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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 late pregnancy

After the first trimester, infection of the vagina, cervix, and fetal membranes or amniotic fluid (chorioamnionitis) is a common cause of spontaneous abortion, rupture of membranes, preterm labour and stillbirth. The same vaginal, cervical and exogenous organisms (gonococci, chlamydia, bacteria associated with bacterial vaginosis, trichomonas, group B streptococci) may be involved in postabortion infection, chorioamnionitis, and postpartum and neonatal infections. Some of these infections often follow vaginal examination or other procedures, which should be avoided in late pregnancy unless necessary. Prevention of these complications also includes detection and treatment of STIs/RTIs during antenatal visits where possible (Chapter 3).


Infection and rupture of membranes

Infection may cause rupture of membranes (ROM) or follow it. All women—whether at term or preterm—with ROM and any signs of infection (fever, increased white blood cells, increased C-reactive protein or foul-smelling discharge) should be given antibiotics intravenously or intramuscularly (Flowchart 7) and urgently referred for care.

When membranes rupture at term, labour usually begins within 24 hours. Women without signs of infection can be observed. If labour does not begin within 24 hours, the woman should be referred to a facility where labour can be safely induced. To further reduce the risk of infection:

  • Avoid vaginal examinations once the membranes have ruptured.
  • If labour has not begun within 18 hours, give antibiotics (Treatment table 12) to reduce the risk of infection before and after delivery.

When membranes rupture before term, complications—preterm delivery, low birth weight, and perinatal morbidity and mortality—are more common. When ROM occurs before onset of labour, management should take into account the health of the mother, gestational age and viability of the fetus, and available options for intervention. Flowchart 7 summarizes the management of women with prelabour rupture of membranes.


 FLOWCHART 7. prelabour rupture of membranes

In choosing the antibiotics to treat infection in a woman with a viable pregnancy, the risks and benefits should be carefully weighed. Antibiotics that may be harmful to the fetus should be avoided where possible (see Annex 4). If infection is severe, however, the priority should be to give effective antibiotic treatment.

Prevention of infection in late pregnancy and preterm delivery should include interventions throughout the pregnancy to prevent and detect STI/RTI. Where feasible, screening for common STIs/RTIs implicated in prelabour ROM and other adverse pregnancy outcomes is recommended at the first antenatal visit, and again later in pregnancy for women at high risk of preterm labour (see Chapter 3). The importance of primary prevention of STI/RTI to a healthy pregnancy should be emphasized to women and their partners.


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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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