydia in pregnancy can cause amnionitis and postnatal endometritis.
- The evidence on its role in spontaneous abortion, preterm rupture of the membranes, preterm birth and neonatal death is unclear from studies to date.
  Fetal and neonatal infection
- Although there is some evidence that intrauterine infection can occur, the major risk to the baby is during vaginal birth through an infected cervix.
- Up to 70% of babies born to mothers with untreated chlamydia will become infected: 30–40% will develop chlamydial conjunctivitis and 10–20% a characteristic pneumonia.
- Chlamydial ophthalmia neonatorum is a notifiable infection.
- Chlamydial ophthalmia neonatorum is now much more common than gonococcal ophthalmia, although in practice the two may occur
together; 50% of those with gonococcal ophthalmia also have chlamydia.
CHLAMYDIA
29
Chlamydial ophthalmia has an incubation period of 10–14 days, much longer than gonococcal ophthalmia, which is evident in about 48h.
It can permanently affect vision and can even cause blindness.
The orbit of the eye is swollen and there is a mucoid discharge, often known as a ‘sticky eye’.
The midwife must take swabs from both eyes, for chlamydia, gonococcal infection and general culture and sensitivity, and ensure they are immediately transported to the laboratory.
After taking the swab, the eyes are regularly cleansed with normal saline.
Inform the paediatrician, or GP in the community, and ensure the baby is examined and treated as a matter of urgency.
The nasopharynx is also likely to be infected, which may lead to pneumonia unless promptly treated with systemic antibiotics.
It is important to diagnose and treat any baby with chlamydial infection.
It is thought that the baby who is affected by chlamydia pneumonia is
more likely to develop obstructive lung disease and asthma than those
with pneumonia from other causes.
It may be up to 7 months before chlamydia infection becomes apparent and cultures from the pharynx, middle ear, vagina, and rectum of the baby are positive.
Knowledge about the prevalence in the community and the effects on both mother and baby should encourage the midwife to take a sexual health history, be proactive in chlamydia testing and offer routine testing to all pregnant women in her care.
Useful websites
British Association for Sexual Health and HIV. Available at: M www.bashh.org.uk.
Chlamydia. Available at: M
www.healthcarea2z.org/ditem_print.aspx/315/Chlamydia (accessed 2.5.10).
National Chlamydia Screening Programme. Available at: M www.chlamydiascreening.nhs.uk/ps/ index.html.
Neonatal Conjunctivitis and Pneumonia due to C. trachomatis. Available at: M www.chlamydiae.
com/restricted/docs/infections/ophth_neonat.asp (accessed 2.5.10).
Further reading
Brocklehurst P, Rooney G (2009). Interventions for treating genital chlamydia trachomatis infection in pregnancy.
Cochrane Database of Systematic Reviews
4
, CD000054.
Dapaah S, Dapaah V (2009). Sexually transmissible and reproductive tract infections in pregnancy. In: Fraser D, Cooper M (eds)
Myles Textbook for Midwives
. 15th edn. London: Churchill Livingstone, pp. 415–32.
1
British National Formulary
(2010). Available at: M
www.bnf.org (accessed 2.5.10).
CHAPTER 3
Sexual health
30‌‌
Genital warts
- Genital warts are caused by the human papilloma virus, types 6 and 11.
- Sexual transmission is the most usual mode of infection.
- The incidence of genital warts diagnosed has steadily been rising over the past 10 years and the highest rates are seen in the female 16–24-year age group.
- They are not only uncomfortable, but also psychologically distressing.
- They are difficult and time-consuming to treat and may reoccur months or years later.
- Refer a woman who has genital warts to a specialist sexual health clinic for treatment and further investigation for other STIs.
- A colposcopy may be performed to exclude warts on the cervix.
- Although most genital warts are benign, it is important that an annual liquid-based cytology screen is recommended, as human papillomavirus (HPV) types 16, 18, 31, 33, and 35 are strongly associated with
  development of cervical cancer.
- The midwife has an important role in sexual health promotion,
  encouraging safer sex and promoting participation in the cervical screening programme, particularly if the woman is over 25 and not yet had her first screening test.
  Genital warts in pregnancy
- Genital warts are caused by HPV.
- In pregnancy the warts may increase considerably in size and have a cauliflower-like appearance.
- Occasionally they are so large and widespread that they may obstruct the vulva and lower vagina and prevent a vaginal birth, therefore requiring a caesarean section.
- The normal treatment is drug contraindicated in pregnancy, because of possible teratogenic effects, therefore pharmacological treatment is not given until after the birth.
- Cryo-cautery is the only treatment possible during pregnancy, done at a specialist sexual health clinic.
  Fetal and neonatal infection
- Babies and young children may develop laryngeal papilloma after being infected by maternal genital warts during vaginal birth.
  Useful websites
  British Association for Sexual Health and HIV. Available at: M
  www.bashh.org.uk. (accessed 2.5.10)
  Further reading
  Dapaah S, Dapaah V (2009). Sexually transmissible and reproductive tract infections in pregnancy. In: Fraser D, Cooper M (eds)
  Myles Textbook for Midwives
  . 15th edn. London: Churchill Livingstone, pp. 415–32.
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  CHAPTER 3
  Sexual health
  32‌‌
  Gonorrhoea
- Gonorrhoea is the second most common STI in the UK.
- Prevalence is highest among sexually active adults under 25 years.
- It is a bacterial infection, caused by
  Neisseria gonorrhoeae
  .
- The organism adheres to mucous membranes and is more prevalent on columnar rather than squamous epithelium.
- The primary sites of infection are the mucus membranes of the urethra, endocervix, rectum, pharynx, and conjunctiva.
- Importantly, gonorrhoea frequently co-exists with other genital mucosal infections, such as those caused by
  Chlamydia trachomatis
  ,
  Trichomonas vaginalis
  , and
  Candida albicans
  .
- Many areas are now also testing for gonorrhoea on the Chlamydia Screening Programme urine samples, because of the prevalence of co-infection. Be aware of the testing procedures in your own area.
- Up to 80% of PID in women under 26 is caused by gonorrhoea or
  chlamydia or both.
- The consequences of untreated gonorrhoea leading to PID include
  infertility, ectopic pregnancy, and chronic pelvic pain. Although uncommon, it may also cause disseminated general disease and arthritis—Reiter’s syndrome.
- 50% of women may be asymptomatic.
- The most common symptom is increased or altered vaginal discharge (penile discharge in men).
- Other symptoms include lower abdominal pain, dysuria, dyspareunia, intermenstrual uterine bleeding, and menorrhagia.
- It is also good practice to screen the male partner(s) and to refer both partners to the local sexual health service for further STI screening, contact tracing, and follow-up.
  Gonorrhoea in pregnancy
- The incidence of 1–5% is small, but the incidence of gonorrhoea nationally is rising, particularly in big cities. Midwives must, therefore, be vigilant, as there is evidence that it is detrimental in pregnancy.
- Gonorrhoea is associated with spontaneous abortion, chorioamnionitis, preterm rupture of the membranes, preterm labour, and very low birthweight. Postnatally, it can cause endometritis and pelvic sepsis, which may be severe.
- A Cochrane systematic review of interventions for treating gonorrhoea in pregnancy has concluded that the well-established treatment with penicillin and probenecid is effective.
  ¹However, antibiotic resistant strains are now becoming apparent and making treatment more difficult.
  Fetal and neonatal infection
- The most common mode of transmission to the baby is through the infected cervix during vaginal birth.
- It may also be transmitted in uterus, following prolonged rupture of the membranes.
- The risk of vertical transmission from an infected mother is 30–50%.
GONORRHOEA
33