16.3 STIs in Pregnancy, Neonates & Children, Contraception, Sexual Health & Psychosexual Problems
Key Takeaways
- Antenatal screening for syphilis, HIV, and hepatitis B is recommended for all pregnant women in Europe because effective treatment prevents most vertical transmission.
- A first episode of genital herpes in the third trimester, especially within 6 weeks of delivery, carries the highest neonatal herpes risk, and caesarean section is recommended.
- Gonococcal ophthalmia neonatorum usually appears 2 to 5 days after birth and chlamydial conjunctivitis 5 to 14 days after birth.
- Gonorrhoea, syphilis, chlamydia, or trichomoniasis beyond the neonatal period in a prepubertal child strongly suggests sexual abuse and needs referral to child safeguarding services.
- A copper intrauterine device inserted within 5 days of unprotected sex is the most effective emergency contraception; ulipristal acetate works up to 120 hours and levonorgestrel up to 72 hours.
Last updated: September 2026
16.3 STIs in Pregnancy, Neonates & Children, Contraception, Sexual Health & Psychosexual Problems
Antenatal Screening
European antenatal programmes offer every pregnant woman testing for syphilis, HIV, and hepatitis B early in pregnancy, because treatment prevents most transmission to the baby. Some countries also screen for chlamydia in younger women, and repeat syphilis and HIV testing in the third trimester for women at ongoing risk.
Specific Infections in Pregnancy
| Infection | Risk to the Baby | Management in Pregnancy |
|---|---|---|
| Syphilis | Transmission at any stage, highest in early (primary and secondary) syphilis; miscarriage, stillbirth, prematurity, congenital syphilis | Benzathine penicillin G by stage; desensitise if allergic (see the syphilis section). Monitor for a Jarisch-Herxheimer reaction, which can cause contractions and fetal distress. Evaluate the newborn |
| HIV | Transmission in utero, at delivery, and through breastfeeding | ART for all pregnant women, continued lifelong. With a viral load below 50 copies/mL near term (around 36 weeks), vaginal delivery is usually planned. The newborn receives antiretroviral prophylaxis. With suppressed viral load, transmission is well below 1% |
| Hepatitis B | Perinatal transmission, often leading to chronic infection | Test HBsAg. With a high maternal viral load, give tenofovir in the third trimester. The baby receives hepatitis B vaccine and immunoglobulin soon after birth (ideally within 12–24 hours) |
| Genital herpes (HSV) | Neonatal herpes: skin, eye, and mouth disease; encephalitis; or disseminated disease | See below |
| Gonorrhoea and chlamydia | Ophthalmia neonatorum; chlamydial pneumonia at 1–3 months; preterm birth | Gonorrhoea: ceftriaxone. Chlamydia: azithromycin or amoxicillin, because doxycycline is contraindicated in pregnancy. Test of cure in pregnancy |
| Trichomoniasis and bacterial vaginosis | Preterm birth and low birth weight | Metronidazole is safe; treat symptomatic women |
| Anogenital warts | Rarely, juvenile recurrent respiratory papillomatosis (HPV 6 and 11) | Warts often grow in pregnancy. Use cryotherapy or trichloroacetic acid; avoid podophyllotoxin and 5-fluorouracil. Caesarean section is not needed for warts alone unless they block the birth canal |
Genital Herpes in Pregnancy
- Highest risk: a first episode (primary infection) in the third trimester, especially within 6 weeks of delivery, because the mother has not yet made protective antibodies. Caesarean section is recommended in this situation.
- Recurrent herpes carries a low neonatal risk (maternal antibodies protect the baby). Vaginal delivery is usually appropriate, and suppressive aciclovir or valaciclovir from 36 weeks reduces lesions at term.
- A first episode earlier in pregnancy is treated with aciclovir, followed by suppression from 36 weeks.
- Neonatal herpes presents in the first weeks of life with vesicles, eye or mouth lesions, lethargy, seizures, or sepsis. It needs urgent IV aciclovir.
Neonatal Infection
| Condition | Typical Onset | Management |
|---|---|---|
| Gonococcal ophthalmia neonatorum | 2–5 days after birth; copious purulent discharge, risk of corneal perforation | Single dose of ceftriaxone (25–50 mg/kg, maximum 125 mg); treat the mother and her partner |
| Chlamydial conjunctivitis | 5–14 days after birth; watery then purulent discharge | Oral macrolide (azithromycin or erythromycin; erythromycin carries a small risk of pyloric stenosis) |
| Chlamydial pneumonia | 1–3 months; afebrile, staccato cough | Oral macrolide |
| Early congenital syphilis | Up to 2 years: snuffles, rash including palms and soles, bullous lesions, hepatosplenomegaly | Aqueous penicillin; see the syphilis section |
| Neonatal herpes | First 1–4 weeks | IV aciclovir |
Children with Genital Infections
The syllabus asks for multidisciplinary management. An STI in a child can come from the mother at birth, from non-sexual contact, or from sexual abuse. Each finding must be interpreted carefully, with a paediatrician and the local child safeguarding team.
| Finding in a Prepubertal Child (beyond the neonatal period) | Interpretation |
|---|---|
| Gonorrhoea, syphilis (not congenital), chlamydia (beyond about the first 2–3 years), trichomoniasis | Strongly suggests sexual abuse; refer to safeguarding |
| Anogenital warts | May be vertical (especially in infants), from caregivers' hand warts, or from autoinoculation, but abuse must be considered, particularly as the child gets older |
| Genital herpes | Possible abuse; also autoinoculation from oral herpes |
| HIV | Usually vertical; consider abuse if the mother is negative |
- Mimics of abuse: lichen sclerosus (purpura and fissures in girls), perianal streptococcal dermatitis, threadworm, labial adhesions, Crohn disease, and accidental injury.
- Forensic standards: use validated tests (for gonorrhoea and chlamydia, culture or a NAAT confirmed with a second target), keep documentation and chain of custody, and involve trained staff.
- Adolescents: follow local laws on consent and confidentiality, assess competence, and screen for exploitation and coercion.
Methods of Contraception
| Method | Typical Effectiveness | Points for Dermatology |
|---|---|---|
| Implant, levonorgestrel IUS, copper IUD (long-acting reversible contraception) | Most effective, below 1% failure a year | Suitable when highly effective contraception is needed with teratogenic drugs (isotretinoin, acitretin, methotrexate, mycophenolate, thalidomide) |
| Injectable progestogen | Effective with timely injections | Bone density loss with long-term use |
| Combined hormonal (pill, patch, ring) | Effective with correct use | Can improve acne and hirsutism (antiandrogenic progestogens). Raises venous thromboembolism risk. Avoid in migraine with aura, smokers over 35, and antiphospholipid antibodies/lupus with thrombosis risk. Oestrogens can worsen melasma, hereditary angioedema, and porphyria cutanea tarda |
| Progestogen-only pill | Effective with strict timing | An alternative when oestrogen is contraindicated |
| Condoms | Less effective alone for pregnancy | The only method that also protects against STIs |
Drug interactions: enzyme inducers reduce hormonal contraception. Dermatology examples include rifampicin (hidradenitis and leprosy regimens), griseofulvin, carbamazepine, St John's wort, and some antiretrovirals. Use an IUD or add another method.
Emergency contraception:
- A copper IUD within 5 days of unprotected sex is the most effective option.
- Ulipristal acetate 30 mg works up to 120 hours.
- Levonorgestrel 1.5 mg works up to 72 hours (less well with higher body weight; double dose with enzyme inducers).
Sexual Health and Psychosexual Problems
The WHO defines sexual health as a state of physical, emotional, mental, and social well-being related to sexuality, not merely the absence of disease. Good venereology care includes sex education, prevention, and attention to sexual function.
- Erectile dysfunction: often vascular and an early marker of cardiovascular disease and diabetes. PDE5 inhibitors (sildenafil, tadalafil) are contraindicated with nitrates.
- Other male problems: premature ejaculation and low desire.
- Female problems: low desire, arousal disorders, dyspareunia, vaginismus, and vulvodynia.
- Impact of skin disease: genital psoriasis, lichen sclerosus, hidradenitis suppurativa, and chronic eczema commonly impair sexual function and should be asked about.
- Anxiety about STIs: some patients have persistent fear of infection despite negative tests ("venereophobia"), which may need psychological support.
- Referral: to psychosexual medicine, psychology, gynaecology, or urology as needed.
- Gender-affirming care: testosterone often causes acne and androgenetic hair loss; oestrogen and antiandrogens reduce body hair.
Test Your Knowledge
A woman at 37 weeks of pregnancy develops her first-ever episode of genital herpes, confirmed by HSV-2 PCR, with painful bilateral ulcers. She has never had symptoms before, and type-specific antibodies are negative. What is recommended for delivery?
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Test Your Knowledge
A newborn develops copious purulent discharge from both eyes on day 3 after birth, and a Gram stain shows Gram-negative intracellular diplococci. What is the diagnosis and treatment?
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D
Test Your Knowledge
A 6-year-old girl has vaginal discharge, and a culture confirmed by a second test grows Neisseria gonorrhoeae. What is the most important step alongside antibiotic treatment?
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D
Test Your Knowledge
A 24-year-old woman had unprotected sex 4 days ago and wants the most effective emergency contraception. What should she be offered?
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D