Gynaecology 2 Flashcards
1
Q
What is the MC STI in the UK and significant cause of infertility
A
Chlamydia
2
Q
RF for Chlamydia?
A
Being young, sexually active and having multiple partners increase the risk of catching the infection. A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on
3
Q
Explain the National Chlamydia Screening Programme
A
Public Health England has set out a National Chlamydia Screening Programme (NCSP). This program aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment. This re-testing is to ensure they have not contracted chlamydia again, rather than to check the treatment has worked.
4
Q
In general, when a patient attends a GUM clinic for STI screening, as a minimum, they are tested for:
A
Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)
5
Q
There are two types of swabs involved in sexual health testing:
What are they
A
Charcoal swabs
Nucleic acid amplification test (NAAT) swabs
6
Q
Microscopy involves gram staining and examination under a microscope. A stain is used to highlight different types of bacteria with different colours. Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS).
Charcoal swabs can confirm:
A
Bacterial vaginosis
Candidiasis
Gonorrhoeae (specifically endocervical swab)
Trichomonas vaginalis (specifically a swab from the posterior fornix)
Other bacteria, such as group B streptococcus (GBS)
7
Q
What is Nucleic acid amplification tests (NAAT)
A
check directly for the DNA or RNA of the organism. NAAT testing is used to test specifically for chlamydia and gonorrhoea. They are not useful for other pelvic infections (except where specifically testing for Mycoplasma genitalium). In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample
8
Q
The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:
A
- Abnormal vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding (intermenstrual or postcoital)
- Painful sex (dyspareunia)
- Painful urination (dysuria)
9
Q
Consider chlamydia in men that are sexually active and present with:
A
- Urethral discharge or discomfort
- Painful urination (dysuria)
- Epididymo-orchitis
- Reactive arthritis
10
Q
Examination Findings For CHlamydia
A
- Pelvic or abdominal tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
*
11
Q
How do you diagnose Chlamydia
A
Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia. This can involve a:
- Vulvovaginal swab
- Endocervical swab
- First-catch urine sample (in women or men)
- Urethral swab in men
- Rectal swab (after anal sex)
- Pharyngeal swab (after oral sex)
12
Q
There are a large number of complications from infection with chlamydia:
A
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
13
Q
Pregnancy-related complications with chlamydia include:
A
- Preterm delivery
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
- Neonatal infection (conjunctivitis and pneumonia
14
Q
First-line for uncomplicated chlamydia infection is
A
doxycycline 100mg twice a day for 7 days.
15
Q
Can you use doxycylcine in preganancy when you have chlamydia
A
No Doxycycline is contraindicated in pregnancy and breastfeeding
- Azithromycin 1g stat then 500mg once a day for 2 days
- Erythromycin 500mg four times daily for 7 days
- Erythromycin 500mg twice daily for 14 days
- Amoxicillin 500mg three times daily for 7 days
These can be used
16
Q
WHat is Lymphogranuloma Venereum
A
Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages:
17
Q
What is Chlamydial Conjunctivitis
A
Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.
Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.
18
Q
Is Chlamydia Gram positive or Gram negative
A
Negative
19
Q
is Neisseria gonorrhoeae gram positive or gram negative
A
Gram-negative diplococcus
20
Q
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with:
A
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain
Testicular pain or swelling (epididymo-orchitis
21
Q
Diagnosis of Gonorrhoea
A
Nucleic acid amplification testing (NATT) is use to detect the RNA or DNA of gonorrhoea
A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities
22
Q
Complications of gonorrhoea
A
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis
23
Q
WHat is Disseminated Gonococcal Infection
A
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
- Various non-specific skin lesions
- Polyarthralgia (joint aches and pains)
- Migratory polyarthritis (arthritis that moves between joints)
- Tenosynovitis
- Systemic symptoms such as fever and fatigue
24
Q
What is Bacterial Vaginosis
A
Bacterial vaginosis (BV) refers to an overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection. It is caused by a loss of the lactobacilli “friendly bacteria” in the vagina. Bacterial vaginosis can increase the risk of women developing sexually transmitted infections.
25
WHat is the main organism ina healthy vaginal bacterial flora
Lactobacilli are the main component of the healthy vaginal bacterial flora.
26
Examples of anaerobic bacteria associated with bacterial vaginosis are:
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
27
It is worth remembering that bacterial vaginosis can occur alongside other infections, including .....
It is worth remembering that bacterial vaginosis can occur alongside other infections, including **candidiasis, chlamydia and gonorrhoea**
28
Risk Factors of Bacterial Vaginosis
Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.
29
If you suspect Bacterial vaginosis what should you ask the patient
sensitively ask about the use of soaps to clean the vagina and vaginal douching and provide information about how these can increase the risk.
30
Presentation of bacterial vaginosis
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
31
Investigations of bacterial vaginosis
**Vaginal pH** can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
A standard charcoal **vaginal swab** can be taken for **microscopy.** This can be a **high vaginal swab** taken during a speculum examination or a **self-taken low vaginal swab**.
Bacterial vaginosis gives **“clue cells”** on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually **Gardnerella vaginalis.**
32
Management for BV
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
**Metronidazole** is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given **orally,** or by **vaginal gel**. **Clindamycin** is an alternative but less optimal antibiotic choice.
Always assess the risk of additional pelvic infections, with swabs for **chlamydia and gonorrhoea where appropriate.**
Provide advice and information about measures that can reduce the risk of further episodes of bacterial vaginosis, such as avoiding vaginal irrigation or cleaning with soaps that may disrupt the natural flora.
33
What advice should you give to patients taking metronidazole?
Whenever prescribing metronidazole advise patients to **avoid alcohol** for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedem
34
Complications
Bacterial vaginosis
Bacterial vaginosis can increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
It is also associated with several complications in pregnant women:
* Miscarriage
* Preterm delivery
* Premature rupture of membranes
* Chorioamnionitis
* Low birth weight
* Postpartum endometritis
35
WHat is Candidiasis
Vaginal candidiasis is commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans.
Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.
36
Candidiasis RF
* Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
* Poorly controlled diabetes
* Immunosuppression (e.g. using corticosteroids)
* Broad-spectrum antibiotics
*
37
Presentation
The symptoms of vaginal candidiasis are:
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
38
vaginal candidiasis
More severe infection can lead to:
* Erythema
* Fissures
* Oedema
* Pain during sex (dyspareunia)
* Dysuria
* Excoriation
39
Investigations for candidiasis
Often treatment for candidiasis is started empirically, based on the presentation.
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH \> 4.5) and candidiasis (pH \< 4.5).
A charcoal swab with microscopy can confirm the diagnosis.
40
Management Options
Treatment of candidiasis is with antifungal medications. These can be delivered in several wa
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
41
The NICE Clinical Knowledge Summaries (2017) recommend for initial uncomplicated cases of candidiasis the options of:
A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
A single dose of clotrimazole pessary (500mg) at night
Three doses of clotrimazole pessaries (200mg) over three nights
A single dose of fluconazole (150mg)
42
What is Mycoplasma Genitalium
Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection. There are developing problems with antibiotic resistance, particularly with azithromycin.
Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. **Urethritis** is a key feature.
43
Mycoplasma genitalium infection may lead to:
* Urethritis
* Epididymitis
* Cervicitis
* Endometritis
* Pelvic inflammatory disease
* Reactive arthritis
* Preterm delivery in pregnancy
* Tubal infertility
44
Investigations of Mycoplasma Genitalium
Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves **nucleic acid amplification tests (NAAT)** to look specifically for the DNA or RNA if the bacteria.
The samples recommended by **BASHH guidelines** (2018) are:
* **First urine sample** in the morning for men
* **Vaginal swabs** (can be self-taken) for women
The guideline recommends checking every positive sample for **macrolide resistance**, and performing a **“test of cure”** after treatment in every positive patient.
45
Management for Mycoplasma Genitalium
The BASHH guidelines (2018) recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections:
* **Doxycycline** 100mg twice daily for 7 days then;
* **Azithromycin** 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
**Moxifloxacin** is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).
46
What is Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.
47
Endometritis is inflammation of the
Salpingitis is inflammation of the
Oophoritis is inflammation of the
Parametritis is inflammation of the
Peritonitis is inflammation of the
Endometritis is inflammation of the **endometrium**
Salpingitis is inflammation of the **fallopian tubes**
Oophoritis is inflammation of the **ovaries**
Parametritis is inflammation of the **parametrium, which is the connective tissue around the uterus**
Peritonitis is inflammation of the **peritoneal membrane**
48
Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:
* Neisseria gonorrhoeae tends to produce more severe PID
* Chlamydia trachomatis
* Mycoplasma genitalium
49
Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such a
**Gardnerella vaginalis** (associated with bacterial vaginosis)
**Haemophilus influenzae** (a bacteria often associated with respiratory infections)
**Escherichia coli** (an enteric bacteria commonly associated with urinary tract infections
50
Pelvic Inflammatory Disease Risk Factors
There risk factors for pelvic inflammatory disease are the same as any other sexually transmitted infection:
* Not using barrier contraception
* Multiple sexual partners
* Younger age
* Existing sexually transmitted infections
* Previous pelvic inflammatory disease
* Intrauterine device (e.g. copper coil)
51
PID
Women may present with symptoms of:
* Pelvic or lower abdominal pain
* Abnormal vaginal discharge
* Abnormal bleeding (intermenstrual or postcoital)
* Pain during sex (dyspareunia)
* Fever
* Dysuria
52
PID
Examination findings may reveal:
* Pelvic tenderness
* Cervical motion tenderness (cervical excitation)
* Inflamed cervix (cervicitis)
* Purulent discharge
Patients may have a fever and other signs of sepsis.
53
Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections:
**NAAT swabs for gonorrhoea and chlamydia**
**NAAT swabs for Mycoplasma genitalium if available**
**HIV test**
**Syphilis test**
A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.
A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.
Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.
54
Management for PID
One suggested outpatient regime (listed here to help your understanding and not as a guide to treatment) is:
A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.
55
PID
Complications
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
56
What is Fitz-Hugh-Curtis Syndrome
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the **liver capsule (Glisson’s capsule)**, leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome results in **right upper quadrant pain** that can be referred to the right shoulder tip if there is diaphragmatic irritation. **Laparoscopy** can be used to visualise and also treat the adhesions by adhesiolysis.
57
What is Trichomoniasis
Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a **protozoan**, and is a single-celled organism with **flagella.** Flagella are appendages stretching from the body, similar to limbs. Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism. The flagella are used for movement, attaching to tissues and causing damage.
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
58
Trichomonas can increase the risk of:
* Contracting HIV by damaging the vaginal mucosa
* Bacterial vaginosis
* Cervical cancer
* Pelvic inflammatory disease
* Pregnancy-related complications such as preterm delivery.
59
Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:
Vaginal discharge- frothy and yellow-green, fishy smell
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
60
Trichomoniasis
Examination of the cervix can reveal a characteristic “\_\_\_\_\_\_\_ \_\_\_\_\_” (also called colpitis macularis
Examination of the cervix can reveal a characteristic “**strawberry cervix**” (also called colpitis macularis
61
Diagnosis of Trichomoniasis
The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).
Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.
A urethral swab or first-catch urine is used in men.
62
Management of Trichomoniasis
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with **metronidazole.**
63
The herpes simplex virus (HSV) is commonly responsible for both ________ (herpes labialis) and \_\_\_\_\_\_
There are two main strains, ____ and \_\_\_\_
The herpes simplex virus (HSV) is commonly responsible for both **cold sores** (herpes labialis) and **genital herpes.**
There are two main strains, **HSV-1** and **HSV-2.**
64
The herpes simplex virus can also cause _____ \_\_\_\_ (small painful oral sores in the mouth), _____ \_\_\_\_ (inflammation of the cornea in the eye) and ______ \_\_\_\_\_ (a painful skin lesion on a finger or thumb).
The herpes simplex virus can also cause **aphthous ulcers** (small painful oral sores in the mouth), **herpes keratitis** (inflammation of the cornea in the eye) and **herpetic whitlow** (a painful skin lesion on a finger or thumb).
65
HSV-1 is most associated with ___ \_\_\_\_\_
HSV-2 typically causes ____ \_\_\_\_\_
cold sores
genital herpes
66
Presentation of Genital Herpes
Signs and symptoms include:
* Ulcers or blistering lesions affecting the genital area
* Neuropathic type pain (tingling, burning or shooting)
* Flu-like symptoms (e.g. fatigue and headaches)
* Dysuria (painful urination)
* Inguinal lymphadenopathy
Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.
67
Diagnosis of Genital Herpes
Ask about sexual contacts, including those with cold sores, to establish a possible source of transmission. They may have caught the infection from someone unaware they are infected and not experiencing any symptoms.
The diagnosis can be made **clinically** based on the history and examination findings.
A **viral PCR** swab from a lesion can confirm the diagnosis and causative organism.
68
\_\_\_\_\_\_\_ is used to treat genital herpes.
Alternatives are ______ and \_\_\_\_\_\_\_
**Aciclovir** is used to treat genital herpes.
Alternatives are **valaciclovir and famciclovir.**
69
genital herpes.
Additional measures, including to manage the symptoms include:
Paracetamol
Topical lidocaine 2% gel (e.g. Instillagel)
Cleaning with warm salt water
Topical vaseline
Additional oral fluids
Wear loose clothing
Avoid intercourse with symptoms
70
HIV leads to opportunistic infections and several AIDS-defining illnesses, such as ______ \_\_\_\_\_. AIDS is now mostly referred to as late-stage HIV.
leads to opportunistic infections and several AIDS-defining illnesses, such as **Kaposi’s sarcoma**. AIDS is now mostly referred to as late-stage HIV.
71
What type of virus is HIV
RNA retrovirus
72
There are two types of HIV
HIV 1 and HIV 2
Which one is more common
HIV 1
73
HIV is not transmitted through day-to-day activities, including kissing. It is spread through:
* Unprotected anal, vaginal or oral sexual activity
* Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)
* Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye
74
HIV destroys the _____ \_\_\_\_ _____ cells of the immune system.
destroys the **CD4 T-helper** cells of the immune system.
75
There is a long list of AIDS-defining illnesses associated with end-stage HIV infection. These occur where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear.
Examples of AIDS-defining illnesses include:
Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis
76
Before doing an HIV antibody tests it is important to
Patients need to give consent for a test. Verbal consent should be documented before a test. Consent only needs to be as simple as “are you happy for us to test you for HIV?” Patients no longer require formal counselling or education before a test.
77
Testing for HIV
**Antibody testing** is the typical screening test for HIV. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing.
Testing for the **p24 antigen**, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test.
**PCR** testing for the **HIV RNA** levels tests directly for the number of **viral copies** in the blood, giving a **viral load.**
78
Monitoring HIV
**CD4 Count**
The CD4 count is the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection:
* 500-1200 cells/mm3 is the normal range
* Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections
**Viral Load (VL)**
Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.
79
What is treatment for HIV
Treatment involves a combination of antiretroviral therapy (ART) medications.
ART is offered to everyone with a diagnosis of HIV irrespective of viral load or CD4 count.
Treatment aims to achieve a normal CD4 count and undetectable viral loa
80
Highly Active Anti-Retrovirus Therapy (HAART) Medication
There are a number of classes of HAART medications that work slightly differently on the virus:
* Protease inhibitors (PIs)
* Integrase inhibitors (IIs)
* Nucleoside reverse transcriptase inhibitors (NRTIs)
* Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
* Entry inhibitors (EIs)
81
Additional Management for HIV
**Prophylactic co-trimoxazole (Septrin)** is given to patients with a CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).
HIV infection increases the risk of developing cardiovascular disease. **Patients with HIV have close monitoring of cardiovascular risk factors and blood lipids**. Appropriate treatment (e.g. statins) may be required to reduce their risk of developing cardiovascular disease.
**Yearly cervical smears** are required for women with HIV. HIV predisposes to developing human papillomavirus (HPV) infection and cervical cancer, so female patients need close monitoring to ensure early detection of these complications.
**Vaccinations** should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid live vaccines.
82
Reproductive Health
HIV advice
Advise condoms for vaginal and anal sex and dams for oral sex, even when both partners are HIV positive. If the viral load is **undetectable,** transmission through unprotected sex is unheard of, even in extensive studies, although infection is not impossible. Partners should have regular HIV tests.
Where the affected partner has an undetectable viral load, unprotected sex and pregnancy may be considered. It is also possible to conceive safely through techniques like **sperm washing and IVF.**
83
Preventing Transmission of HIV During Birth
The mother’s viral load will determine the mode of delivery:
* **Normal vaginal delivery** is recommended for women with a viral load \< 50 copies / ml
* **Caesarean section** is considered in patients with \> 50 copies copies / ml and in all women with \> 400 copies / ml
* **IV zidovudine** should be given during the caesarean if the viral load is unknown or there are \> 10000 copies / ml
**Prophylaxis treatment** may be given to the baby, depending on the mothers viral load:
* Low-risk babies, where the mother’s viral load is \< 50 copies per ml, are given zidovudine for four weeks
* High-risk babies, where the mother’s viral load is \> 50 copies / ml, are given **zidovudine, lamivudine and nevirapine** for four weeks
This description of measures to prevent vertical transmission is an over-simplified illustration of the **BHIVA guidelines**. You don’t need to know the details for your medical school exams, but it is helpful to be aware of the basic principles.
84
Breast Feeding with HIV
IS it recommended
HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable. Breastfeeding is not recommended for mothers with HIV. However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.
85
How to reduce the risk of HIV transmission
**Post-exposure prophylaxis (PEP)** can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours). The sooner it is started, the better. A risk assessment of the probability of developing HIV should be balanced against the side effects of PEP.
PEP involves a combination of **ART therapy**. The current regime is **Truvada** (emtricitabine and tenofovir) and raltegravir for 28 days.
HIV tests are done **immediately** and also a minimum of **three months** after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.
86
Syphilis is caused by bacteria called _________ \_\_\_\_\_. This bacteria is a\_\_\_\_\_\_\_\_ a type of _spiral-shaped bacteria._ The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is __ days on average.
Syphilis is caused by bacteria called **Treponema pallidum**. This bacteria is a **spirochete**, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is 21 days on average.
87
Syphilis can also be contracted through:
* Oral, vaginal or anal sex involving direct contact with an infected area
* Vertical transmission from mother to baby during pregnancy
* Intravenous drug use
* Blood transfusions and other transplants (although this is rare due to screening of blood products)
88
Stages of Syphilis
Explain primary, secondary, latent, tertiary, neurosyphilis
**Primary syphilis** involves a painless ulcer called a chancre at the original site of infection (usually on the genitals).
**Secondary syphilis** involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage.
**Latent syphilis** occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.
**Tertiary syphilis** can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.
**Neurosyphilis** occurs if the infection involves the central nervous system, presenting with neurological symptoms.
89
Primary syphilis can present with:
A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
Local lymphadenopathy
90
Secondary syphilis typically starts after the chancre has healed, with symptoms of:
* Maculopapular rash
* Condylomata lata (grey wart-like lesions around the genitals and anus)
* Low-grade fever
* Lymphadenopathy
* Alopecia (localised hair loss)
* Oral lesions
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Tertiary syphilis can present with several symptoms depending on the affected organs. Key features to be aware of are:
Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis
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Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of:
Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
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WHat is Argyll-Robertson pupil
Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
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Diagnosis of syphilis
**Antibody testing** for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.
Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing.
Samples from sites of infection can be tested to confirm the presence of **T. pallidum** with:
* Dark field microscopy
* Polymerase chain reaction (PCR)
The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests are two non-specific but sensitive tes
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Management for syphilis
All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need:
* Full screening for other STIs
* Advice about avoiding sexual activity until treated
* Contact tracing
* Prevention of future infections
A single deep intramuscular dose of **benzathine benzylpenicillin (penicillin)** is the standard treatment for syphilis.
Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. **Ceftriaxone, amoxicillin and doxycycline are alternatives.**
