1、妇产科学妇产科学第第1919章章 性传播疾病性传播疾病【教学目标】【教学目标】了解淋病、梅毒及病毒和沙眼衣原了解淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径、体感染的生殖道炎症的发病原因、传播途径、临床表现及诊断治疗和预防措施。临床表现及诊断治疗和预防措施。【教学重点】【教学重点】淋病、梅毒及病毒和沙眼衣原体感淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的传播途径、临床表现及诊断染的生殖道炎症的传播途径、临床表现及诊断治疗和预防措施。治疗和预防措施。【教学难点】【教学难点】淋病、梅毒及病毒和沙眼衣原体感淋病、梅毒及病毒和沙眼衣原体感染的生殖道炎症的发病原因、传播途径。染的生
2、殖道炎症的发病原因、传播途径。Sexually Transmitted Diseases Bacterial infections:Chlamydia trachomatis Neisseria gonorrhoeae(GO)Syphilis Viral infections:Herpes genitalis Human papillomavirus(HPV)Human immunodeficency virus(HIV)Chlamydia vaginitis E Chlamydia trachomatis Salpingitis (Peritonitis,infertility,etopic
3、 pregnancy,premature labor,stillbirth possible)S Often symptom free,associated with other pathogens of vaginitis(GO,vaginosis),Dysuria,pollakisuria,white glassing discharge.Chlamydia should be suspected in any patient with acute PID,possible GO or trichomonas vaginitis D Intracelluar inclusion,immun
4、ology with monoclonal antibody.T Azithromycin 1g oral,single dose Doxycycline 100mg bid for 7 d,Minocine?Ofloxacin 100 mg tid for 7 d Erythromycin 500 mg qid for 7 d.for pregnant patients Gonorrhea(GO)E Gramnegative gonococci(Diplococci),Optimal pH 7.2,incubation time:ca.1 w.S 50-80%women with GO ar
5、e asyptomatic.Acute infection in urethra,cervix,Sknes glands,Bartholins glands,evtl rectum.Confined in the mucosa only Profuse purulent urethral and vaginal discharge,urethral burning,dysuria,bladder irritability,inflammation of urethra,cervix,Skenes and Bartholins glands.Co-infection with other STD
6、 is common.Causing recurrent PID,chronic pelvic pain or infertility due to tubal damage or hydrosalpinx formation.Women with a history of salpingitis 710 X ectopic pregnancy If treatment of the acute phase delayed or inadequate,GO via ascending surface spreading usually toward the end or after the n
7、ext menstrual period Acute salpingitis and pelvic peritonitis.Accompany symptom:Condylomata acuminata.D History of exposure,microscopy,culture,PCR ELISA.T Ceftriaxone 1g iv+Doxycycline 100 mg bid for 7 d.Failure is rare and a follow up culture is not necessary.For pregnant patients.Ceftriaxone 250 m
8、g i.m.as single dose +Erythromycine 500 mg qid oral.for 7 d.Syphilis E Treponema pallidum by direct genital or oral-genital contact with an actively infected sexual partner.Following transfusion with blood from an infected donor Transplacental spread:Mother fetus.Primary stage of the disease in the
9、reproductive tract.S Prim.Stage:Incubation time 23 w.Ulcus durum with indolent swelling of regional LN in genital area.68 w.healing up.S Sec.stage:Otherwise 612 w.after formation of prim.affection Lymphogen or hematogen spreading Generalization of LN swelling,macular,later mixed with popular exanthe
10、ma,together with condylomata lata in genital area,alopecia and tonsillitis.Tert.Stage:Latent time 10-20 years,Serotest:positive,without syndrome and sign.Mostly affected in CNS,cardiovascular system,gumma in face,body and extremities.Lesions of the reproductive tract are uncommon.D Darkfield examina
11、tion,Serologic test (Cardiolipin,TPHA,FTA),RPR(rapid plasma reagin).T Benzathine（苄星）（苄星）penicillin G 24 million u.i.m.or aqueous procaine penicillin G 600 000 u./di.m.for 8 d.Erythromycin 500 mg oral qid for 15 d in pregnant patients.Patients should be followed by quatitative VDRL titers and examina
12、tion at 3,4,12 months after treatment.A 4x decline at 6.month or 8 x decrease by 12 months should be anticipated,if the disease has been cured.Herpes genitalisNeonatal HSV infection in the US incidence of app.1133 cases/100 000 live birthHSV 30%spontaneous abortions.Babies born to mothers with activ
13、e herpes virus infected.50%with disseminated disease die,even with antiviral therapy.Among neonates with encephalitis 50%of survivors are left with severe neurologic impairment.App.85%of early neonatal herpes infections are aquired during delivery from virion contaminated maternal vaginal secretions
14、,therefore C-section for women with active genital lesions at time of labor.40 70%of all neonates with herpes are born to asymptomatic mothers.Incubation period about 6 d with first episodes lasting for 10 12 d.Location:Vulva,vagina,cervix,perineal and perianal skin,often extending to the buttocks.P
15、rim.infection with symptoms such as malaise,low grade fever and inguinal adenopathy.Aseptic meningitis with fever,headache and menigismus can be found in some patients 5 7 d after genital lesions.60 90%of patients with recurrence of herpetic lesions in the first 6 m.after initial infection.Recurrenc
16、es are similar in character,but milder in severity and shorter in duration.D 1.Suspicion and clinical findings.2.Viral culture.3.Immunofluorescence techniques to detect viral particles.T 1.Sitz baths,followed by drying with a heat lamp or warm hair dryer.2.Topical anesthetic(2%lidocaine jelly)3.Loca
17、l antibacterial cream.4.Acyclovir ointment or oral acyclovir(200 mg tid)for patients having frequent recurrence.Acyclovir prophylaxis for herpes infction during pregnancy:At 36 w of gestation to(1)women who have experienced symptomatic HSV during their pregnancy Effective of reducing both symptomati
18、c recurrence and asyptomatic shedding or to(2)women with history of HSV but no recurrence during pregnancy.Human Papillomavirus(HPV)1.The most common viral STD in the USA.2.found in 2.5 4%of women,presenting3.as condylomata acuminata.2.Subtypes 16,18,31,33,35 Cervical 3.neoplasia.90%of pateints with
19、 cervical 4.squamous cell carcinomas are HPV(+).3.Incubation period 1 6 m.4.Often accompanied by trichomonasis or5.bacterial vaginosis.T 1.Podophyllin(not be used during pregnancy).2.Laser ablation,cryotharapy or electrodessication.3.5 FU cream as an adjunct for cervical vaginal lesions.HIV and AIDS
20、 HIV(gp 120)APC(i.e DC)via gp120+DC SIGN(dendritic cell specific ICAM-grabbing non-integrin)+CD4R CD4+T cells via CCR5.HIV(gp 120)Endothelial cells via DC-SIGNR CD4+T cells via CCR5.1.Infected via blood transfusion,pregnancy or drug associated use of contaminated needles,but sexual transmission is a
21、 major mode of spread.2.In 90%of patients,infection by HIV produces only nonspecific symptoms,often mimicking mononucleosis,febrile pharyngitis with fever,sweat,lethary嗜睡,arthralgia,myalgia,headache,photophobia and lymphadenopathy seen soon after infection.Following the initial infection carrier sta
22、te without symptoms but viral shedding occurs.Immune dysfunction becomes apparent roughly 10 years after the initial infection.D:Immunoassay,Western blot or immunofluorescence assays.T:Azidovudine or combination multidrug therapy to delay the progress of HIV.E Pathogen organisms:2/3 gram negative ba
23、cteria(E.Coli,Pseudomonas假单胞菌假单胞菌,Proteus变形杆菌变形杆菌,Klebsiella,Occasionally Clostridium)Endotoxin Septic shock,if untreated 50%Puerperal and postabortal pelvic inflammatory diseasesPathogenesis of septic shock:Endotoxin(Lipopolysaccharide or lipoprotein=carbon-hydrate-complex)1.Releasing of catecholam
24、ines Vasoconstriction,initially microcirculation Peripheral vascular resistanceTissue perfusiona.a.Skin pale,cold and clammy,fever.b.Stagnant anoxia Tissue damage,metabolic acidosisEdema Pulmonary edema.Hypovolemic stage Renal function,Liver jaundice In irreversible phase(Vasomotor collapse)Generali
25、zed vasodilatation Final state.2.Neurotoxic effectMental confusion or semicoma!Risk factors:a.Anemia,malnutrition,chronic disease.b.Coitus immediately before delivery.c.PROM(Premature rapture of membranes)d.Chorioamnionitis.e.Intern CTG.f.Sectio.g.Forceps and trauma of birth canal.h.Postpartal bleed
26、ing.S Fever,Pulse,Shaking chills,Pelvic pain+,Tenderness+,Purulent discharge+,Leukocytosis+,Later onOligouria,Hypotension,Pulseless,Subnormal temperature with pale,cold,clammy skin,Dyspneic and cyanotic,Metal confusionnear moribund,Anuric,semicomatose T For simple,uncomplicated case,initially bacter
27、iogram or blood culture,broad spectrum antibiotics,i.e.Penicillin 10-20 million units i.v.After 6-12 hrs,afebrile,fluid and electrolyte balance,Emptying all retained infected and necrosis tissue.For early endotoxic shock,massive antibiotic therapy i.v.Penicillin 40 60 million units/d,or Cephalosporin+Gentamycin 6080 mg tid i.m.,if urine output o.k.(Nephrotoxic and ototxic!)Fi.v.fluid therapy(CVP!urin output!)FCorticosteroid for all patients i.v.vasospasm,cardiac output.e.g hydrocortisone 2.05.0 g/dRemoval the source of infection.Tetracycline 2g/dMetronidazole
