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Obstetrics > Genital tract infections and pelvic pain > Flashcards

Genital tract infections and pelvic pain Flashcards

1
Q

Name causes of increased vaginal discharge?

A

Physiological:

  • Oestrogen related - puberty, pregnancy, COCP
  • Cycle related - maximal mid-cycle and premenstrual
  • Sexual excitement and intercourse

Pathological
Infection
- Non-sexually transmitted (BV, candida)
- Sexually trasmitted (TV, chlamydia, gonorrhoea).

Non-infective

  • Foreign body (retained tampon, condom, or post-partum swab).
  • Malignancy (any part of the genital tract).
  • Atrophic vaginitis (often blood-stained)
  • Cervical ectropion or endocervical polyp.
  • Fistulae (urinary or faecal).
  • Allergic reactions
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2
Q

A women complains of increased vaginal discharge. What would you want to know from history?

A
  • Characteristics of discharge (onset, duration, odour, colour).
  • Associated symptoms (itching, burning, dysuria, superficial dyspareunia).
  • Relationship of discharge to menstrual cycle.
  • Precipitating factors (pregnancy, contraceptive pill, sexual excitement)
  • Sexual history (RFs for STIs)
  • Medical hx (diabetes, immune-compromised)
  • Non-infectious causes (FB, ectopy, malignancy, dermatological conditions)
  • Hygiene practices (douches, bath products, talcum powder)
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3
Q

A women complains of increased vaginal discharge, how would you examine her?

A
  • External genital inspection for vulvuitis, obvious discharge, ulcers, or other lesions.
  • Speculum: appearance of vagina, cervix, foreign bodies, amount, colour and consistency of discharge.
  • Bimanual examination (masses, adnexal tenderness, cervical motion tenderness)
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4
Q

A woman complains of increased vaginal discharge. What investigations would you request?

A
  • Endocerivcal or vulvovaginal swabs for gonorrhoea and chlamydia.
  • High vaginal swabs (Amies transport medium)
  • Vaginal pH measurement.
  • Saline wet mount and Gram staining
  • Colposcopy (if abnormal cervical appearance)
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5
Q

Describe the features of normal vaginal discharge?

A

Clear/white, mucoid consistency, nil odour or vulval itching.

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6
Q

Describe vaginal discharge with trichomonal infection?

Name the treatment of choice

A

Green/grey colour, frothy consistency, offensive odour, vulval itching. Tx metronidazole

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7
Q

Describe vaginal discharge with gonococcal infection?

A

Greenish colour, watery consistency, nil odour or vulval itching.

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8
Q

Describe vaginal discharge with BV infection?

A

White/grey colour, watery consistency, offensive odour, , nil vulval itching.

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9
Q

Name RFs for STIs (8)?

A

Multiple partners (tow or more in the last eyar)
Concurrent partners
Recent partner change (in past 3months)
Non-use of barrier protection
STI in partner
Other STI
Younger age (particularly aged = 25 years)
Involvement in the commercial sex industry.

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10
Q

What undertaking an STI screen, what symptoms would you ask about?

A

Lumps, bumps, ulcers , rash, itching, IMB or PCB, low abdominal pain, dysparaeunia, suddden/distinct change in discharge.

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11
Q

What are the incubation periods for STIs and HIV?

A

bacterial STIs: 10 -14 days.

For HIV and syphilis it may be up to 3 months

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12
Q

What are some important complications of Chlamydia trachomatis?

A
  • PID (10-40% of infections result in PID)
  • Perihepatitis (Fitz-Hugh-Curtis syndrome).
  • Reiter’s syndrome (more common in med): arthritis, urethritis, conjunctivitis.
  • Tubal infertility
  • Risk of ectopic pregnancy
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13
Q

What is the treatment and mng for Chlamydia trachomatis

A

Azithromycin 1g single dose or doxycycline 100mg BD for 7 days.
Contact tracing and treatment of partners.

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14
Q

What are the implications of Chlamydia trachomatis infection in pregnancy?

(and what is the treatment for pregnant women)

A

A/W preterm rupture of membranes (PROM) and premature delivery.

The risks to the baby are?
- neonatal conjunctivitis (30% within the first 2 weeks)
- Neonatal pneumonia (15% within the first 4 months)
Tx for pregnant women?
- erythromycin 500mg BD for 10-14 days

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15
Q

What type of virus is HSV?

A

DNA virus

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16
Q

Describe the aetiology recurrent HSV attacks?

What are triggers for recurrent attacks?

A

thought to result from reactivation of latent virus in the sacral ganglia.
Triggers: stress, sexual intercourse, menstruation

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17
Q

What are some complications of HSV infection (usually primary infection)?

A

Meningitis
Sacral radiculopathy - causing urinary retention and constipation.
Transverse myelitis
disseminated infection.

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18
Q

What type of bacteria is Neisseria gonorrhoeae:

A

intracellular Gram -ve diplococcus.

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19
Q

What are the complications of gonorrhoea infection?

A 
PID (10% of infections result in PID)
Bartholin's or Skene's abscess
Disseminated gonorrhoea may cause: fever, pustular rash, migratory polyarthralgia, septic arthritis.
Tubal infertility
Risk of ectopic pregnancy
20
Q

what is treatment for gonorrhoea infection

A

Ceftriaxone 500mg IM stat, plus azithromycin 1g PO stat.
Contact tracing and treatment of partners.
The same abx are recommended for treatment in pregnancy.

21
Q

What are the implications for gonorrhoea infection in pregnancy?

A

Preterm rupture of membranes and premature delivery
chorioamnionitis.
The risks to the baby are ophthalmia neonatarum (40-50%)

22
Q

What type of bacteria is syphilis?

A

Spirochaete.

23
Q

What are symptoms of primary syphilis?

A

10-90 days postinfection
painless, genital ulcer (chancre) - may passed unnoticed in the cervix.
Inguinal lymphadenopathy.

24
Q

What are symptoms of secondary syphilis?

A

Occurs within the first 2 years of infection
Generalized polymorphic rash affecting palms and soles.
Generalised lymphadenopathy
Genital condyloma lata
Anterior uveitis.

25
What are the signs of tertiary syphilis?
Presents in up to 40% of people infeted for at least 2 years, but may take 40+yrs to develop Neurosyphilis: tabes dorsalis and dementia Cardiovascular syphilis: commonly affecting the aortic root. Gummata: inflammatory plaques or nodules.
26
What are the implications of syphilis infection on pregnancy?
Preterm delivery Stillbirth Congenital syphilis Miscarriage.
27
What type of organism is trichomonas vaginalis:
Flagellated protozoan.
28
How might the appearance of the cervix in trichomonas vaginalis infection be described?
"Strawberry" cervix. (from punctate haemorrhages 2%
29
How do you dx trichomonas infection?
- Direct obervation of the organism by a wet smear (Normal saline) or acridine orange stained slide from teh poseterior vaginal fornix (sensitivity 40-70% cases) - Culture media (dx 80%) - NAATs (sensitivities and specificities) approaching 100%
30
Describe treatment for trichomonas? What are the birth complications? (2)
Metronidazole 2g PO single dose Metronidazole 400-500mg BD for 5-7 days. Contact tracing and treatment of partners. PTB, low birth weight.
31
What is bacterial vaginosis? Is it sexually transmitted?
BV is caused by an overgrowth of mixed anaerobes, including Gardnerella and Mycoplasma hominis, which replace the usually dominant vaginal lactobacilli. Not sexually transmitted. Triggers remain unclear.
32
How do you diagnosis BV?
Amsel criteria (3 out of 4 required for dx) - Homogenous grey-white discharge - Increased vaginal pH > 5.5 - Characteristic fishy smell. - Clue cells present on microscopy (squamous epithelial cells with bacteria adherent on their walls).
33
What is the treatment for BV?
May resolve spontaneously but has high risk of recurrence. Most women prefer treatment: Metronidazole 400mg PO BD for 5/7 OR Metronidazole 2g (single dose) Clindamycin 2% cream vaginally at night for 7 days. LIfestyle factors: avoidance of vaginal douching/overwashing which can destroy natural vaginal flora.
34
What are the implications of BV for pregnancy?
- Mid-trimester miscarriage - PROM - PTB
35
What are predisposing factors for candidiasis?
factors that alter the vaginal micro-flora and include: - immunosuppression - abx - pregnancy - DM - anaemia
36
When do you treat candidiasis and what is the treatment?
Treat when symptomatic (as many women are chronic carriers) - Clotrimazole 500mg pessary +/- topical clotrimazole cream; OR - Fluconazole 150mg (single dose) - C/I in pregnancy. Lifestyle: wear cotton underpants. avoiding chemical irritantse.g. soap and bath salts. NB: no apparent adverse effect o n pregnancy. Topical imidazoles are not systemically absorbed and are therefore safe at all gestations.
37
How is PID caused and what are the most common causative organisms?
Commonly caused by ascending infection fromteh endocervix, but may also occur from descending inection from organs such as the appendix. Causative organisms: - 25% of cases estimated to be caused by Chlamydia trachomatis and Neisseria gonorrhoea - Anaerobes and endogenous agents,either aerobic or facultative, may be responsible for the remainder.
38
What are the risk factors for PID?
Age < 25 years Previous STIs New sexual partner/multiple sexual partners - Uterine instrumentation such as STOP and intrauterine contraceptive devices. - Post-partum endometritis.
39
How do you diagnose PID? i.e. what are the signs and symptoms
PID can be asymptomatic, dx being made retrospectiely when being investigated for subfertility. Symptoms may include: - Pelvic pain (may be unilateral), constant or intermittent - Deep dyspareunia - Vaginal discharge (usually due to concurrent vaginal infection) - Irregular and/or more painful menses - IMB/PCB - Fever (unusal in mild/chronic PID) Signs (at least one should be present when making a PID diagnosis) are: - Cervical motion pain - Adnexal tenderness (commonly bilateral, but may be unilateral) - elevated temperature (unusal in mild/chronic infection)
40
What investigations would you request when suspecting PID?
Tests for gonorrhoea and chlamydia WCC + CRP USS may be indicated if a tubo-ovarian abscess is suspected. Laparoscopy is the gold standard test; however, it is invasive and only used where dx is uncertain.
41
What are the complications of PID (5) ?
``` Tubo-ovarian abscess Fitz-Huge-Curtis syndrome Recurrent PID Ectopic pregnancy Infertility ```
42
What is inpatient/outpatient mng of PID?
IV ceftriaxone 2g OD + IV doxycycline 100mg BD, followed by PO doxycycline 100mg BD 14 days + PO metronidazole 400mg BD 14 days.
43
A women comes in with acute pelvic pain, what questions do you ask in history?
``` Pain: site, nature, radiation, aggravaating/relieving factors. LMP Contraception Recent unprotected sexual intercourse RFs for ectopic pregnnacy Vaginal discharge or bleeding. Bwowel symptoms Urinary symptoms Precipitating factors (physical and psychological) ```
44
A woman comes in with acute pelvic pain, which invxs do you request and why?
Urinary//serum hCG - to exclude ectopic/miscarriage MSU: exclude UTI/pyelo Triple swabs: high vaginal, cervial and endocervical chlamydia) - exclude PID Pelvic USS- exclude appendicitis, ovarian cyst accident. AXR, CT , MRI as appropriate. Diagnostic lap - as required,
45
What diagnoses comprise ovarian cyst accident?
Torsion, haemorrhage, rupture.

Obstetrics (14 decks)

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