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Year 4k: Obs and Gynae > Gynaecological Infections > Flashcards

Gynaecological Infections Flashcards

1
Q

What is the definition of Pelvic Inflammatory Disease?

A
  • Used to describe infection and inflammation of female pelvic organs including uterus, fallopian tube, ovaries and surrounding peritoneum. Usually result from ascending infection from endocervix
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2
Q

What are forms of Pelvic Inflammatory disease?

A
  • Cervicitis: vaginal discharge, inflammation, tenderness
  • Endometritis: menstrual irregularity, midline abdominal pain
  • Tubal infection: erythema, oedema, exudate, low bilateral abdominal pain, adnexal swelling, tenderness
  • Intra-abdominal: peritonitis, peri-appendicitis, perihepatitis, peri-sigmoiditis
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3
Q

What are risk factors of Pelvic Inflammatory disease?

A
  • Non-use of barrier contraception
  • Previous episode of PID
  • Earlier age of first intercourse
  • Multiple sexual partners
  • Diabetes
  • Immunocompromised
  • Co-existing endometriosis
  • TOP/Miscarriage
  • Coil insertion
  • Instrumentation of uterus
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4
Q

What are some causative organisms of PID?

A
  • Chlamydia trachomatis (most common cause)
  • Neisseria gonorrhoea
  • Mycoplasma genitalium
  • Mycoplasma hominis
  • E.coli
  • Gardnerella vaginalis/anaerobes
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5
Q

What are some signs and symptoms of Pelvic Inflammatory Disease?

A
  • Vaginal or cervical discharge
  • Bilateral lower abdominal pain
  • Fever >38 o
  • Deep dyspareunia
  • Dysuria and menstrual irregularities may occur
  • Cervical excitation
  • Cervical motion tender
  • Adnexal tenderness (adnexal mass with tubo-ovarian abscess)
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6
Q

What are investigations of Pelvic Inflammatory Disease?

A
  • Pregnancy test done to exclude ectopic pregnancy
  • MSU
  • High vaginal swab and urethral swabs – often negative
  • Screen for Chlamydia and Gonorrhoea
  • Full blood count – leucocytosis
  • CRP
  • Amylase – usually normal or slightly raised
  • USS – pelvis/abdomen
  • X-ray
  • Diagnostic Laproscopy is definite
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7
Q

What is the medical management of Pelvic Inflammatory Disease?

A
  • Outpatient: [PO Ofloxacin + PO Metronidazole] or [IM Ceftriaxone 500mg + PO Doxycycline 100mg + PO Metronidazole 400mg]
  • Inpatient: IV Ceftriaxone 2g daily plus I.V. doxycycline 100 mg twice daily followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days
  • Surgical treatment: laparoscopy/laparotomy for drainage*
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8
Q

What advice should be given to patients being managed for Pelvic Inflammatory disease?

A
  • Counselling: risk of ectopic, subfertility
  • Partner notification and treatment
  • In mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ’ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
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9
Q

What are complications of Pelvic Inflammatory Disease?

A
  • Perihepatitis (Fitz-Hugh Curtis Syndrome)
  • Infertility (risk may be as high as 10-20% after a single episode)
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Tubo-ovarian abscess
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10
Q

What are clinical features of Perihepatitis?

A
  • Occurs in around 10% of cases of PID and is more common in chlamydial PID
  • It is characterised by right upper quadrant pain and may be confused with cholecystitis.
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11
Q

What are the difference between laparoscopy and laparotomy?

A

Laparoscopy

  • Quicker procedure
  • Smaller incisions
  • Less postoperative pain

Laparotomy

  • More thorough exploration of pelvis and loops of bowel
  • Thorough washout of pelvis and abdomen with possible reduction in pus remnants
  • Advanced laparoscopic skills not required
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12
Q

What is Thrush?

A

Thrush (vaginal candidiasis) is an extremely common condition which many women diagnose and treat themselves. The organisms responsible is

  • Candida albicans (80%)
  • Other Candida species (20%)
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13
Q

What are risk factors of Thrush?

A
  • Diabetes mellitus
  • High oestrogen levels
  • Drugs: antibiotics, steroids
  • Pregnancy
  • Immunosuppression: HIV
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14
Q

What are signs and symptoms of Thrush?

A
  • Cottage cheese, no offensive discharge. pH 4
  • Vulvitis: superficial dyspareunia, dysuria
  • Itch
  • Vulval erythema, fissuring, satellite lesions may be seen
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15
Q

What are investigations for Thrush?

A
  • High vaginal swab not routinely indicated unless clinical features not consistent with candidiasis
  • In GUM – microscopy shows spores, pseudohyphae plus neutrophils
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16
Q

What is the management of Thrush?

A

Local treatment (specifically used in pregnancy)

  • Clotrimazole pessary (e.g. clotrimazole 500mg)
  • PLUS Clotrimazole 1% cream (+/- HC 1%) topical BD for 2 weeks

Oral treatment (contraindicated in pregnancy)

  • Itraconazole 200mg PO bd for 1 day or Fluconazole 150mg PO
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17
Q

What is recurrent vaginal candidiasis?

A
  • BASHH define this as 4 or more episodes per year
  • Compliance with previous treatment should be checked
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18
Q

How is reccurent vaginal candidiasis confirmed?

A
  • Diagnosis of candidiasis should be confirmed
    • High vaginal swab for microscopy and culture
    • Blood glucose test to exclude diabetes
  • Exclude differentials such as lichen sclerosis
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19
Q

How is Recurrent Vaginal Candidiasis treated?

A

Consider the use of an induction-maintenance regime

  • induction: oral fluconazole every 3 days for 3 doses
  • maintenance: oral fluconazole weekly for 6 months
    • Clotrimazole pessaries can be used if fluconazole is contraindicated

Consider alternative regimens including cetirizine 10 mg OD

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20
Q

What are common causes of Vaginal Discharge?

A
  • Physiology
  • Candida
  • Trichomonas Vaginalis
  • Bacterial Vaginosis
  • Less Common Causes: Gonorrhoea, Chlamydia (rarely the presenting symptoms), Ectropion, Foreign body, Cervical cancer
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21
Q

What history has to be explored in a patient presenting with vaginal discharge?

A
  • Presenting complaint:
    • Is it normal for you?
    • What is it like (colour, consistency, odour)?
    • Any associated symptoms such as pain, bleeding, itching or rashes?
    • Are there any triggers (cyclical, sex, antibiotics)?
  • Further history:
    • Sexual history, contraception, pregnancy risk
    • Washing habits? Douching, bath vs shower, product?
  • STI risk factors:
    • ​Age?
    • >1 sexual partner in 12 months? New sexual partner?
    • Unprotected sex?
22
Q

What has to be examined in a patient presenting with vaginal discharge?

A
  • Rashes: erythema, fissures, lumps/bumps
  • Ulcers
  • Speculum: ph of discharge, internal lesions, discharge, cervix health, cervicitis?, lesion, polyps, ulcers
  • Bimanual examination if lower abdominal pain/deep dyspareunia
23
Q

What are tests for patients presenting with vaginal discharge?

A
  • High vaginal swabs: wet mount and gram stain for microscopy, culture (for trichomonas vaginalis/candida/other organisms using charcoal swabs)
  • Vulvovaginal swab: NAAT for N. gonorrhoeae and C. trachomatis
  • Other tests: culture for other organisms if relevant, HSV PCR from cervix if required
24
Q

What are symtpoms of urinary tract infections and its significance in pregnancy?

A

Presentation

  • Dysuria and frequency are common, but women may experience suprapubic burning secondary to cystitis

In pregnancy

  • 1 in 25 women develop UTI in pregnancy.
  • Associated with pre-term delivery and intrauterine growth restriction
25
Q

What is the risk of transmission of Blood-borne viral infections?

A

Transmission is through sex, blood, body fluids (IVDU, needlestick, transplant/transfusion), and vertical transmission (breastfeeding)

  • HEP B ≈ 1 in 3
  • HEP C ≈ 1 in 30
  • HIV ≈ 1 in 300
26
Q

What risk assessment has to be made in blood-borne infections?

A
  • Source Patient
    • Risk factors
    • Known positive?
    • Viral load
  • Nature of Exposure
    • Skin puncture/Broken skin/Intact Skin
    • Hollow vs solid need – size of bore
    • Gloves
    • Time to first aid measures
  • Recipient HEP B vaccine status
27
Q

What testing has to be done post-needle stick injury?

A
  • Source patient -consent for immediate testing
    • HIV
    • HBsAg
    • HCV – anti-HCV initially
  • Recipient
    • Original blood sample stored
    • Further tests at 6, 12, 24 weeks
  • While wating
    • Safe sex
    • Good infection control
    • Avoid blood donation
28
Q

Which patient group is affected disproportonately by HIV?

A
  • MSM and Black Africans are disproportionally affected
29
Q

What are stages of HIV infection?

A
  • Seroconversion illness: non-specific symptoms resolving in 2-3 weeks
  • Asymptomatic stage of HIV: can last several years
  • Symptomatic HIV: weakened immune system
  • Late-stage HIV: AIDS-defining illnesses such as cancer, TB, pneumonia
30
Q

How is HIV tested?

A
  • 4th generation combo assay (EIA)
    • Detect Anti-HIV antibodies and p24 antigens
    • Has shorter window period
  • Confirmatory tests are done in the lab if positive – immune blot
31
Q

What is the viral load?

A

Number of copies of HIV per ml of blood.

  • Likelihood of passing on the disease linked to vial load
  • U=U (undetectable=untransmissible). People with HIV on effective treatment and with an undetectable viral are not infectious
32
Q

How can you reduce trasmission of HIV?

A
  • Using condoms
  • Pre-exposure prophylaxis. Take within 72 hours after HIV exposure
  • Take HIV medication if positive
33
Q

What is the presentation of Hepatitis B disease?

A

Often subclinical or flu-like disease

  • Acute presentation
    • Jaundice
    • Dark urine/pale stool due to intrahepatic cholestasis
    • Rash
    • Polyarthritis
    • Fever
    • Tender hepatomegaly
  • Chronic
    • Either compensated or decompensated liver failure
34
Q

What are the biochemical markers of Acute Hepatitis B infection?

A
  • HBsAg positive
  • HBcAb positive (IgM)
  • HBsAb negative
35
Q

What are the biochemical markers of Chronic Hepatitis B infection?

A
  • HBsAg positive
  • HBcAb positive
  • HBsAb negative
36
Q

What are the biochemical markers of Cleared Hepatitis B infection?

A
  • HBsAg negative
  • HBcAb positive
  • HBsAb positive
37
Q

What are the biochemical markers of immunisation against Hepatitis B?

A
  • HBsAg negative
  • HBcAb negative
  • HBsAb positive
38
Q

How does primary prevention of Hepatitis B take place?

A

Advice to patient

  • Inform GP and dentist
  • Do not donate blood/organs/semen, do not share needle or works,
  • Cover wounds, clean blood spills and use condoms for sexual activity

Pregnancy

  • Mother may require antiretroviral if high viral load. Vaccinate neonate and consider HBIG if high risk

Sexual contact

  • Vaccination, HBIG if recent (<7 days) exposure and use condoms/dental damn until immune

Household

  • Vaccination. Do not share razor/toothbrushes
39
Q

What are clinical features of Hepatitis C?

A
  • Usually asymptomatic or mild. Incubation period is about 6 weeks
  • 20% clear infection but 80% progress to chronic infection resulting in cirrhosis and hepatocellular carcinoma
40
Q

How should testing for Hepatitis C be conducted?

A
  • Anti HCV used for initial screening
    • Show current and past infection.
    • Become positive 4-10 weeks after exposure. There are new combo test that detect HCV-Ag which have reduced window period
    • Antibody provides incomplete protection – reinfection possible
  • Next test is HCV RNA to distinguish current from past infection. If HCV RNA present then it means you are infected and infectious
41
Q

How is Hep C prevented?

A
  • Risk modification
  • Consider Hep B vaccine for the baby
42
Q

What are cuases of Genital Ucers/Sores?

A
  • Infective: Herpes Simplex, Herpes Zoster, Syphilis, Tropical Disease (LGV, Granuloma Inguinale, Chancroid)
  • Dermatological: Fixed drug reactions, Bechet’s, Apthosis, Lichen Planus, Pemphigus, Malignancy
  • Non-infective: Trauma, Physical chemical
43
Q

What are types of Herpes Simplex Infection?

A
  • HSV 1: Orofacial (mean recurrences is 1)
  • HSV 2: Genital (4 mean recurrences)
44
Q

What are clinical features of HSV infections?

A
  • Incubation period of 3-14 days. Progresses through 4 stages:
    • Starts as painful red macular lesion
    • Progresses to fluid filled ulcers which burst into painful ulcers.
    • These ulcers then dry up forming a dry kelki lesion.
  • Can have anal lesions
  • Best time to swab is when it is moist
45
Q

What are tests for Herpes Simplex Infections?

A

Immediate

  • HSV PCR Swab is highly sensitive and type specific

Delayed

  • Full STI screen
  • Syphilis serology (follow up in 1 month)
  • HIV antibody test
46
Q

What is the management of Herpes Simplex Infection?

A
  • Symptomatic: rest, analgesia, Vaseline and saline washing
  • Systemic Antivirals: acyclovir 400 mg TDS
  • 5% lidocaine ointment
  • Avoid sexual contact and advise disclosure to partners
47
Q

What complicatons of HSV infections?

A
  • Urinary Retention
  • Adhesions
  • Meningism
  • Emotional Distress
  • Recurrences
48
Q

How is HSV treated in pregnancy?

A
  • If primary infection in last trimester – caesarean
    • Lower risk of vertical transmission if recurrent episode
  • Occasional use of prophylactic therapy in last trimester
  • Discordant couples should avoid unprotected sexual contact in pregnancy
49
Q

What are the stages and presentations of Syphillis?

A
  1. Primary Syphilis
  • Presents as a Shanker which is a primary syphilitic ulcer.
  • Appear 9-90 days after infection and may go unnoticed.
  1. Secondary Syphilis
  • Can arise 6 weeks to 6 months later as systemic complications. Can remain latent after this phase
  • Can be patchy alopecia and macular papular rash
  1. Tertiary Syphilis
    * Many years later, it may arise in untreated patients in which there are lesions that cause neurological and cardiovascular complications
50
Q

How is Syphilis tested for?

A
  • From lesions: dark group microscopy and treponemal PCR swab
  • Blood test
    • Treponemal enzyme immunoassay (EIA)
    • Treponema Pallidum Particle Agglutination Assay (TPPA)
    • Rapid Plasma Reagin Test (RPR)
  • Full STI screen
51
Q

How is Syphilis managed?

A
  • Early syphilis: Single dose Benzathine Penicillin IM
  • Late syphilis: 3 consecutive doses Benzathine Penicillin IM

Year 4k: Obs and Gynae (19 decks)

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