Oxford Handbook of Midwifery (21 page)

Useful websites

British Association for Sexual Health and HIV. Available at: M www.bashh.org.uk.

Jatia KK (2009).
Neonatal Conjunctivitis
. Available at: M http://emedicine.medscape.com/
article/1192190-overview (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.

1
Brocklehurst P (2001). Interventions for treating gonorrhoea in pregnancy (Cochrane review). In:
The Cochrane Library
, Issue 3. Oxford: Update Software,

CHAPTER 3
Sexual health

34‌‌

Hepatitis B

• The hepatitis B virus (HBV) is the most commonly transmitted blood- borne virus worldwide and a major public health problem.
  
• It is an important cause of both mortality and morbidity from acute infection and chronic long-term sequelae, including cirrhosis of the liver and primary liver cancer.
  
• The virus can be transmitted both sexually and parenterally through infected blood and blood products.
  
• Other body fluids, such as saliva, menstruation, and vaginal discharge, seminal fluid, breast milk, and serous exudates have been implicated, but infection via these routes is far less common.
  
• Unsterilized equipment, such as that associated with injecting drug users sharing equipment, tattooing, and acupuncture is a source of infection.
  
• Importantly, healthcare workers may be infected through needlestick
  injury and must follow local policy for reporting such injuries and
  

  subsequent testing. In the UK, all healthcare workers at any risk are
  

  required to be immunized against HBV.
  

• Although the initial acute phase is characterized by a flu-like illness, followed by a phase characterized by jaundice, loss of appetite, nausea and fatigue, it may be asymptomatic in 10–50%.
  
• In chronic infection there are often no physical signs or symptoms, but there may be signs of chronic liver disease.
  
• The midwife has an important health promotion role, in careful history taking, detecting risk factors, giving evidence-based information and encouraging women to participate in antenatal HBV testing.
  

  Hepatitis B in pregnancy
  

• If a woman is a carrier of HBV, she has an 85% risk of transmission of the virus to her infant.
  
• Acute HBV infection occurring during pregnancy is associated with an increased risk of spontaneous abortion and preterm labour and birth.
  
• The objective of offering HBV screening to pregnant women, and immunization of babies born to infected mothers, is to reduce the perinatal transmission of this infection.
  
• All women are offered screening for HBV during early pregnancy.
  

  Fetal and neonatal infection
  

• If the mother tests positive for HBV, her baby will be vaccinated shortly after birth.
  
• Obtain consent for the baby’s immunization prior to birth, and give the first dose as early as possible, but always within 24h.
  
• If the mother became infected during pregnancy or does not have the HBe antibodies, the baby should receive hepatitis B-specific immunoglobulin (HB1g) at birth, injected at a different site to the vaccine. This will give immediate immunity and reduces vertical transmission by 90%.
  
• Encourage and support breastfeeding, as there is no additional risk of virus transmission to the baby.
  

HEPATITIS B

35

Useful website

British Association for Sexual Health and HIV. Available at: www.bashh.org.uk.

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. 415–432.

CHAPTER 3
Sexual health

36‌‌

Hepatitis C

• The hepatitis C virus occurs throughout the world and is mainly transmitted by infected blood, blood products and inoculation through the skin.
  
• With screening of all blood donors in the UK for the past 20 years, the incidence of transmission via infected blood and blood products is virtually nil, however this may not be true elsewhere.
  
• In intravenous drug users the infection rate is over 60%, by contamination from sharing needles and syringes.
  
• Sexual transmission rates are very low.
  
• The midwife has an important health promotion role in encouraging positive sexual health.
  

  Hepatitis C in pregnancy
  

• Careful sexual health and intravenous drug taking history will indicate possible risk factors for infection.
  

  •
  As with all other blood borne viruses it is important to follow universal
  

  safe precautions when handling blood and body fluids, to avoid possible health care worker infection.
  

• Find out what special precautions and handling of blood and body fluids are to be taken locally for a person known to be hepatitis C positive.
  
• The vertical transmission rate is 5% or less, but may be increased in a mother who is also HIV positive.
  
• Currently, there is no way of preventing vertical transmission, but avoiding unnecessary procedures, such as rupturing the membranes or applying a fetal scalp electrode will help.
  

  Fetal and neonatal infection
  

• Encourage and support breastfeeding, as there is no evidence that breastfeeding increases the risk of transmission, unless the mother is symptomatic and has a high viral load.
  
• Encourage high standards of personal hygiene in the mother and the importance of hand washing when handling her baby.
  

  Useful website
  

  British Association for Sexual Health and HIV. Available at: M www.bashh.org.uk.
  

  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. 415–432.
  

  This page intentionally left blank
  

  CHAPTER 3
  Sexual health
  

  38‌‌
  

  Herpes simplex virus
  

• There are two types of the herpes simplex virus (HSV).
  
• HSV1 is usually acquired in childhood or as a young adult coming into contact with infected oral secretions and causes ‘cold sores’.
  
• HSV2 is sexually transmitted and the most common cause of genital herpes.
  
• Once acquired, HSV remains in the body for life and will cause frequent infection.
  
• The chance of becoming infected is increased with factors such as early age of initiation of sexual activity, the number of sexual partners, and previous genital infections.
  
• If the individual already has HSV1 virus, the symptoms of HSV2 first infection may be less severe.
  
• Commonly, the infection causes painful, vesicular, or ulcerative lesions of the skin and mucous membranes. Dysuria and an increased
  

  vaginal discharge may also occur. These are more pronounced in first infection.
  

• Systemic infection characterized by high temperature and myalgia may occur.
  
• Occasionally, the infection may be asymptomatic in adults.
  

  Definitions
  

• First episode primary infection:
  is the first infection with either HSV1 or HSV2 virus. The symptoms tend to be pronounced and the lesions may last 2–3 weeks.
  
• First episode non-primary infection
  : the first infection with either HSV1 or HSV2, but the person already has pre-existing antibodies to the other type.
  
• Recurrent infection
  : recurrence of clinical symptoms.
  

  Diagnosis
  

• Viral cultures from open lesions, with a special viral swab, are the easiest and one of the best methods of diagnosing infection. The swab should be sent to the laboratory immediately.
  
• Other specialist tests may be carried out in a sexual health clinic, where the woman should be referred for treatment.
  

  HSV in pregnancy
  

• The effects of the first or recurrent infection, as discussed above, on the mother, will be treated as in the non-pregnant state and includes antiviral therapy, analgesia, saline baths, and topical anaesthetic gel to soothe the pain and discomfort.
  
• If the mother acquires primary infection in the first or second trimester oral antiviral therapy, aciclovir, will be commenced. Occasionally,
  

  the clinical manifestation may warrant intravenous therapy to reduce virus shedding and promote healing. Although not licensed for use in pregnancy, the clinical evidence is that its use is safe.
  

• If the mother is immunocompromised, as in HIV, the dose will need to be increased.
  

  HERPES SIMPLEX VIRUS
  

  39