Viral infections Genital warts Copyright 2004 by Delmar

§ -Genital warts are caused by the human papillomavirus (HPV). § -HPV, genital warts, caused by types 6 and 11. § -Transmission is primarily by sexual contact but infants and young children may develop laryngeal papillomas after being infected from maternal genital warts at delivery Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 2

§ women in the 16– 19 and 20– 24 year age -groups. § -Most genital warts are asymptomatic and painless and many resolve spontaneously in healthy women. § -cause irritation and soreness, causing psychological and psychosexual distress Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 3

§ -like cauliflower-like masses § -treatment is aimed at removing the warts Copyright 2004

§ - Warts are usually treated with locally applied caustic agents such as podophyllum. § -this is contraindicated in pregnancy because of possible teratogenicity. § - Treatment is not recommended during pregnancy, trichloroacetic acid, cryotherapy, diathermy, laser therapy or surgery may be appropriate § Women presenting with genital warts should be fully investigated to exclude other sexually transmitted infections Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 5

§ - colposcopy should be performed to exclude flat warts on the cervix § - Most genital warts are benign, but cervical intraepithelial neoplasia is strongly associated with HPV types 16, 18, 31, 33 and 35, therefore an annual cervical smear is recommended § -Prophylactic vaccines to prevent primary infection with HPV and reduce the incidence of related conditions such as cervical cancer and genital warts are being developed. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 6

Hepatitis B virus § -Hepatitis B virus (HBV) is an hepadnavirus belonging to a family of DNA viruses that cause acute infection of the liver. § -HBV can be transmitted sexually, parenterally or vertically from mother to fetus § - Body fluids such as saliva, menstrual and vaginal fluid, serous exudates, seminal fluid and breastmilk have been implicated in the spread of infection, but infectivity is largely related to blood and body fluids contaminated with blood. § -Transmission occurs in injecting drug-users sharing needles and syringes, tattooing or acupuncture, or as a consequence of needle -stick injury in healthcare workers Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 7

§ -Acute infection with HBV is asymptomatic § there are two phases of symptoms: § • the prodromal phase (3– 10 days) characterized by flu-like symptoms of malaise, myalgia and fatigue, often accompanied by pain in the right hypochondrium § • the icteric phase (7– 21 days) characterized by jaundice, anorexia, nausea and fatigue. § symptoms can persist for 12 or more weeks (cholestatic symptoms of itching and deep jaundice). § -The diagnosis of HBV relies on serological tests. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 8

§ - HBV is diagnosed by the presence of Ig. M antibodies to the HBV core (anti-HBc Ig. M). § -Hepatitis B surface antigen (HBs. Ag) § -Patients who remain HBs. Ag positive after six months named carriers. § - hepatitis Be antigen (HBe. Ag) which can be detected during the acute phase but disappears quickly unless the individual becomes a carrier. § -The appearance of anti-HBs in the serum indicates immunity. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 9

§ -Chronic infection are seen in immunocompromised patients with HIV infection, chronic renal failure and those receiving immunosuppressive therapy § -the population carries the hepatitis B virus. HBe. Ag positive carriers are much more likely to transmit the infection during sexual contact or from mother to baby at birth § -More than 90% of infants born to HBe. Ag positive mothers will also become chronic carriers unless immunized. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 10

§ - All pregnant women should be offered antenatal screening for HBV and babies born to infected mothers should be vaccinated at birth § -In addition, the babies of mothers who have become infected with HBV during pregnancy and those who do not have anti-HBe antibodies should also receive hepatitis B specific immunoglobulin (HBIg § - Infected mothers should continue to breastfeed as there is no additional risk of transmission Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 11

Hepatitis C virus § § § (HCV) blood donors intravenous drug users. - Acute HCV infection is usually asymptomatic. -severe liver damage, liver cirrhosis, and hepatocellular carcinoma § - blood products, intravenous drug use, tattooing, and mother-to-child transmission Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 12

§ -Vertical transmission rates are low, § co-infection with HIV has been associated with a greater likelihood of transmitting HCV to the fetus. § - Breastfeeding does not pose an important risk of transmission if the nipples are not traumatized and maternal HCV infection is quiescent -Sexual transmission rates are very low but these are increased in high risk groups such as female sex workers and those with multiple sexual partners § -routine screening of pregnant women for HCV is not recommended Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 13

Herpes simplex virus § -There are two (HSV) subtypes. § -Type 1 (HSV-1) causes the majority of orolabial infections, and is often acquired during childhood through direct physical contact with oral secretions. § -Type 2 (HSV-2) is associated with genital disease and is acquired through contaminated secretions during sexual contact. § - Genital HPV-1 can be acquired through orogenital contact § the incidence of genital HSV-1 infection is increasing, especially in young women § - Genital herpes is a lifelong infection. Once acquired, the virus becomes latent in sensory nerve ganglia and reactivates periodically Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 14

§ -Infected people shed the virus regardless of whether or not lesions are present. § -Previous oral infection with HSV-1 provides a high level of protection against genital HSV-1 infection but not against genital HSV-2 infection. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 15

§ -asymptomatic, but painful, vesicular or ulcerative lesions on the vulva, perineum, vagina and cervix. § - Dysuria and vaginal or urethral discharge § fever, headache and myalgia. Symptoms more severe in women than in men Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 16

HSV in pregnancy § -Neonatal herpes is a severe systemic viral infection with a high morbidity and mortality § - Women who have had herpes prior to pregnancy will have developed antibodies to the virus. § -The fetus will also develop these antibodies and consequently at birth will have passive immunity. § -The greatest risk to the fetus is therefore if the mother acquires a primary infection during late pregnancy and the baby is born before the development of maternal antibodies § -Primary infection in early pregnancy can lead to congenital HSV infection which although rare can cause severe congenital abnormalities. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 17

§ - About 70% of cases of neonatal HSV infection are caused by HSV-2 and result from contact with maternal genital secretions during delivery. § - Neonatal herpes may be acquired from an ascending infection following rupture of the membranes. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 18

Diagnosis § § clinically. - HSV DNA detection by PCR - Viral cultures from open lesions. direct immunofluorescence assay (IFA) or enzyme immunoassay (EIA). § -Serological tests for HSV specific antibody § - The presence of HSV-2 antibodies is indicative of genital herpes Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 19

Management of HSV infection in pregnancy § -a genitourinary physician. § -Primary infection acquired during the first or second trimester should be treated with acyclovir. § - Acyclovir reduces viral shedding, reduces pain and promotes the healing of lesions. § -Caesarean section is recommended for all women presenting with first-episode genital herpes lesions at the time of delivery as the risk of viral shedding and vertical transmission is high. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 20

§ -risk of pre-term labour § -Continuous acyclovir in the last 4 weeks of pregnancy may reduce the risk of clinical recurrence at term. § - It has been proposed that specific antibody testing be undertaken in the latter half of pregnancy in order to identify babies at risk of infection. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 21