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Department of Reproductive Health and Research (RHR), World Health Organization

Sexually transmitted and other reproductive tract infections

A guide to essential practice



Management of STIs/RTIs
Chapter 9. STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period


Infection in early pregnancy

Upper genital tract infection is different in pregnant than in non-pregnant women. Women with pre-existing pelvic inflammatory disease have difficulty becoming pregnant—acute infection in the uterus interferes with fertilization and implantation of the ovum, while established PID may cause scarring, infertility and ectopic pregnancy. Almost all infections that do occur develop during the pregnancy itself, usually because of some event that disrupts the body’s normal defences.

Most infectious complications of early pregnancy are related to spontaneous or induced abortion. Spontaneous abortion (or miscarriage) is common in the first trimester and usually resolves without complication. Induced abortion is also common and risk of infection is high when it is performed in unsafe conditions. Spontaneous or induced abortion is incomplete when tissue remains inside the uterus, and infection may develop if any remaining products of conception are not removed.

Such details are not always apparent when a woman seeks medical care for abortion complications. In fact, women with problems following induced abortion may not mention having had a procedure, especially in places where abortion is illegal. They may simply complain of spontaneous bleeding or other problems instead. Health care providers should thus have a high index of suspicion and manage possible infection following abortion based on objective signs, regardless of history.


Management of postabortion complications

The treatment of complicated abortion includes stabilization of the patient, removal of remaining products of conception from the uterus, and administration of intravenous or intramuscular antibiotics (Flowchart 6, Treatment table 11). Abortion complications can be life-threatening and timely assessment and management are critical. A rapid assessment —short history, vital signs, general examination and abdominal and genital examination—should be performed and emergency treatment started. Women with signs of shock should be stabilized with intravenous fluids. All women with signs of shock or infection in early pregnancy should be given the first dose of antibiotics intravenously or intramuscularly, and referred immediately to a facility that can provide appropriate management, including safe evacuation of the uterine contents.


FLOWCHART 6. Possible complications of abortion


Incomplete abortion and risk of infection

Bleeding in early pregnancy may indicate that abortion is threatened, in progress or incomplete, or may be a sign of ectopic pregnancy or other problem. Signs of incomplete abortion are a soft, enlarged uterus and open cervical os. Abdominal pain frequently precedes or accompanies abortion, postabortion infection and ectopic pregnancy. Severe pain without bleeding may be a sign of ectopic pregnancy.

The treatment of incomplete abortion involves removal of remaining products of conception. This can be safely performed using manual vacuum aspiration (MVA) or other methods. If there are signs of infection, women should be treated with antibiotics (see Chapter 3). All other women should be counselled to come back immediately if any signs of infection appear.

Women with light bleeding and no signs of shock or infection should be further evaluated if they do not improve in the next few days.


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Infections of the male and female reproductive tract and their consequences:

What are RTIs?

Why STI/RTIs are important?

What can be done about RTIs?

The role of clinical services in reducing the burden of STI/RTI

Preventing STIs/RTIs and their complications

How to prevent STI

How to prevent iatrogenic infections

How to prevent endogenous infections

Detecting STI/RTI

Detecting STI/RTI


Vaginal infections

Cervical infections

Pelvic inflammatory disease

HIV counselling and testing

STI/RTI education and counselling

Key points

Privacy and confidentiality

General skills for STI/RTI education and counselling

Health education


Promoting prevention of STI/RTI and use of services

Key points

Reducing barriers to use of services

Raising awareness and promoting services

Reaching groups that do not typically use reproductive health services

STI/RTI Assessment during Routine Family Planning Visits

Key points

Integrating STI/RTI assessment into routine FP services

Family planning methods and STIs/RTIs

STI/RTI Assessment in pregnancy, childbirth and the postpartum period

Key points

Management of symptomatic STIs/RTIs

Syndromic management of STI/RTI

Management of common syndromes

STI case management and prevention of new infections

STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

Key points

Infection in early pregnancy

Infection in lated pregnancy

Infection following childbirth

Vaginal discharge in pregnancy and the postpartum period

Sexual violence

Key points

Medical and other care for survivors of sexual assault

Annex 1. Clinical skills needed for STI/RTI


Common STI/RTI symptoms

Examining patients

Annex 2. Disinfection and universal precautions

Preventing infection in clinical settings

High-level disinfection: three steps

Universal precautions

Annex 3. Laboratory tests for RTI

Interpreting syphilis test results

Clinical criteria for bacterial vaginosis (BV)

Wet mount microscopy

Gram stain microscopy of vaginal smears

Use of Gram stain for diagnosis of cervical infection

Annex 4. Medications

Medications in pregnancy

Antibiotic treatments for gonorrhoa

Annex 5.

STI/RTI reference table


Additionnal resources


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