During routine antenatal examinations, detecting external genital lesions in pregnancy represents a critical clinical opportunity for obstetricians and primary care clinicians. Maternal sexually transmitted infections and localized dermatoses often manifest silently, yet they carry profound implications for vertical pathogen transmission, maternal morbidity, and adverse neonatal outcomes. Consequently, thorough clinical evaluation during early prenatal care enables prompt diagnosis, prevents complications, and guides targeted therapeutic interventions.

Epidemiology and Clinical Spectrum of Genital Lesions in Pregnancy

The Philani Ndiphile study evaluated 2,247 pregnant individuals during their initial antenatal care encounters to establish lesion epidemiology. Clinicians documented external lesions in approximately 2.7% of the total cohort, representing 61 pregnant individuals. Although this aggregate prevalence appears relatively modest, the clinical implications remain substantial across high-burden settings. Furthermore, maternal genital pathology encompasses diverse morphological presentations, ranging from benign cysts to destructive ulcerations. Clinicians categorized these findings into distinct phenotypes, including condylomata, inflammatory dermatitis, ulcerative or erosive defects, and purulent boils. In addition, scarring, cystic swellings, and unclassified dermatological changes emerged across the examined cohort. Syphilis and herpes simplex virus frequently drive ulcerative presentations, whereas human papillomavirus typically produces exophytic warts. However, non-infectious inflammatory disorders also mimic infectious etiologies, complicating bedside assessment. Therefore, clinicians cannot rely solely on visual inspection to determine etiology. Integrating systematic physical assessment with rapid laboratory diagnostics remains vital for identifying subtle maternal infections that would otherwise escape prompt clinical recognition.

Impact of Maternal HIV Status on Lesion Prevalence

A pivotal finding from the clinical trial data demonstrates a marked disparity based on maternal HIV status. Specifically, lesion prevalence was nearly fivefold higher among women living with HIV compared to their HIV-negative peers, reaching 6.1% versus 1.3%. Immune dysregulation directly impairs mucosal defense barriers, thereby increasing vulnerability to opportunistic infections and aggressive microbial replication. Consequently, human papillomavirus and herpes simplex virus reactivate more aggressively under immunocompromised maternal conditions. Moreover, chronic immunosuppression alters lesion morphology, frequently resulting in atypical, extensive, or recalcitrant ulcerations that resist conventional short-course therapies. Cellular immune suppression also delays spontaneous lesion resolution, leading to prolonged viral shedding in the birth canal. As a result, infants born to immunocompromised mothers face heightened risks of intrapartum pathogen acquisition. Furthermore, disrupted epithelial barriers in the lower genital tract significantly facilitate HIV viral shedding, elevating the risk of vertical transmission during vaginal delivery. Clinicians must therefore maintain heightened clinical vigilance when examining pregnant women with HIV co-infection.

Diagnostic Challenges and Limitations of Syndromic STI Management

In resource-constrained healthcare environments, healthcare providers predominantly depend on syndromic STI management protocols. These algorithms initiate immediate empiric treatment based on visible clinical signs, bypassing expensive laboratory infrastructure. However, syndromic algorithms display considerable limitations when applied to antenatal populations. Classical genital ulcer disease algorithms assume high positive predictive values for syphilis or chancroid, yet herpes simplex virus now predominates globally. Furthermore, mixed infections occur frequently, where an individual presents with both treponemal disease and viral ulcerations simultaneously. Syndromic management also overlooks atypical presentations and completely misses asymptomatic cervical or vaginal infections. Consequently, empiric treatment algorithms may fail to resolve the underlying condition or result in overtreatment with inappropriate antibacterial regimens. In addition, relying purely on syndromic guidelines risks misclassifying benign dermatological conditions, such as hidradenitis suppurativa or contact dermatitis, as communicable venereal diseases. Therefore, integrating point-of-care molecular assays, rapid treponemal tests, and HIV screening into standard antenatal clinics provides far superior clinical precision.

Morphological Diversity: Distinguishing Infectious from Non-Infectious Etiologies

Clinicians encountered wide morphological variability during the antenatal evaluations, underscoring the complexity of genital dermatoses. Exophytic warts and verrucous condylomata represent human papillomavirus infection, which demands careful monitoring due to potential intrapartum airway contamination in newborns. In contrast, painful vesicular lesions that progress to shallow erosions strongly suggest genital herpes simplex virus reactivation. Primary syphilis classically presents as a solitary, indurated, painless chancre, although atypical or multiple ulcers frequently appear in immunosuppressed patients. Meanwhile, inflammatory and dermatitis-like presentations often reflect non-sexually transmitted conditions, including candidiasis, eczema, or severe intertrigo exacerbated by increased gestational moisture. Similarly, cystic swellings, such as Bartholin duct cysts, require differentiation from purulent abscesses or painful furuncles. Consequently, accurate phenotypic differentiation prevents diagnostic misadventures and patient anxiety. Healthcare providers should avoid premature diagnostic closure based exclusively on macroscopic appearances. Instead, clinicians must combine rigorous inspection with targeted microbiological swabs and serological investigations to confirm the precise etiology before establishing long-term therapeutic plans.

Evidence-Based Management and Antenatal Care Strategies

Optimizing pregnancy outcomes requires a comprehensive, multipronged management strategy that integrates medical therapy, partner notification, and meticulous intrapartum planning. For bacterial etiologies such as primary syphilis, parenteral benzathine penicillin G remains the undisputed first-line curative regimen, effectively preventing congenital syphilis. For recurrent or primary genital herpes, clinicians should initiate suppressive antiviral therapy with oral acyclovir or valacyclovir from thirty-six weeks of gestation onward. Consequently, suppressive therapy reduces viral shedding, prevents active lesions at term, and diminishes the necessity for emergency cesarean section. In addition, women living with HIV require immediate optimization of combination antiretroviral therapy to achieve complete viral suppression prior to labor. Furthermore, clinicians must ensure confidential partner notification and presumptive treatment to prevent immediate maternal reinfection. Scheduled follow-up examinations are essential to verify lesion healing and document treatment adherence. By harmonizing syndromic management protocols with modern point-of-care laboratory screening, obstetric teams can effectively safeguard both maternal reproductive well-being and neonatal health throughout the perinatal continuum.

Frequently Asked Questions

How should clinicians evaluate genital lesions in pregnancy during antenatal visits?

Clinicians must perform a gentle pelvic speculum and external genital examination during the initial antenatal consultation. When identifying any visible lesion, practitioners should document morphology, pain, induration, and regional lymphadenopathy. Additionally, clinicians should order rapid syphilis serology, HIV testing, and viral swabs for herpes simplex virus. Integrating bedside physical inspection with targeted diagnostic tests ensures accurate identification, prevents inappropriate empiric antibiotic therapy, and establishes timely management protocols for safeguarding fetal health.

Why do women living with HIV experience higher rates of genital lesions?

Women living with HIV experience significant cell-mediated immune suppression, which diminishes mucosal defense mechanisms across the lower genital tract. Consequently, opportunistic pathogens and dormant viruses, such as human papillomavirus and herpes simplex virus, reactivate with greater frequency and severity. Furthermore, systemic immune activation impairs epithelial wound healing, leading to persistent, atypical, and recurrent ulcerations. This compromised barrier integrity elevates mucosal inflammation and amplifies the risk of secondary bacterial infections during pregnancy.

What are the primary perinatal risks associated with untreated genital ulcers?

Untreated genital ulcers pose severe hazards to both mother and fetus. Treponema pallidum easily traverses the placenta, causing congenital syphilis, spontaneous abortion, hydrops fetalis, or stillbirth. Similarly, active maternal herpes simplex virus at the time of delivery carries substantial risk of neonatal herpes transmission, resulting in encephalitis or fatal systemic disease. Furthermore, persistent epithelial ulcerations heighten the probability of intrapartum HIV transmission, requiring careful obstetric planning and potential cesarean delivery.

Disclaimer: This content is for informational and educational purposes only. It does not constitute medical advice and should not replace clinical judgment or institutional protocols. Healthcare professionals must evaluate individual clinical circumstances, contraindications, and potential drug interactions before making therapeutic decisions. Refer to the latest local and national guidelines for clinical practice.

References

1. Onyema C et al. Clinician-observed genital lesions among pregnant women in a high HIV/sexually transmitted infection prevalence setting. Int J STD AIDS. 2026 Sep 09. doi: 10.1177/09564624261487933. PMID: 42715544.
2. World Health Organization. Guidelines for the management of symptomatic sexually transmitted infections. Geneva: World Health Organization; 2021.
3. National AIDS Control Organisation. National Guidelines for Prevention and Management of Sexually Transmitted and Reproductive Tract Infections. New Delhi: Ministry of Health and Family Welfare, Government of India; 2022.