Genital Tract Infections And Bleeding In Late Pregancy Flashcards
Upper genital tract infections affect where?
State the structures above the place the infections affect
INTRODUCTION
• There are a number of infections that involve the female genital tract • Sexually transmitted
• Non-sexually transmitted
• Many are associated with discharges, itching and pain
• A number of important complications may be associated with some of these infections
4-Feb-2022 3
UPPER GENITAL TRACT INFECTIONS • Infection of the genital tract above the internal os
• Structures above the internal os include:
A. uterus (endometritis and myometritis),
B. fallopian tubes (salpingitis),
C. parametria (parametritis),
D. ovaries (oophoritis)(Ovaritis generally refers to inflammation of the ovaries, and oophoritis refers to inflammation of the substance of the ovaries, the oocytes in particular.)
E. pelvic peritoneum (peritonitis)
• Example—PID
What is PID(upper genital tract Infection UGTI)
Which common STIs often start PID as primary organisms?
NAME FOUR SEcondary opportunistic organisms that quickly join when the first primary organisms infect.
State five risk factors of PID
STATE Three other ways PID can be caused
PELVIC INFLAMMATORY DISEASE (PID)
⎯ is an infectious and inflammatory disorder of the upper genital tract of a female.
⎯ acute or chronic
• Aetiology and pathogenesis
• Causative organisms—polymicrobial in about 30-40% of cases(polymicrobial diseases as those diseases that can occur with organisms from different kingdoms, from different genera in a kingdom, from different species in a genus, from different strains in a species, and finally from different substrains in a strain. Polymicrobial diseases, which are recognised with increasing frequency, are acute and chronic diseases caused by various combinations of viruses, bacteria, fungi, and parasites)
⎯ Two most common sexually transmitted infections that often start it as primary organisms: Chlamydia trachomatis and Neisseria gonorrhoea
⎯ Secondary opportunistic organisms quickly join: bacteriodes sp., peptococcus, Peptostrptococcus, E coli, Staph, Strep, anaerobes, herpes simplex virus 2, etc)
• Risk factors— STIs, multiple sexual partners, unprotected penetrative vaginal sex, young age at first intercourse, invasive procedures, etc.
4-Feb-2022 6
• OTHER WAYS PID CAN RESULT
1. Following termination of pregnancies (birth and abortion)
2. Following invasive procedures of the genital tract (insertion of IUCD(intrauterine device, also known as intrauterine contraceptive device or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are one form of long-acting reversible birth control), hysterosalpingography(Hysterosalpingography (HSG) is an X-ray procedure that is used to view the inside of the uterus and fallopian tubes. It often is used to see if the fallopian tubes are partly or fully blocked. It also can show if the inside of the uterus is a normal size and shape. ),D&C, etc)
3. Infection in other organs (e.g., appendicitis, can spread to tubes and ovaries)
State five clinical features of PID(History)
State six things to be done or seen in examination for PID (abdominal exam and pelvic exam)
According to Molander et al, state the three significant predictors of the diagnosis of PID
CLINICAL FEATURES
• Acute or chronic
• Nausea,
• vomiting,
• pelvic and abdominal pain of varying severity,
• fever,
• abnormal vaginal discharge in about 75% of cases,
• unanticipated vaginal bleeding, often post coital
Examination
• Abdominal— tenderness, rebound tenderness(Rebound tenderness is a clinical sign in which there is pain upon removal of pressure rather than application of pressure to the abdomen or Blumbergs sign) , guarding(Guarding is a finding on examination of the abdomen - there is tenderness causing the patient to constantly tense the abdominal wall muscles when the examiner attempts palpation.)
• On pelvic examination, 1 or more of the following is present :
• Cervical motion tenderness
• Uterine tenderness
• Adnexal tenderness
• Digital vaginal examination—mucopurulent discharge on fingers, often offensive
• According to Molander et al, the following are significant predictors of the diagnosis,
• Adnexal tenderness(Adnexal tenderness is a technical term for pain in the area of a woman’s uterus. Adnexa is a Latin word meaning attachment or appendages.)
• Fever
• Elevated erythrocyte sedimentation rate (ESR)
How is PID diagnosed
What is the standard for diagnosis of PID
State six additional criteria that improve diagnostic specificity
State four radiological investigations and six non radiological investigations for PID
DIAGNOSIS AND INVESTIGATIONS
• Diagnosis in emergency situation is often based on clinical criteria, with or without additional laboratory and imaging evidence
• Laparoscopy— standard for the diagnosis of PID (but if clinical criteria has diagnosed it rightly you don’t do the laparoscopy unless the infection recurs ,you’re investigating chronic pelvic pain or infertility,if you’re not sure it’s PID but you think it’s appendicitis or some other disease you can’t confirm on ultrasound. The aim of the surgery is to first make the diagnosis, by taking some of the fluid for culture and sensitivity and to drain the puss. )
Additional criteria that improve diagnostic specificity:
ØOral temperature higher than 38.3° C (101° F)
ØAbnormal cervical or vaginal mucopurulent discharge
ØAbundant white blood cells (WBCs) on saline microscopy of vaginal secretions
ØElevated erythrocyte sedimentation rate (ESR) (≥40 mm/h)
ØElevated C-reactive protein (CRP) level (≥ 60 mg/L)
ØLaboratory evidence of cervical infection with N gonorrhoeae or C trachomatis (via culture or DNA probe)
vRadiological
1. Laparoscopy
Investigations
2. Transvaginal ultrasonographic scanning
3. Magnetic resonance imaging (MRI) showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian abscess (TOA)
4. Endometrial biopsy showing endometritis
4-Feb-2022 10
vNon-radiological
1. FBC
2. ESR; CRP
3. Blood culture
4. C/S of mucopurulent discharge 5. HVS; Endocervical swab—C/S 6. Urethral swab—C/S
7. Viral screen
8. Urine—R/E; C/S
STATE the three main aims of treating PID
How is PID TREATED
If patient is admitted,what is done for her?
State six complications of PID
TREATMENT
• Main aim of treatment
• relief of acute symptoms,
• eradication of current infection,
• minimisation of the risk of long-term complications
• Managed as in-patients or out-patients depending on severity In-patient Rx
• Admit
• IV access—for resuscitation, drugs, samples of blood
• Bed rest
• Pain relief
• Antibiotics (broad spectrum)
• Surgical Rx— drainage, adhesiolysis, copious irrigation or unilateral adnexectomy.
• IUCD may still be left in situ (CDC)
COMPLICATIONS
• Repeated episodes of PID
• Chronic pelvic pain
• Abscesses (e.g., in tubes, ovaries)
• Ectopic pregnancies
• Infertility
• Peritonitis
What are lower Genital tract infections
State six examples
LOWER GENITAL TRACT INFECTIONS
• Infections of the genital tract below the level of the internal os
• E.g.,
• vulva (vulvitis),
• infections in the bartholin’s glands (Bartholin’s abscesses,
• infections in the paraurethral glands,
• vagina (vaginitis),
• cervix (cervicitis),
• endocervix (endocervicitis).
Under common causes of vaginitis and vaginal discharges,what is TRICHOMONAS VAGINALIS (TV)?
What is the mode of transmission?
What does vaginal discharge caused by Trichomoniasis look like?
State five symptoms of this infection
Common causes of vaginitis and vaginal discharges
TRICHOMONAS VAGINALIS (TV) INFECTION
• TV is a motile, flagellated, anaerobic protozoan
• Causes Trichomoniasis
• Mode of transmission—sexual. That is, it is an STD
CLINICAL FEATURES
vAbout 50% of TV infections are asymptomatic
vVaginal discharge. Typical discharge is frothy (bubbly) yellow-green
and offensive.
vVulvar pruritus or irritation
vDeep dyspareunia
vDysuria
vLower abdominal pain
vVaginal erythema
vStrawberry cervix due to capillary dilatation and punctate haemorrhages
How is TVdiagnosed
What lab tests are done for TV?
How is it treated?(both males and females
DIAGNOSIS
• Clinical
• Hx + examination
• Laboratory
• Wet prep microscopy: Motile protozoa by direct observation in wet prep in 60-80%
• Immediate Diamond media culture
• Currently, molecular diagnositic tests are recommended.
TREATMENT
• Antibiotics (mainly the 5-nitro-imidazoles—metronidazole, tinidazole).
⎯ Systemic therapy is essential as TV in the urethra and paraurethral glands may escape local applications
• Since it is an STI, both the patient and their sexual partner must be treated.
• Antihistamins for vulva itch (pruritus)
For men
For Trichomonas vaginalis
y Metronidazole, oral, 400 mg 12 hourly for 7 days
Or
y Metronidazole, oral, 2 g stat. Or
y T inidazole, oral, 2 g stat. Or
y Secnidazole, oral, 2 g stat.
For women
T reatment for trichomoniasis and bacterial vaginosis
y Metronidazole, oral, 2 g stat. (contraindicated during the 1st trimes- ter of pregnancy)
Or
y Metronidazole, oral, 400 mg 8 hourly for 5 days (contraindicated during the 1st trimester of pregnancy)
Or
y Secnidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Or
y Tinidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Or
y Clindamycin cream (2%), topical (preferred in pregnancy)
What organism causes candida infections
What kind of organism is the organism that causes this infection
Is Candidiasis an STI?
When does Candidal vulvovaginitis occur?
Explain the PATHOGENESIS OF VULVOVAGINAL CANDIDIASIS
CANDIDA INFECTIONS
• Candida organisms—are gram- positive fungi
• Causes—candidiasis
• Candida is part of the normal flora of the vagina
• They are commensal saprophytic organisms of the vaginal mucosal surface and are found in low numbers in 25% of asymptomatic women.
• NOT an STI
• Pathophysiologically, Candidal vulvovaginitis occurs
when Candida species superficially penetrate the mucosal lining of the vagina and cause an inflammatory response.
PATHOGENESIS OF VULVOVAGINAL CANDIDIASIS
ØThere is yeast overgrowth in the vagina
• Circumstances leading to this overgrowth:
• dark and moist areas in the perineum serving as good media for growth.
• wearing of tight clothes and nylon panties
• extra folds of skin—making them areas good for growth
ØGrowth also occurs when the normal bacteria in the vagina change (as can happen with antibiotic intake) or when there are hormonal changes (as can happen with contraceptive intake or pregnancy
Candida infection produces what?
When are symptoms of candida infections often worse?
When do they improve?
State six symptoms of candida infections
What kind of discharge is seen in this kind of infection
What do people who sleep with people with this infection complain of after sex without a condom
CLINICAL FEATURES
• Infection produces vulvovaginitis
• Symptoms are often worse before onset of menses and improve during menstruation
vVulvar pruritus
vVaginal soreness, irritation, or burning
vSuperficial dyspareunia-Painful intercourse
vErythema and swelling of labia
vErythema of vaginal mucosa
vExternal dysuria
vNormal cervix
vVaginal discharge.
• Typically, discharge is—
⎯ non-offensive,
⎯ thick,
⎯ cheese-like,
⎯ contain floccules(small, loosely held mass or aggregate of fine particles, resembling a tuft of wool and suspended in or precipitated from a solution.)
⎯ is adherent to the vaginal mucosa as whit plaques, which when peeled or scraped off reveal punctate haemorrhages.
Discharge may vary from watery to thick homogenous.
vMinutes to hours after intercourse without a condom, partners may complain of a transient rash, erythema, pruritus, or burning sensation of the penis.
If clue cells are seen, it means bacterial vaginosis is present.
How is candida infection diagnosed (it’s a lower genital tract infection)
What lab tests are done
What kind of culture is used
How is it treated?
DIAGNOSIS
• Clinical
• Hx +examination
• Laboratory
• Microscopy
⎯ 10% KOH wet prep microscopy
• Culture
⎯ Nickerson’s medium or Sabouraud-dextrose agar plate
TREATMENT
• Antifungals
⎯ Pessaries ⎯ Oral
• Antihistamins for itching
• Pain relief
Treatment for candidiasis
y Miconazole vaginal tablets, 200 mg inserted into vagina at night for 3 days
y Or
y Clotrimazole, vaginal tablets, 200 mg inserted into vagina at night
y Clotrimazole cream, apply 12 hourly (for vulval irritation)
What are the organisms that cause bacterial vaginosis
What causes this infection?
State six risk factors of this infection
BACTERIAL VAGINOSIS
• Not clear whether it is an STI or not
• One cannot get it from toilet seats, bedding, or swimming pools (CDC)
• Common organisms—are anaerobes (Gardnerella, Ureaplasma, etc)
• It is a result of an imbalance of “good” and “harmful” bacteria in the vagina. That is, it is caused by a change in the natural balance of bacteria in the vagina
Risk factors
1. Douching,
2. Recent antibiotic use
3. Decreased oestrogen production
4. Wearing an intrauterine device (IUD)
5. Lack of condom use
6. Multiple sex partners or new sexual partners
State six symptoms of bacterial vaginosis
Why is it called vaginosis instead of vaginitis?
When is the discharge worse?
How is it diagnosed?
CLINICAL FEATURES
• Histologically, the vagina is not inflammed, hence it is called vaginosis instead of vaginitis.
• Also, it is named bacterial vaginosis because bacteria are the aetiological agents
vIt is associated with PID
vVaginal discharge
vTypically, discharge is
vVery offencsive (fish-like)
vOdour is worse after sex
vPain, itching, or burning sensation in the vagina
vDysuria (rare)
vItching around the outside of the vagina
vDyspareunia (rare)
vVulvar irritation uncommon
DIAGNOSIS
• Clinical
• Hx + Examination
•
CONCLUSION
• Infections of the female genital tract may be classified as upper or lower depending on the strucutres involved.
• Infections above the internal os—
⎯ are called upper genital tract infections; infections below the internal os are lower genital tract infections
• Many of the infections may lead to both local and systemic complications
• Infections may be sexually transmitted or non-sexually transmitted
True or false
State some lab investigators for bacterial vaginosis
What are clue cells
How is the infection treated
State five complications of the infection
Laboratory
• PH of discharge is greater than or equal to 4.5
• The discharge has an amine-like odour when mixed with 10% KOH solution [called Whiff test or amine odour test)
• Culture and sensitivity??? [[To R/o other infectious agents]] ⎯ Of discharge
⎯ HVS and Endocervical swab where discharge is not obvious
• Microscopy
⎯ Clue cells form more than 20% of the vaginal epithelial cells.
§Clue cells are vaginal squames that are so heavily covered with clusters of adherent bacteria that they look stippled or granular, and show no distinct edges or borders
TREATMENT
vPain relief
vAntihistamins for itching
vAntibiotics are the mainstay
⎯ Metronidazole (oral or gel) ⎯ Secnidazole
⎯ Clindamycin (oral or gel)
4-Feb-2022 35
COMPLICATIONS
vPregnacy complications :
⎯ Recurrent abortion
⎯ Preterm labour
⎯ Pre-labour rupture of membranes ⎯ Puerperal sepsis
vPID
vHigher susceptibiltiy to STIs
Treatment for trichomoniasis and bacterial vaginosis
y Metronidazole, oral, 2 g stat. (contraindicated during the 1st trimes- ter of pregnancy)
Or
y Metronidazole, oral, 400 mg 8 hourly for 5 days (contraindicated during the 1st trimester of pregnancy)
Or
y Secnidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Or
y Tinidazole, oral, 2 g stat. (contraindicated during the 1st trimester of pregnancy)
Or
y Clindamycin cream (2%), topical (preferred in pregnancy)
Bleeding in late pregnancy is a common and major cause of maternal morbidity and mortality
• Includes APH and PPH(Antepartum haemorrhage (APH) • Postpartum haemorrhage (PPH))
• Both APH and PPH are associated with haemodynamic compromise of the woman, and consequently foetal compromise as well
True or false
What is Antepartum haemorrhage
State four causes of APH
ANTEPARTUM HAEMORRHAGE (APH)
⎯ Is bleeding from the genital tract of a pregnant woman after the 28th week of pregnancy and before delivery of the baby
• Ante= before; partum= birth of baby
• A major cause of maternal mortality and morbidity
Causes
Bleeding from the placental site
Bleeding from local lesions in the genital tract
Ruptured uterus
Bleeding from vasa praevia
