Gynaecology And GUM

Question 1

Give five differential diagnoses for intermenstrual vaginal bleeding

Answer 1

Infection
Malignancy
Fibroids
Pregnancy
Hormones

Question 2

Give four diagnoses to consider for post-coital bleeding

Answer 2

Cervical ectropion
Infection
Malignancy
Atrophic vaginitis

Question 3

Give four causes of post menopausal vaginal bleeding

Answer 3

Infection
Malignancy
Atrophy
HRT

Question 4

Four things to ask about when considering vaginal discharge indicating infection.

Answer 4

Colour
Consistency
Amount
Smell

Question 5

Things to consider when taking a menstrual history.

Answer 5

Age of menarche and/or menopause
Duration of bleeding
Cyclicity (establish accuracy)
Any recent changes?
Any dysmenorrhea?
Date of last menstrual period
Use of contraception (what method currently, past methods used, future plans).

Question 6

A luteal cyst is a physiological ovarian cyst related to ovulation. How do they form?

Answer 6

When the corpus luteum has released its egg, it may become filled with blood or fluid and continue to grow. This does not disappear even if the egg is fertilised.

Question 7

How does a follicular cyst (Graaffian cyst) (physiological ovarian cyst) develop?

Answer 7

These develop during the run up to ovulation. They occur when the follicle doesn’t rupture or release it’s egg, or when a mature follicle collapses in on itself.

Question 8

How would Polycystic Ovarian Syndrome (PCOS) present on USS?

Answer 8

Greater than or equal to 12 visible cysts
Ovarian volume greater than 10ml
Ring of pearls

Question 9

Chocolate cysts are indicative of what?

Answer 9

Endometriosis/Endometrioma. Chocolate cysts are ovarian cysts that present as a result of bleeding into the cyst from ectopic endometrial tissue.

Question 10

Fibromas (sex cord stromal tumours) are the most common stromal tumour. They often present with Meig’s syndrome. What is Meig’s syndrome?

Answer 10

A triad of:

Benign ovarian tumour
Pleural effusion
Ascites

Question 11

Ovarian Cysts (teratomas) comprised of mature tissues of different lineages e.g. skin, hair follicles and sweat glands are types of what tumour group?

Answer 11

Dermoid cysts (Benign Germ Cell Tumours).

Question 12

Cystadenomas (benign epithelial tumours) can be serous, mutinous or papillary. Which of the three are most likely to be bilateral?

Answer 12

Serous cystadenoma.

Question 13

How do ovarian cysts typically present?

Answer 13

Usually - completely asymptomatic.

Bloating - early satiety and often confused with IBS
Lower abdominal pain
Back pain
Dyspareunia (mass effect)
Urinary frequency
Constipation
Rupture and torsion (Acute severe pain, fever, nausea and vomiting).

Question 14

Give the structural causes of Heavy Menstrual Bleeding.

Answer 14

PALM COINE - PALM is structural, COINE is non-structural

Polyps
Adenomyosis
Leiomyoma (fibroid)
Malignancy and hyperplasia

Coagulopathy
Ovulatory dysfunction
Iatrogenic
Not yet classified
Endometrial

Question 15

What is the most common coagulopathy to cause heavy menstrual bleeding?

Answer 15

Von Willebrand’s disease.

Suggestions of the history include HMB since menarche, history of post-partum haemorrhage, surgical related bleeding or dental related bleeding, easy bruising, epistaxis, bleeding gums, family history of bleeding disorder.

Also consider an anticoagulant use such as warfarin.

Question 16

What are the three categories for investigating an ovarian cyst when using the a Risk of Malignancy Index? (RMI)

Answer 16

USS findings (multilocular cyst, solid areas, metastasis, ascites, bilateral lesions - 1 feature = 1pt, 2+ features = 3 points).
Ca125 (measured from a blood test giving a value in units/ml).
Menopausal status (premenopausal = 1pt, postmenopausal = 3pts).

E.g. a postmenopausal (3pts) patient with a Ca125 of 100 (100 units) and bilateral lesions with solid areas (3pts) identified on USS would score 3x100x3 = 900.

Patients with an RMI greater than 250 should be referred to a specialist gynaecologist.

Question 17

1st line Investigations for ovarian cyst:

Answer 17

USS (looking for multilocular cysts, solid areas, metastases, ascites and bilateral lesions).
CT
MRI

Question 18

How would you manage an ovarian cyst in a premenopausal woman?

Answer 18

USS - if nonspecific suspicious - rescan in six weeks, if persistent then recalculate RMI and follow up with booods and biopsy.

If under 40 years, check for markers of germ cell tumours (AFP, Beta HCG, LDH).

If persistent cyst and greater than 5cm, opt for laparoscopic removal.

Question 19

How would you manage a postmenopausal woman with an ovarian cyst (depends on RMI staging)?

Answer 19

Low RMI - follow up for one year with USS and Ca125

Moderate RMI - bilateral oophorectomy - histology on specimen - if neoplastic, staving scan and surgical removal of uterus and lymphatics.

High RMI - staging laparotomy.

Question 20

Polycystic ovarian syndrome is characterised by androgen excess and multiple cystic immature follicles in the ovaries, it affects 5-10% of premenopausal women. What are the two key hormonal features of PCOS?

Answer 20

Androgen excess - this is due to excess LH which results from an increase in GnRH pulse frequency. LH stimulates the ovaries (theca cells) to produce androgens which are responsible for the presentation. The high androgens suppress the LH surge and are responsible for anovulation in PCOS

Insulin resistance - this causes hyper insulinaemia. This in turn suppresses the production of sex hormone binding globulin (SHBG) which in turn leads to more unbound androgens.

Question 21

How does PCOS typically present?

Answer 21

Oligmoenorrhoea/amenorrhoea (primary)
Infertility
Hirsutism
Acne
Obesity
Depression
Acanthosis nigricans
Chronic pelvic pain
Male pattern baldness
Hypertension

Question 22

What are the three main differential diagnoses for Polycystic ovarian syndrome?

Answer 22

Hypothyroidism - oligomenorrhoea, obesity, insulin resistance and hair loss

Hyperprolactinaemia - oligo/amenorrhoea, acne, hirsutism

Cushing’s - obesity and insulin resistance, acne, depression.

Question 23

The Rotterdam criteria are used to diagnose PCOS if two of the three criteria are met. What are the three criteria?

Answer 23

Oligo/anovulation
Clinical signs of hyper-androgenism
Cystic changes on ultrasound scan (greater than or equal to 12 cysts or greater than 10ml ovarian volume).

Question 24

Consider how the following would be affected in PCOS.

(1) testosterone
(2) sex hormone binding globulin
(3) LH
(4) FSH
(5) progesterone
(6) oestrogen
(7) glucose
(8) prolactin

Answer 24

(1) Testerone raised - hyperandrogenism (hair, acne, deeper voice, male pattern baldness etc).
(2) SHBG low - hence more free androgens
(3) LH raised
(4) FSH normal
(5) progesterone usually low
(6) oestrogen usually high
(7) glucose high (insulin resistance)
(8) prolactin - can be slightly high but usually normal

Question 25

How would you go about managing PCOS? Consider the following: (1) Obesity (2) Hyperglycaemia and insulin resistance (3) Anovulation (4) Hirsutism (5) Menses

Answer 25

(1) Obesity - Seek to achieve a BMI or less than 30 (ideally 17-25). Consider orlistat. (2) Insulin resistance - Metformin (3) Anovulation - Clomiphene citrate induces regular ovulation but can overstimulate the ovaries (OHSS) and increase risk of multiple pregnancies. OHSS presents with enlarged ovaries on USS, abdominal pain, nausea and vomiting, ascites, oliguria, pleural effusion, respiratory distress. Metformin also helps. It is recommended for women trying to conceive who have a BMI > 25. It improves insulin sensitivity as well as helping with menstrual disturbance and ovulatory function. Prevention of endometrial hyperplasia - anovulation leaves the endometrium with unopposed oestrogen exposure. There is a need to overcome this by inducing a minimum of three periods a year. This can be done with low dose COCP, or progesterone analogue (dydrogesterone). (4) Hirsutism - Anti-androgens (cyproterone) as used in CaProstate hormonal therapy. Teratogenic in pregnancy. (5) Menses - COCP - can be used to provide menstruation and decrease the risk of endometrial cancer, aim for three or more periods a year.

Question 26

Define primary and secondary dysmenorrhoea.

Answer 26

Dysmenorrhoea (painful periods) is the most common of all gynaecological symptoms. It is generally described as a crappy lower abdominal pain, which starts at the onset of menstruation. Primary - menstrual pain with no underlying pelvic pathology. Secondary - menstrual pain that occurs with an associated pelvic pathology.

Question 27

Explain the pathophysiology behind dysmenorrhoea.

Answer 27

In the absence of fertilisation of the egg, the corpus luteum regresses and there is a subsequent decline in oestrogen and progesterone production. The endometrial cells are sensitive to this decline in progesterone and respond with prostaglandin release. These prostaglandins have two main actions within the uterus. (1) Spiral artery vasospasm - this leads to ischaemic necrosis and shedding of the superficial layer of the endometrium. (2) Increased myometrial contractions. Primary dysmenorrhoea is thought to occur secondary to the excessive release of prostaglandins (PGF2 and PGE2) by endometrial cells.

Question 28

What are the main risk factors for dysmenorrhoea?

Answer 28

``` Early menarche Long menstrual phase Heavy periods Smoking Nulliparity ```

Question 29

Primary dysmenorrhoea is a diagnosis of exclusion and thus other diagnoses to consider are the main causes of secondary dysmenorrhoea. What are these differentials?

Answer 29

Endometriosis (functional endometrial tissue outside of the uterus - usually on ovaries, Fallopian tubes or tissues surrounding the uterus). Adenomyosis (abnormal presence of endometrial tissue within the myometrium). Pelvic Inflammatory a Disease (infection of the uterus, Fallopian tubes, ovaries and inside of the pelvis caused by bacteria that spread from the vagina and cervix). Risk factors include chlamydia and gonorrhoea infection. Adhesions Non gynaecological differentials such as IBS and inflammatory bowel disease.

Question 30

How would you investigate dysmenorrhoea?

Answer 30

There are no specific investigations. Work up is ruled out on ruling out underlying pathology. If the patient is at high risk of an STI, high vaginal swab and endocervical swabs are indicated to screen for underlying infection. If on examination, a pelvic mass is palpated, a transvaginal ultrasound scan should be performed.

Question 31

Management of Dysmenorrhoea As there is no pathology to treat in primary dysmenorrhoea, the aim is symptomatic relief. This can be achieved via lifestyle changes, pharmacological therapy and non pharmacological measures. Consider some of these treatments.

Answer 31

Lifestyle - smoking cessation (there is a clear relationship between smoking and dysmenorrhoea). Pharmacological - 1st line is analgesia - NSAIDs (ibuprofen, naproxen, mefanamic acid). They work by inhibiting the production of prostaglandins which have been implicated in the pathogen rise of primary dysmenorrhoea. (And/Or a Paracetamol). 2nd line - 3 to 6 month trial of hormonal contraception. Monophasic COCP is most commonly used first line, intrauterine system such as the mirena coil may also be effective. Non-pharmacological - local application of heat (hot water bottle or patch). TENS (Transcutaneous electrical nerve stimulation).

Question 32

The mainstay in management of Pelvic Inflammatory Disease is antibiotic therapy. Treatment is a 14 day course of broad spectrum antibiotics with good anaerobic coverage. This should be commenced immediately, before swabs are available. What antibiotic options are available?

Answer 32

(1) Doxycycline, Ceftriaxone, Metronidazole (2) Ofloxacin and Metronidazole Analgesics such as paracetamol should also be considered in treatment and the patient should be advised to rest and avoid sexual intercourse until the course of antibiotics is complete and all partners are treated.

Question 33

What situations should a woman presenting with PID be admitted to hospital?

Answer 33

If pregnant, especially if there is risk of ectopic pregnancy. Severe symptoms such as nausea, vomiting, high fever Signs of pelvic peritonitis Unresponsive to oral antibiotics and need for IV therapy Need for emergency surgery or suspicion of alternative diagnosis

Question 34

Delaying treatment of Pelvic Inflammatory Disease or having repeated episodes of PID can lead to serious and long term complications. What are these?

Answer 34

Ectopic pregnancy (resulting from the scarring and narrowing of the Fallopian tubes). Infertility (10% of women with PID) Tubo-ovarian abscess Chronic pelvic pain Fitz-Hugh Curtis syndrome (perihepatitis that typically causes RUQ pain and adhesions).

Question 35

A complication of untreated or recurrent pelvic inflammatory disease is Fitz-Hugh Curtis syndrome. What is this?

Answer 35

Perihepatitis that results in RUQ pain and adhesions.

Question 36

What are the first line investigations for suspected pelvic inflammatory disease?

Answer 36

Endocervical swabs to test for chlamydia and gonorrhoea as well as high vaginal swabs to test for trichomonas vagina lies and bacterial vaginosis. In the UK, testing is by nucleic acid amplification (NAAT). Further investigations include: - Full STI screen - HIV, Syphilis, Gonorrhoea and Chlamydia as a minimum should be offered to all women with PID. - Urine dipstick +/- MSU - rule out UTI - Pregnancy test - rule out pregnancy - Transvaginal ultrasound - if there is severe disease or diagnostic uncertainty - Laparoscopy - used to observe gross inflammatory changes and to obtain a peritoneal biopsy. This is indicated only in severe cases where there is diagnostic uncertainty.

Question 37

What are the main differential diagnoses for pelvic inflammatory disease?

Answer 37

``` Ectopic pregnancy (pregnancy test is mandatory to exclude this). Ruptured ovarian cyst Endometriosis UTI ```

Question 38

What are the clinical features of pelvic inflammatory disease?

Answer 38

Lower abdominal pain Dyspareunia (painful sexual intercouse) Menstrual abnormalities (menorrhagia, dysmenorrhoea or intermenstrual bleeding) Post-coital bleeding Dysuria (painful urination) Abnormal vagina discharge (especially if purulent or with unpleasant odour). In advanced cases, women can experience severe lower abdominal pain , (fever >38C) and nausea + vomiting. On vaginal examination there may be tenderness of the uterus and adnexae or cervical excitation on bimanual palpation. There may be a palpable mass in the lower abdomen with an abnormal vaginal discharge noted.

Question 39

Pelvic inflammatory disease refers to an infective inflammation of the uterus, endometrium, Fallopian tubes, ovaries and peritoneum, it is caused by the spread of bacterial infection from the vagina or cervix to the upper genital tract. What are the main risk factors for pelvic inflammatory disease?

Answer 39

``` Sexually active Aged 15-24 Recent change in sexual partner Intercourse without barrier contraception History of STI Personal history of PID ``` PID can also occur via instrumentation if the cervix (inadvertently introducing bacteria into the female reproductive tract). Procedures include gynaecological surgery, termination of pregnancy or insertion of an intrauterine contraceptive device.

Question 40

What organisms are the main culprits responsible for Pelvic inflammatory disease?

Answer 40

Chlamydia trachomatis Neisseria gonorrhoea Also implicated are: Streptococcus Bacteriodes Anaerobes

Question 41

The mainstay in management of Pelvic Inflammatory Disease is antibiotic therapy. Treatment is a 14 day course of broad spectrum antibiotics with good anaerobic coverage. This should be commenced immediately, before swabs are available. What antibiotic options are available?

Answer 41

(1) Doxycycline, Ceftriaxone, Metronidazole (2) Ofloxacin and Metronidazole Analgesics such as paracetamol should also be considered in treatment and the patient should be advised to rest and avoid sexual intercourse until the course of antibiotics is complete and all partners are treated.

Question 42

What situations should a woman presenting with PID be admitted to hospital?

Answer 42

If pregnant, especially if there is risk of ectopic pregnancy. Severe symptoms such as nausea, vomiting, high fever Signs of pelvic peritonitis Unresponsive to oral antibiotics and need for IV therapy Need for emergency surgery or suspicion of alternative diagnosis

Question 43

Delaying treatment of Pelvic Inflammatory Disease or having repeated episodes of PID can lead to serious and long term complications. What are these?

Answer 43

Ectopic pregnancy (resulting from the scarring and narrowing of the Fallopian tubes). Infertility (10% of women with PID) Tubo-ovarian abscess Chronic pelvic pain Fitz-Hugh Curtis syndrome (perihepatitis that typically causes RUQ pain and adhesions).

Question 44

A complication of untreated or recurrent pelvic inflammatory disease is Fitz-Hugh Curtis syndrome. What is this?

Answer 44

Perihepatitis that results in RUQ pain and adhesions.

Question 45

What are the first line investigations for suspected pelvic inflammatory disease?

Answer 45

Endocervical swabs to test for chlamydia and gonorrhoea as well as high vaginal swabs to test for trichomonas vagina lies and bacterial vaginosis. In the UK, testing is by nucleic acid amplification (NAAT). Further investigations include: - Full STI screen - HIV, Syphilis, Gonorrhoea and Chlamydia as a minimum should be offered to all women with PID. - Urine dipstick +/- MSU - rule out UTI - Pregnancy test - rule out pregnancy - Transvaginal ultrasound - if there is severe disease or diagnostic uncertainty - Laparoscopy - used to observe gross inflammatory changes and to obtain a peritoneal biopsy. This is indicated only in severe cases where there is diagnostic uncertainty.

Question 46

What are the main differential diagnoses for pelvic inflammatory disease?

Answer 46

``` Ectopic pregnancy (pregnancy test is mandatory to exclude this). Ruptured ovarian cyst Endometriosis UTI ```

Question 47

What are the clinical features of pelvic inflammatory disease?

Answer 47

Lower abdominal pain Dyspareunia (painful sexual intercouse) Menstrual abnormalities (menorrhagia, dysmenorrhoea or intermenstrual bleeding) Post-coital bleeding Dysuria (painful urination) Abnormal vagina discharge (especially if purulent or with unpleasant odour). In advanced cases, women can experience severe lower abdominal pain , (fever >38C) and nausea + vomiting. On vaginal examination there may be tenderness of the uterus and adnexae or cervical excitation on bimanual palpation. There may be a palpable mass in the lower abdomen with an abnormal vaginal discharge noted.

Question 48

Pelvic inflammatory disease refers to an infective inflammation of the uterus, endometrium, Fallopian tubes, ovaries and peritoneum, it is caused by the spread of bacterial infection from the vagina or cervix to the upper genital tract. What are the main risk factors for pelvic inflammatory disease?

Answer 48

``` Sexually active Aged 15-24 Recent change in sexual partner Intercourse without barrier contraception History of STI Personal history of PID ``` PID can also occur via instrumentation if the cervix (inadvertently introducing bacteria into the female reproductive tract). Procedures include gynaecological surgery, termination of pregnancy or insertion of an intrauterine contraceptive device.

Question 49

What organisms are the main culprits responsible for Pelvic inflammatory disease?

Answer 49

Chlamydia trachomatis Neisseria gonorrhoea Also implicated are: Streptococcus Bacteriodes Anaerobes

Question 50

What type of bacterium is Chlamydia trachomatis?

Answer 50

Obligate intracellular gram negative with three different serotypes. Serotypes A-C cause ocular infection Serotypes D-K cause classic genitourinary infection Serotypes L1-L3 cause lymphogranuloma venereum (LGV) - an emerging infection in men who have sex with men, often resulting in proctitis.

Question 51

Risk factors for chlamydia infection.

Answer 51

``` Aged under 25 Sexual partner positive for chlamydia Recent change in sexual partner Co-infection with another STI Non-barrier contraception or lack of consistent use of barrier contraception. ```

Question 52

Symptoms of Chlamydia

Answer 52

Women ``` Dysuria Abnormal vagina discharge Intermenstrual or postcoital bleeding Deep dyspareunia Lower abdominal pain ``` Men Urethritis - dysuria and urethral discharge Epididymo-orchitis - testicular pain In addition to the genutourinary features, Chlamydia can also affect the conjunctivae of the eye leading to irritation (chlamydial conjunctivitis), the rectum (discomfort and discharge) and the pharynx (often asymptomatic).

Question 53

Signs of chlamydial infection on examination

Answer 53

Men Epididymal tenderness Mucopurulent discharge Women Cervicitis +/- contact bleeding Mucopurulent endocervical discharge Pelvic tenderness Cervical excitation

Question 54

Differential diagnoses for chlamydia?

Answer 54

A full STI screen should be undertaken for a patient presenting with chlamydia due to the common presenting symptoms of various STIs (in particular as it is clinically difficult to differentiate between gonorrhoea and chlamydia so many NAATs offer dual testing for both diseases). Treatment for gonorrhoea covers both Neisseria gonorrhoea and Chlamydia trachomatis

Question 55

Investigations if chlamydial infection is suspected

Answer 55

Chlamydia testing (nucleic acid amplification testing - NAAT). Women - vulvovaginal swab (1st choice) or first catch urine sample or endocervical swab. Men - first catch urine sample (1st choice) or urethral swab. If indicated, swabs may also need to be taken from the rectum, eyes and throat. If positive, contact tracing is necessary so that patient’s current sexual partner(s) and recent partners can be tested and treated. Patients are recommended to have a full STI screen due to the possibility of co-infection and the similar nature of signs and symptoms.

Question 56

Antibiotic treatment is recommended for uncomplicated Jorge it all chlamydial infection. What agents are used?

Answer 56

Doxycycline (100mg BD for 7 days) OR Azithromycin 1g single dose Or alternatively when doxycycline and azithromycin are contraindicated Erythromycin 500mg BD for 10-14 days Ofloxacin 200mg BD or 400mg OD for 7 days Patients are also advised to avoid sexual intercourse and oral sexual until they and/or their partner have completed treatment (or 7 days following azithromycin). Test of cure is not usually required unless the patient is pregnant, compliance was poor or symptoms persist.

Question 57

Complications of chlamydia

Answer 57

Both: Chlamydia can result in sexually acquired reactive arthritis where the joints/eyes/urethra become inflamed. This is more common in men. Men: epididymitis or epididymo-orchitis causing the testes to become painful and swollen. If left untreated this can affect fertility. Women: salpingitis and/or endometritis which can result in PID. PID can lead to perihepatitis (fitz-Hugh Curtis), ectopic pregnancy and may ultimately result in infertility.

Question 58

What type of organism is Neisseria gonorrhoea?

Answer 58

Gram negative diplococcus It has a strong affinity for mucus membranes and can affect the uterus, urethra, cervix, Fallopian tubes, ovaries, testicles, rectum, throat and less commonly the eyes.

Question 59

Risk factors for gonorrhoea?

Answer 59

Common to other STIs ``` Aged under 25 years Men who have sex with men Living in high density urban areas Previous gonorrhoea infection Multiple sexual partners ```

Question 60

Symptoms of gonorrhoea?

Answer 60

Women Altered/increased vaginal discharge (commonly thin, watery green or yellow). Dysuria Dyspareunia Lower abdominal pain Rarely - intermenstrual and/or postcoital bleeding Men Mucopurulent/purulent urethral discharge Dysuria

Question 61

Signs of gonorrhoea?

Answer 61

Women Mucopurulent endocervical discharge Easily induced cervical bleeding Pelvic tenderness Often examination can be normal. Men Mucopurulent/purulent urethral discharge Epididymal tenderness Also Anal signs - usually asymptomatic but can be anal discharge, pain and discomfort Pharyngeal infection usually asymptomatic

Question 62

Investigations for suspected gonorrhoeal infection?

Answer 62

Females Endocervical/vaginal swab - NAAT Endocervical/urethral swab - microscopy and culture Male First pass urine - NAAT Urethral/meatal swab - microscopy and culture

Question 63

Management of gonorrhoea?

Answer 63

Single dose IM injection of 1g ceftriaxone Screening for other STIs should be offered Encourage future safe sex and patients should abstain until both partners have completed treatment. To ensure antibiotics have successfully treated a patient, a test of cure is recommended during a follow-up appointment.

Question 64

Complications of gonorrhoea?

Answer 64

Women Can lead to PID - chronic pain, infertility, ectopic pregnancy. Men Spread from urethra to testes - epididymal-orchitis (painful but rarely leads to infertility). Can also lead to prostatitis. Disseminated gonococcal infection is uncommon but can lead to joint pain and skin lesions.

Question 65

When should a patient with gonorrhoeal infection be admitted to hospital?

Answer 65

Systemic symptoms are present - malaise, fever, rash, joint pain. This suggests disseminated gonorrhoea which can potentially develop into a life-threatening infection such as gonorrhoeal meningitis. Females who show signs of complicated or severe PID.

Question 66

Discuss gonorrhoea in pregnancy.

Answer 66

Having gonorrhoea during pregnancy may be associated with complications such as perinatal mortality, spontaneous abortion, premature labour and early foetal membrane rupture. Gonorrhoea can be vertically transmitted during delivery from an untreated mother and this can cause the neonate time have gonococcal conjunctivitis. Here the neonate will experience eye pain, redness and discharge. Prophylactic antibiotics can prevent this and treatment is the same as for uncomplicated gonorrhoea (1g IM Ceftriaxone injection). For the infected neonate, urgent referral and appropriate treatment is necessary to prevent long term damage and blindness.

Question 67

Drug of choice for treatment of vaginal thrush (Candida albicans)

Answer 67

Clotrimazole pessary and clotrimazole cream Itraconazole If recurrent - Fluconazole

Question 68

Treatment of bacterial vaginosis

Answer 68

Metronidazole 400mg BD for 5 days