Pregnancy and Sexually Transmitted Infections (STIs) - What Do I Need to Know?

This week I want to answer concerns regarding complications of STI's (Sexually Transmitted Infections) in pregnancy. Pregnancy brings on many changes, and causes most of us to worry about our diet, exercise and everything that touches our bodies. So finding out about an STI can be especially concerning to women.

In fact, what may seem like an STI may not be. Pregnancy changes your body so quickly that you may notice an increase in vaginal moisture & discharge, irritation or even a different odor than you're used to. Of course you may worry that something is very wrong.

During your first or second prenatal visit, your OB doctor will do several tests on you, including vaginal cultures and blood tests for the most common STI/STD's. This list may include: HPV (human papilloma virus), bacterial vaginosis (BV), herpes (HSV), chlamydia, trichomoniasis, gonorrhea(GC), hepatitis B, HIV and Syphillis. Often herpes is left off the prenatal panel, but it can be requested as an add on. This is because most women are already aware of having had an outbreak, so they have already been diagnosed. Herpes will generally only interfere with pregnancy if lesions appear at the time of delivery, and in that case a cesarean section would likely be performed.

Women who are pregnant can become infected with the same sexually transmitted diseases as women who are not pregnant. Pregnancy does not provide any protection for women or their babies. But, during pregnancy a woman's immune system has a harder time fighting off infection. The only way to be sure you are protected is to use latex condoms with each act of intercourse, unless you are sure you are in a monogamous relationship with a partner with no STI’s.

Women can become infected with an STI like herpes, HPV and condyloma, years before they meet their current sexual partner. When they become pregnant and their immune system is weaker, they can begin having herpes outbreaks, condyloma overgrowth and abnormal pap smears due to HPV infection, without ever being aware they were carrying these viruses. It can be very shocking to wake up with clusters of warts growing around the vaginal, labial and anal areas, or to find red, hot herpes blisters having never been aware you were harboring a virus. But remember, this does not necessarily mean your partner is being unfaithful.

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What You Need to Know About Human Papillomavirus (HPV)

Human papillomavirus (HPV) seems to be one of those infections women get that has a lot of rumors and misinformation associated with it. Some patients come in saying, "I have HPV and my doctor told me I have pre-cancer." Others come in worried because you have an abnormal pap smear and HPV infection and have been told that you have cervical cancer. HPV can, indeed, cause cervical, anal and oral cancer. It is also the cause of genital warts, but just having an abnormal pap smear and an HPV infection does not mean you have cancer or that you will ever get cancer.

HPV is the most common sexually transmitted infection in the United States. An estimated 20 million people are currently infected, and an estimated 6.2 million new HPV infections occur annually. HPV infection is common among adolescents and young adults. Prevalence among adolescent girls is as high as 64%. Up to 75% of new infections occur among persons 15–24 years of age. It is estimated that more than 80% of sexually active women will have been infected by age 50.

About 11,070 new cases of cervical cancer will be diagnosed in the United States a year, and, of those, approximately 3,870 women will die as a result of cervical cancer. HPV is believed to be responsible for nearly all of these cases of cervical cancer. HPV types 16 and 18 are associated with 70% of these cancers.

HPV is classified as either high- or low-risk types. The low-risk types do not carry a risk of cancer, but can cause genital warts, and, for some women, an increase in discharge, negative culture results and no treatment. Low- and high-risk HPV infections can just come and go, and even spontaneously resolve. High-risk types, if persistent, are the ones tested for on pap smears and will cause cancer if they do not resolve. The high risk types are: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 73 and 82.

In addition to cervical cancer, HPV is believed to be responsible for 90% of anal cancers, 40% of vulvar, vaginal, or penile cancers, and 12% of oral and pharyngeal cancers. Population-based estimates, primarily from clinics treating persons with sexually transmitted infections, indicate that about 1% of the sexually active adolescent and adult population in the United States have clinically apparent genital warts. More than 90% of cases of anogenital warts are associated with the low-risk HPV types 6 and 11.

HPV is transmitted by direct contact, usually sexual, with an infected person. Transmission occurs most frequently with sexual intercourse but can occur following nonpenetrative sexual activity. Studies of newly acquired HPV infection demonstrate that infection occurs soon after onset of sexual activity. HPV transmission can be reduced, but not eliminated, through the use of condoms and recent studies demonstrated a significant reduction in HPV infection among young women after initiation of sexual activity when their partners used condoms consistently and correctly. Abstaining from sexual activity is the surest way to prevent genital HPV infection. For those who choose to be sexually active, a monogamous relationship with an uninfected partner is the only sure way to ever prevent HPV infection.

The reason I bring this up is because there is so much conversation that HPV is only caused by risky behavior, when the truth is, if you are virgin and marry or have your first sexual experience with someone who has HPV you can get it that fast just like getting any other sexually transmitted disease.

We've heard it said that Risk factors for HPV infection are related to sexual behavior, including the number of sex partners, lifetime history of sex partners, and the partners’ sexual history. Most studies
suggest that young age (less than 25 years) is a risk factor for infection.
Most cases and deaths from cervical cancer can be prevented through regular Pap tests at your gynecologist.

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Should I be Tested For an STD?

For many of us this may be an uncomfortable and embarrassing question. I know many of my patients will tell the staff they are coming in for a different reason, and only when they are finally in the exam room with me they are comfortable enough to share their concerns about possible STDs. 

Some of them have just discovered that their partner has been cheating on them, and are emotionally devastated. Maybe you or someone close to you has recently experienced this and can understand how scary it can be not knowing if you might have contracted something serious from an unfaithful partner. Even if you are single and dating and are careful to use condoms everytime, the worry is still there as condoms don’t protect from all STDs. 

Testing for STDs should begin when you become sexually active or have symptoms that make you worry that something may be wrong. Symptoms like vaginal bumps, blisters or open sores should be shared with your OB/Gyn.

So should vaginal discharge that is odorous, itchy, bloody, or higher volume than normal. If the infection gets to your kidneys or fallopian tubes and into the pelvis, it can cause fevers, severe pain and possibly PID (pelvic inflammatory disease). PID can cause scarring of the fallopian tubes and eventually infertility. I would never want to think that any of you or my patients would suffer from this and try to self- treat because they were too embarrassed to see their doctor. We are here to help you and want to see you get better. 

The home tests that you can get from the drug store can be used, but will often read positive when no infection is present at all. So a follow-up with your doctor is still a good idea. 

The best time to screen for STDs & STIs is during your annual exam. It is also a good time to ask questions and get information on prevention.

Some STDs (like HIV, Hep B, & Herpes or syphilis) may not show up right away on initial testing and take a few months to pick up on a blood test, so follow-up in 6 months to confirm that tests are truly negative.

I hope this helps. I know a lot of my patients ask me if douching helps get rid STDs and I have told them that it can actually force the infection up further through the cervix and into the uterus and fallopian tubes. This in itself can cause PID as discussed above.

A much better way to clean out your vagina is to use the WaterWorks Vaginal Cleansing system. It will rinse out excess discharge and infection-causing bacteria. [Note: this will not cure any STD or prevent an STD]. WaterWorks uses only fresh water (no chemicals!) and is FDA cleared. It does not use a shooting action so will not push the infection further up into the uterus or fallopian tubes. It may help you heal faster along with taking the prescribed medications. Don't share your WaterWorks with anyone else!

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What is the Difference Between an STD and STI and How Can You Prevent Them?

Essentially, they represent almost the same thing. STD is an abbreviation for a Sexually Transmitted Disease and STI is an abbreviation for a Sexually Transmitted Infection. The best way to describe the difference between an STI and an STD is that you can have an infection without having any symptoms; however once symptoms appear, it becomes an STD.

STIs, like many infections,can be passed from one person to another, even when there are no symptoms. Examples include Herpes, HIV, HPV and Hepatitis. A mother can pass these to her infant through childbirth and breastfeeding when she is unaware of being infected. Other infections such as the flu, common cold and mononucleosis, can also be transmitted during sex from oral contact and kissing, but would not be considered to be 'sexually transmitted infections'.

It’s important to know that just having sex won't necessarily give you an STD or an STI. You have to have sexual relations with another person who is infected in order to receive the infection. Also, if a person is treated for a STD/STI and returns to the same sexual partner they can become re-infected if their partner has not been treated. So if you get an STD/STI it is important that your partner be checked and treated as well.

So how do you protect yourself from contracting an STD/STI?

Prevention through avoiding exposure is the best strategy for controlling the spread of STIs. We know that protected vaginal and anal intercourse carries the highest risks for the most dangerous sexually transmitted infections. Abstaining from sex is the only way to be 100% confident of avoiding Sexually Transmitted Infections but let's get real! If abstinence is not an option, then condoms, used properly, can reduce your risk  significantly. Condoms be used with each act of sexual intercourse. But even this practice not completely eliminate the risk of transmission of STIs. Condoms can fail, slip off, be punctured, or break down from spermacides or lubricants. In the best conditions, they provide great protection against HIV and Gonorrhea, but are less effective against Genital Herpes and Chlamydia. They provide no protection from HPV.

Nearly everyone has taken risks sexually, but please beware of the potential consequences which can impact your health and the course of your life. Many STDs can last a lifetime, put stress on relationships, cause sterility or birth defects and even lead to major illness and death. Know the risks! Sexually Transmitted Infections are not all transmitted the same way.

Unprotected Vaginal and Anal sex can lead to the transmission of:
-trichamonas
-gonorrhea
-chlamydia
-syphylis
-pubic lice, Hep B, HPV,HSV,HIV

Unprotected oral sex can lead to the transmission of:
-gonorrhea
-chamydia
-syphilis
-Hep B, HSV, HPV

Even sexual play without intercourse can lead to the transmission of:
-HSV,HPV
-pubic lice
-gonorrhea
-chlamydia
-trichamonas

The most important thing to remember is to take care of yourself, and if you feel that something isn't right, make an appointment with your doctor.

Always be safe when it comes to your health.

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Can Douching After Sex Prevent STIs?

No, douching after sex will not prevent STIs or STDs. In fact, there is no post-sex STD/STI protection, and even condoms won't protect against all infections. The only 100% fool-proof method is abstinence, and since that isn't likely to happen, knowing how to protect yourself is important.

But douching is not the answer. I know many of you douche for a variety of reasons, even though over the past few months we have talked about the many reasons you should not douche. Douching is not healthy, and regular douching can change the delicate chemical balance of the vagina, actually making a woman more susceptible to infections. Douching can introduce new bacteria into the vagina which can spread up through the cervix, uterus, and fallopian tubes. Researchers have found women who douche regularly experience more vaginal irritations and infections such as bacterial vaginosis, and an increased number of sexually transmitted infections.

We have discussed the WaterWorks vaginal cleansing system in past blogs. It is important to note that WaterWorks will also not prevent STI/STDs after sex. However, because it uses a unique medical grade stainless steel nozzle and plain tap water it will not destroy the natural flora or chemical balance which protect the vagina. It also uses a downward rinsing action unlike traditional douches and has been FDA cleared to safely eliminate vaginal odor. You can use it every time you bathe or shower after sex to safely clean the vagina of unwanted discharge or blood without the worry of pushing infection or sperm further up into your cervix and uterus.

Please, choose your sexual partners wisely, be careful and use protection against STDs.

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I’m pregnant! What risks do Sexually Transmitted Infections (STIs) pose for my developing fetus?

Sexually Transmitted Infections cause the same problems in pregnant women as they do in non-pregnant women. But in pregnancy they pose added risks to the unborn child. These infections can cause preterm birth, preterm labor and early breaking of the water which can cause infections of the uterus. Once the uterus becomes infected, the baby can become sick and this could cause the baby to suffer brain damage, pneumonia, low birth weight, blindness, deafness, meningitis and even death.

Of course many of these problems can be prevented, as most STI/STD's (Sexually Transmitted Diseases) can be effectively treated with antibiotics. When women get routine prenatal care, routine screening can be done any time there is a suspected problem. Many STI's like chlamydia,`gonorrhea, trichomoniasis and BV (Bacterial Vaginosis) remain in the vagina, and as long as the water is not broken, can be treated without ever impacting the baby. Unfortunately, some STI’s can cross the placenta and make their way via the mother's blood to the baby. HIV and Syphilis are examples of this but studies have shown that women who are treated for syphilis do not pass it to their babies. Likewise for women who are HIV positive but treated with antiviral therapy will have only a 2% chance of passing it to their babies.

Some STD’s if untreated, can be passed to the baby via the vaginal fluids during the delivery process. So the best, safest approach to preventing STI's in pregnancy and reducing the chance of harm to the baby is to go to your doctor for prenatal care. Make sure you are checked for all the necessary STI's. Ask questions there is no such thing as a dumb question. Ask to be rechecked if you are worried. Remember it's important.  It could impact your baby's life and your ability to have more children in the future.

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