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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
Q

What are the signs of tertiary syphilis?

A

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
Q

What are the implications of syphilis infection on pregnancy?

A

Preterm delivery
Stillbirth
Congenital syphilis
Miscarriage.

27
Q

What type of organism is trichomonas vaginalis:

A

Flagellated protozoan.

28
Q

How might the appearance of the cervix in trichomonas vaginalis infection be described?

A

“Strawberry” cervix. (from punctate haemorrhages 2%

29
Q

How do you dx trichomonas infection?

A
  • 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
Q

Describe treatment for trichomonas?

What are the birth complications? (2)

A

Metronidazole 2g PO single dose
Metronidazole 400-500mg BD for 5-7 days.
Contact tracing and treatment of partners.

PTB, low birth weight.

31
Q

What is bacterial vaginosis?

Is it sexually transmitted?

A

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
Q

How do you diagnosis BV?

A

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
Q

What is the treatment for BV?

A

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
Q

What are the implications of BV for pregnancy?

A
  • Mid-trimester miscarriage
  • PROM
  • PTB
35
Q

What are predisposing factors for candidiasis?

A

factors that alter the vaginal micro-flora and include:

  • immunosuppression
  • abx
  • pregnancy
  • DM
  • anaemia
36
Q

When do you treat candidiasis and what is the treatment?

A

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
Q

How is PID caused and what are the most common causative organisms?

A

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
Q

What are the risk factors for PID?

A

Age < 25 years
Previous STIs
New sexual partner/multiple sexual partners
- Uterine instrumentation such as STOP and intrauterine contraceptive devices.
- Post-partum endometritis.

39
Q

How do you diagnose PID? i.e. what are the signs and symptoms

A

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
Q

What investigations would you request when suspecting PID?

A

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
Q

What are the complications of PID (5) ?

A 
Tubo-ovarian abscess
Fitz-Huge-Curtis syndrome
Recurrent PID
Ectopic pregnancy
Infertility
42
Q

What is inpatient/outpatient mng of PID?

A

IV ceftriaxone 2g OD + IV doxycycline 100mg BD, followed by PO doxycycline 100mg BD 14 days + PO metronidazole 400mg BD 14 days.

43
Q

A women comes in with acute pelvic pain, what questions do you ask in history?

A 
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
Q

A woman comes in with acute pelvic pain, which invxs do you request and why?

A

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
Q

What diagnoses comprise ovarian cyst accident?

A

Torsion, haemorrhage, rupture.

Obstetrics (14 decks)

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