Sexually transmitted diseases in pregnancy

Braulio Heredia Hernández, M.D.^I , Alejandro Velasco Boza, M.D.^II,
Eduardo Cutié León, M.D.^III, Ana Bertha Álvarez Pineda, M.D. ^IV

ABSTRACT:  A descriptive study of 120 pregnant women at term or near term was conducted from November 1996 to February 1997 to determine the incidence of sexually transmitted diseases in pregnant women.   All the women  were either patients in the Perinatal Care Unit of the Eusebio Hernández Gyneco-Obstetric Teaching Hospital or outpatients of the same hospital.  Simple and cultured vaginal swab samples were analyzed along with endocervical Gram stains demonstrating a 77.5% incidence of STDs, with negative results in only 23%. The most frequent conditions were Candidiasis (40%), bacterial vaginosis (25%) and vaginal trichomoniasis (13%).  There were only two cases of Neisseria gonorroheae (1.7%).  A total of 30.8% experienced complications during puerperium with the most frequent disorder being endometriosis (20%).

Subject headings: SEXUALLY TRANSMITTED DISEASES; EXUDATES AND TRANSUDATES/microbiology; PREGNANCY COMPLICATIONS, INFECTIONS; PERINATAL CARE.

The spread of sexually transmitted diseases (STDs) throughout the world has become a challenge for public health.  STDs are becoming more prevalent and causing health problems that affect men, women, children and even unborn babies.¹

Cervical cancer, dementia and death are the consequences of some STDs, which are also the main causes of infertility in men and women in many countries.  Some STDs affect the fetus and the newborn; the pregnancies of women who suffer from these diseases may end with the death of the fetus, the newborn or the birth of a child who is seriously ill.²

The propagation of STDs depends on the following factors:

• Sexual behavior and attitudes.
• Increase in the number of sexual partners.
• Availability of services for early diagnosis and identification of contacts.
• Changes in viruses and sensitivity of organisms that cause STDs.

Available evidence demonstrates the urgency of combining strategies to prevent and cure STDs in order to minimize their dissemination.  Health workers must develop specific actions including educational and advisory activities on the causes, symptoms and risks of these diseases – an effort we hope to support with this study.

Methods

A study of 120 pregnant women receiving follow-up at the outpatient service for pregnant women at term and in the perinatal care unit of the Eusebio Hernández Gyneco-Obstetric Teaching Hospital was made from November 1996 through February 1997.

In the outpatient service, a microbiology laboratory technician  took the samples of vaginal exudate for simple and cultured swabs.  The physicians took them in the perinatal care unit.  Samples were taken regardless of whether or not these pregnant women had symptoms of sexually transmitted diseases.  The attending physicians were informed of positive results to help them determine appropriate  therapy  (Tables 1-5).

Results

Table 1 shows the high incidence of positive results for the simple vaginal swabs—93 cases (77%)—with only 27 cases (22.5%) negative.  It also shows the results of Gram endocervical swabs,  taken to investigate the possible presence of intracellular Gram-negative diplococcus ( Neisseria gonorroheae).  Only two cases (1.7%) were positive.

Table 1. Results of microbiological study

	Vaginal  swab		Endocervical   Gram
Results	No.	%	No.	%
Positive	93	77.5	2	1.7
Negative	27	22.5	118	98.3
Total	120	100.0	120	100.0

Table 2 shows the microorganisms found in simple vaginal swabs.  There were 48 cases (40%) of Candida S.P., 30 cases (25%) of bacterial vaginosis and only 15 cases (12.5%) of trichomoniasis.

Table 2. Microorganisms found in simple swabs 

Microorganisms	No.	%
Candida S.P.	48	40.0
Bacteria	30	25.0
Trichomona	15	12.5
No pathogenic microorganisms	27	22.5
Total	120	100.0

Table 3 shows the results of the cultured vaginal and endocervical swabs.  Thirty-three cases (27.5%) were positive.

Table 3. Results of cultured vaginal and endocervical swab samples

Results	No.	%
Positive	33	27.5
Negative	87	72.5
Total	120	100.0

The bacteria most frequently found in cultured vaginal and endocervical swabs (Table 4) were E. coli , with eleven cases (9.2%); coagulase-positive staphylococcus, with 8 cases (6.6%); and streptococcus, with 7 cases (5.8%).

Two cases of Neisseria gonorroheae (1.7%) were also found.  The results were negative in 87 cases (72.5%).

Table 4. Bacteria contained in cultured vaginal and endocervical swabs

Bacteria	No.	%
E. coli	11	9.2
Coagulase-positive staphylococcus	8	6.6
Streptococcus	7	5.8
Non-enterococcus Group D (2)	-	-
Enterococcus Group D (4)	-	-
Group B (1)	-	-
Proteus rettgeni	1	0.8
Klebsiella pneumonieae	2	1.7
Neisseria gonorroheae	2	1.7
Citrobacter	2	1.7
Negative	87	72.5
Total	120	100.0

Table 5 shows the microbiological results throughout the post-partum period.  Of the women studied, 30.8% had complications after birth.  The most frequent disorder found was endometriosis—24 cases (20%).  Eighty-three women (69.2%) had a normal puerperium.

Table 5. Result of microbiological studies in puerperium evolution

Results	No.	%
Endometriosis
Cesarean	10	8.4
Transpelvian birth	14	11.6
Episiotomy infection	8	6.6
Infection of abdominal surgical wound	5	4.2
Normal puerperium	83	69.2
Total	120	100.0

Discussion

Sexually transmitted diseases spread so fast that the damage they cause to health are ever greater, and the literature has little information about these diseases in pregnancy.

Cervico-Vaginal Infections in Pregnant Women, a paper presented by Dr. Ana Bertha Álvarez Pineda, M.D.  in a forum at the Eusebio Hernández Hospital in Havana in 1996, showed that 60% of  results were positive, while our study showed a 77% incidence (Table 1).  The simple swabs (Table 2) had microorganisms such as Candida S.P. (40%), bacterial vaginosis (25%) and trichomoniasis (12.5%).  The literature reports that Candida S.P. is found in 20-25% of all cases.  This disease has been considered an STD since 1967 and it is now accepted that at least 50% of the cases reported result from sexual intercouse.⁴

Bacterial vaginosis (BV) is the current name for a polymicrobian clinical syndrome characterized by an abnormal vaginal secretion, presenting alterations in the vaginal ecosystem, and displacement of lactobacilli by anaerobic microorganisms.  Its etiology is associated with anaerobic agents such as Bacteroids, Prevotella, and Peptostreptococcus, as well as Mobiluncus curtissic and maulers, Mycoplasmas hominis and Ureaplasma ureliticum.  This last is reported to be present in 40-80% of pregnant women, whose children are usually infected, and there are indications that a causal relationship exists between this infection in newborns and the evolution of a bronchopulmonary dysplasia, most frequent in less mature children^5,6.

In general, BV has a negative relation to pregnancy and shows a strong association with chorioamnionitis, amnionitis, ovular infection, premature rupture of the ovular membranes, and premature birth.  The baby is frequently infected.  The literature reports that about 33% of the cases have BV^7-9 . Our study showed 25%.

Tropical countries report that 15-40% of women of reproductive age are infected with trichomonas^7,8,10. Trichomoniasis is known to be one of the most common STDs among women and can be asymptomatic in 50% of the cases.  It is estimated that 180 million women in the world suffer from vaginitis due to trichomonas every year.⁴

Its frequent association with Neisseria gonorroheae and other microorganisms of bacterial vaginosis must be taken into account.

Neisseria gonorroheae was found in 1.7% of the cases studied (Table 4), a figure that may seem small but, if 100,000 pregnant women are considered, this would mean 1700 cases—a result that is similar  to that reported by Dr. Onelia Ferrer, M.D.  The literature states³ that the frequency of these disorders among female adolescents is 510 cases out of 10,000.  When the sample includes women of all ages, the percentage decreases; if the sample includes only pregnant women, the incidence is even less¹¹.

Dr. Susana Fiorito, M.D. found a prevalence of 1% of gonorrhea among pregnant women, and it is noteworthy that she also found 7% of Chlamydia trachomatis in the same group.  (Ferrer O. personal communication, Provincial Center for Hygiene and Epidemiology, Havana, 1997.) (Fiorito S. Enfermedades de transmisión sexual en mujeres embarazadas. Fifth Latin-American Tropical Medicine Congress, Cuba, March 1997).

As shown in Table 4, the most frequently found bacterium in our patients was the E. coli (92%).  The literature shows⁴ that the most frequently isolated germs are the Gram-negative aerobic, particularly the enterobacteria, and the most frequently found is the E. coli. Then come the anaerobic (among the BV) and then the aerobic streptococcus and, among them, the beta-hemolytic group B streptococcus, whose relationship to dangerous perinatal affections is known.

Infection is still one of the main causes of death in childbirth in the world.  The puerperal infection is polymicrobian and has special characteristics that differentiate it from other infectious processes in other fields such as pediatrics, surgery and family medicine, because these patients are immunodepressed and the infection, in addition to being polymicrobian, has an insidious beginning, with worse evolution and prognosis, and even obtaining a sample can prove difficult.  In our study, we found large numbers of puerperal women with septic complications (30.8%), and thus we propose that specialists in OB-GYN further study these topics, which we are sure will result in better outcomes for mothers and children in the future, and to decreased maternal and perinatal morbimortality.

References

1. Guerra Macedo C. Enfermedad y daño a la salud. Las condiciones de la salud en las Américas. OPS 1: 1994:188-196.

2. Perea JE. Enfermedades de transmisión sexual. Cap. 1. Ediciones Doyana, Barcelona. 1993:1-7.

3. Schwatch SK National Surveillance of antimicrobial resistance in Neisseria gonorroheae. Medical Aspect of Human Sexuality. Feb.1992: 19-20.

4. Obstetricia y Ginecología Infanto Juvenil: Su importancia. Ciudad de la Habana, Socudef. 1996:35-60.

5. Slavin MB, Single dose oral fluroconazol vs intravaginal terconazole in treatment of Candida Vaginalis. J Fla Med Assoc 10:1992.

6. Remington Jack S. Klein Jerome Q. Infection diseases of the fetus and newborn infant. 4ta de Philadelphia: WB Saunders, 1995: 619-646.

7. López Kaufman C, Bagnati E, Trumper E. Vaginosis bacteriana. Revista de la Sociedad de Ginecología Infanto Juvenil. 2:1991.39-49.

8. Sweet R. Nuevos enfoques terapéuticos de la vaginosis bacteriana. Am J Obstet Gynecol, 1993 (169):479-82.

9. Sobel JD. Bacterial Vaginosis: assessment and treatment. J Ann Intern Med 111:1989:551-3.

10. Hillier SL. The normal vaginal flora, H202 producing lactobacilli and bacterial vaginosis in pregnant women. Clin Infect Dis 4:1993-273-281.

11. Palomares JC. Perea ES. Resistencia en N. gonorroheae. Enf Infec Microbiol Clin 1987:5:3-6.

This article originally appeared in the Revista Cubana de Obstetricia y Ginecología, vol. 24, no.1, (pp. 28-33),  January-April, 1998.  

1. First Degree Specialist in Gynecology and Obstetrics.  Assistant Professor of Faculty #2. Higher Institute of Medical Sciences of Havana. 
    
2. Second Degree Specialist in Gynecology and Obstetrics.  Assistant Professor of Faculty #2.  Higher Institute of Medical Sciences of Havana.
    
3. Second Degree Specialist in Gynecology and Obstetrics.   Professor of Faculty #2.  Higher Institute of Medical Sciences of  Havana.
    
4. First Degree Specialist in Microbiology.