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Gynaecology > Infections/ GUM > Flashcards

Infections/ GUM Flashcards

1
Q

Barriers to sexual history

A 
embarrassment
misunderstanding language
fear of judgement or stigmatisation
lack of privacy
time pressure
difficulty understanding patients ICE
third party
gender
age/ capacity
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2
Q

potential concerns of patient in GUM clinic

A 
judgement
examination
confidentiality
infection, cure to infection
society
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3
Q

6Cs of sexual history

A 
contraception
cycle: periods, LMP, IMB/PCB
children
cervical smear
chlamydia
hep C/B
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4
Q

Females/ trans males symptoms

A 
Vaginal discharge 
Vulval skin problems 
Genital lumps/ ulcers 
Intermenstrual bleeding and post-coital bleeding 
Deep and superficial dyspareunia  
Dysuria and urinary frequency 
Abdominal pain  
STI contact/ sexual assaults/ contraception/ TOP/ sexual dysfunction 
Rectal symptoms 
Asymptomatic screens
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5
Q

Males/ trans females symptoms

A 
Urethral discharge 
Dysuria and urinary frequency 
Genital lumps/ ulcers 
Testicular pain/ swelling 
Rectal symptoms 
Sexual dysfunction and assaults 
Asymptomatic screens
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6
Q

Investigations for symptomatic males

A 
urethral smear
first pass urine
bloods HIV/ syphilis +/- Hep B/C
MSM: rectal/pharyngeal swabs
urine dip
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6
Q

Investigations for asymptomatic males

A

first pass urine
bloods HIV/ syphilis +/- Hep B/C
MSM: rectal and pharyngeal swabs

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7
Q

symptomatic females investigations

A

high vaginal loop swab for microscopy and pH testing
vulvovaginal swab ‘dual NAAT’
bloods- HIV/syph +/- Hep B/C

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8
Q

asymptomatic female investigations

A

self-taken vulvo-vaginal swab ‘dual NAAT’
serology: STI/ HIV
urinalysis/ pregnancy test

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9
Q

HPV types causing genital warts

A

6 and 11

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10
Q

Investigations for genital warts

A

external genital warts: speculum
internal genital warts: colposcopy
anal warts and rectal bleeding: proctoscopy

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11
Q

management of HPV

A

topical podophyllum and cryotherapy
imiquimod second line
majority clear without intervention within 1-2 years

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12
Q

non-specific urethritis features

A

Urethral discharge, dysuria, penile irritation

Diagnosed through gram stain and microscopy of urethral sample:

> 5 polymorphonuclear leucocytes per high power field

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13
Q

management of non-specific urethritis

A

Mx: STI screen, 1 week doxycycline

Inflammation of urethra in absence of diagnosis of chlamydia or gonorrhea

Recurrent diseases requires GUM input

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14
Q

bacterial vaginosis triggers

A 
Sex 
Menses 
Receptor oral SI 
Vaginal douching 
Perfumed bath products 
Change in sexual partners 
Presence of STI
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15
Q

anaerobic bacteria associated with BV

A

Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species

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16
Q

risk factors for BV

A

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

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17
Q

presentation of BV

A

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.

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18
Q

BV investigations

A

vaginal pH: swab and pH paper >4.5
charcoal vaginal swab for microscopy
clue cells on microscopy
hay-ison criteria and amsel criteria

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19
Q

BV management

A

asymptomatic resolves without treatment
metronidazole 400mg BD 5days
clindamycin alt as metronidazole makes breast milk bitter

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20
Q

complications in pregnant women BV

A 
Miscarriage 
Preterm delivery 
Premature rupture of membranes 
Chorioamnionitis 
Low birth weight 
Postpartum endometritis
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21
Q

Risk factors for vaginal candidiasis

A

increased oestrogen
poorly controlled diabetes/ immunosuppression
broad spectrum antibiotics
mucosal breakdown: sexual contact, dermatitis
recurrent candidiasis associated with atopy

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22
Q

presentation of candidiasis

A

Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
Cottage-cheese
Vulval erythema +/- fissures, pH 4

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23
Q

severe candida infection

A

Erythema

Fissures

Oedema

Pain during sex (dyspareunia)

Dysuria

Excoriation

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24
Q

Investigations in candidiasis

A

pH <4.5 (BV TV >4.5)
high vaginal swab
microscopy: spres, pseudohyphase plus neutrophils
culture may grow candida but doesn’t distinguish colonisation

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25
Q

Management options for candida

A 
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator: 
BD for 2 weeks

Antifungal pessary:
Clotrimazole 500mg

Oral antifungal tablets:
Fluconazole 150mg PO STAT
Avoid in pregnancy/ breast feeding

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26
Q

recurrent candida mx

A

> 4/yr
6 month regime
Fluconazole 150mg every 72 hours for 3 doses
Fluconazole 150mg once a week for 6 months
Clotrimazole pessaries if fluconazole contraindicated

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27
Q

canesten duo

A

single fluconazole tablet

clotrimazole cream externally for vulval symptoms

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28
Q

what is the most common STI in the UK?

A

chlamydia trachomatis

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29
Q

chlamydia trachomatis

A

gram-negative bacteria

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30
Q

national chlamydia screening programme

A

screen sexually active
<25 years old
re-test after 3 months if positive

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31
Q

which STIs are patients tested for in a GUM clinic?

A

chlamydia
gonorrhea
syphilis
HIV

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32
Q

charcoal swabs can confirm which infections

A 
bacterial vaginosis
candidiasis
gonorrhea (endocervical)
trichomonas vaginalis (posterior fornix swab)
GBS
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33
Q

chlamydia presentation in women

A 
asymptomatic in majority
abnormal discharge
pelvic pain
abnormal vaginal bleeding (IMB, PCB)
painful sex
painful urination
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34
Q

chlamydia in men presentation

A 
urethral discharge or discomfort
painful urination (dysuria)
sexually active
epididymo=orchitis
reactive arthritis
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35
Q

extra-genital symptoms chlamydia

A

conjunctivitis
pharyngitis
SA reactive arthritis
proctitis

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36
Q

first line management for chlamydia

A

doxycycline 100mg BD 7 days

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37
Q

chylamydia pregnancy mx

A

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

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38
Q

advice after chlamydia diagnosis

A

Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection

Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners

Test for and treat any other sexually transmitted infections

Provide advice about ways to prevent future infection

Consider safeguarding issues and sexual abuse in children and young people

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39
Q

complications of chlamydia

A 
Pelvic inflammatory disease 
Chronic pelvic pain 
Infertility 
Ectopic pregnancy 
Epididymo-orchitis 
Conjunctivitis 
Lymphogranuloma venereum 
Reactive arthritis
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40
Q

pregnancy-related complications of chlamydia

A

Preterm delivery

Premature rupture of membranes

Low birth weight

Postpartum endometritis

Neonatal infection (conjunctivitis and pneumonia)

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41
Q

lymphogranuloma venereum

A

MSM

condition affecting lymphoid tissue around site of infection with chlamydia

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42
Q

lymphogranuloma venereum

A

MSM

condition affecting lymphoid tissue around site of infection with chlamydia

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43
Q

lymphogranuloma venerum

primary stage

A

painless ulcer

penis, vaginal wall, rectum (anal sex)

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44
Q

lymphogranuloma venerum

secondary stage

A

lymphadenitis
swelling, inflammation, pain in lymph nodes
infected with the bacteria

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45
Q

lymphogranuloma venerum

tertiary stage

A

proctitis: anal pain, change in bowel habit, tenesmus, discharge

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46
Q

management of lymphogranuloma venerum

A

doxycycline 100mg BD for 21 days

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47
Q

presentation of gonorrhea in females

A

50% symptomatic
odourless purulent discharge, green or yellow
dysuria
pelvic pain

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48
Q

male gonorrhea presentation

A

symptomatic 90%
Odourless purulent discharge, possibly green or yellow

Dysuria

Testicular pain or swelling (epididymo-orchitis)

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49
Q

gonorrhea investigations

A

NAAT to detect RNA/DNA

charcoal swab for antibiotic choice: microscopy, sensitivity, culture

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50
Q

uncomplicated gonococcal infection mx

A

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known

A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

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51
Q

test of cure post gonorrhea treatment

A

72 hours after treatment for culture

7 days after treatment for RNA NAAT14 days after treatment for DNA NAAT

52
Q

complications of gonorrhea

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

53
Q

features of disseminated gonococcal infection

A

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

54
Q

mycoplasma genitalium bug

A

gram positive

flask-shaped, slightly curved organelle

55
Q

mycoplasma genitalium infection

A

urethritis
epididymitis
mucopurulent cervicitis
Endometritis

Pelvic inflammatory disease

Reactive arthritis

Preterm delivery in pregnancy

Tubal infertility

NGU

Sexual partners of persons MG +ve (3 months)

56
Q

management of mycoplasma genitalium

A

doxycycline 100mg BD 7 days then

azithromycin 1g stat then 500mg OD 2 days

57
Q

PID organs involved

A 
endometritis
salpingitis
oophoritis
parametritis
peritonitis
cervicisits
58
Q

PID organisms

A

STi:
Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium

Non-STI PID:
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)
Vaginal flora introduced by surgery, IUD insertiion
Anaerobes: prevotella, atopobium, leptotrichia

59
Q

salpingitis features

A

erythema, oedema, exudate
low bilateral abdominal pain
adnexal swelling, tenderness

60
Q

endometritis features

A

menstrual irregularity

midline abdominal pain

61
Q

cervicitis features

A

vaginal discharge
inflammation
tenderness

62
Q

risk factors for PID

A

Not using barrier contraception

Multiple sexual partners

Younger age, <25

New sexual partner

TOP/ miscarriage

Instrumentation of uterus

Coil insertion

Low socioeconomic status

Low educational attainment

Existing sexually transmitted infections

Previous pelvic inflammatory disease

Intrauterine device (e.g. copper coil)

Appendicitis

History of multiple partners

63
Q

PID symptoms

A

Pelvic

64
Q

PID examination

A

Pelvic tenderness

Cervical motion tenderness (cervical excitation)

Inflamed cervix (cervicitis)

Purulent discharge

Lower abdominal tenderness, usually bilateral

Uterine/ adnexal tenderness

Adnexal mass

Muco-purulent vaginal discharge

Contact bleeding/ cervicitis

Fever >38degrees

Tenderness in RUQ

65
Q

DD PID

A

Gynaecological:
Ectopic pregnancy
Ovarian cyst (torsion, rupture, haemorrhage)
Endometriosis

Urinary tract infections:
Cystitis

GI tract:
Inflammatory bowel
Appendicitis
Irritable bowel

66
Q

PID ix

A

NAAT: gonorrhea, mycoplasma genitalia, chlamydia
HIV, syphilis
high vaginal swab: BV, cadidiasis, trichomoniasis
endocervical/ vaginal swabs: gonorrhea, chlamydia, trichomonas vaginalis, mycoplasma genitalia
pregnancy test
urine dipstick
CRP/ ESR/ WCC
transvaginal USS
laparoscopy

67
Q

PID management

A

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)

68
Q

PID: sepsis or pregnanct

A

admission to hospital for IV ax
IV ceftriaxone and doxycycline, then oral metronidazole and oral doxycycline

IV for 24 hours after clinical improvement

69
Q

PID abscess

A

Review after 72 hours:
IV therapy if no/ minimal improvement
Remove IUC if in-situ

Review in 2-4 weeks:
Ensure symptoms resolved
Check compliance with antibiotics
Follow-up contacts; have they been screened and treated

70
Q

complications of PID

A

Sepsis

Infertility

Chronic pelvic pain

Ectopic pregnancy

Fitz-Hugh-Curtis syndrome

Tubo-ovarian abscess

71
Q

Fitx-Hugh-Curtis syndrome

A

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.

72
Q

syphilis incubation period

A

21 days

73
Q

primary syphilis presentation

A

chancre
resolves over 3-8 weeks
local lymphadenopathy

74
Q

secondary syphilis presentation

A

Maculopapular rash

Condylomata lata (grey wart-like lesions around the genitals and anus)

Low-grade fever

Lymphadenopathy

Alopecia (localised hair loss)

Oral lesions: snail track mucous lesions

75
Q

tertiary syphilis presentation

A

Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)

Aortic aneurysms

Neurosyphilis

76
Q

neurosyphilis features

A

Headache

Altered behaviour

Dementia

Tabes dorsalis (demyelination affecting the spinal cord posterior columns)

Ocular syphilis (affecting the eyes)

Paralysis

Sensory impairment

77
Q

diagnosis of syphilis

A

Treponemal enzyme immunoassay
Treponema pallidum particular agglutination assay
Rapid plasma reagin test
GUM referral
samples from sites: dark field microscopy, PCR

78
Q

management of syphilis

A

Full screening for other STIs

Advice about avoiding sexual activity until treated

Contact tracing

Prevention of future infections

IM benzathine benzylpenicillin
1 dose weekly for early latent, primary and secondary
3 doses weekly for late latent, cardiovascular and gummatous

79
Q

what can trichomoniasis increase risk of?

A

Contracting HIV by damaging the vaginal mucosa

Bacterial vaginosis

Cervical cancer

Pelvic inflammatory disease

Pregnancy-related complications such as preterm delivery.

80
Q

trichomoniasis presentation

A

Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:

Vaginal discharge : frothy and yellow-green

Itching

Dysuria (painful urination)

Dyspareunia (painful sex)

Balanitis (inflammation to the glans penis)

Vulval soreness/ itching: vulvitis, vaginitis

strawberry cervix: colpitis macularis, cervicitis

vaginal ph>4.5

Non specific urethritis in men

81
Q

diagnosis of trichomonas vaginalis

A

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.

Wet mount

A urethral swab or first-catch urine is used in men.

Urethral culture or culture FVU in men

82
Q

trichomonas management

A

Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.

Treatment is with metronidazole:

Metronidazole 400mg PO BD 7 days

Metronidazole 2g PO stat

Treat male partners empirically

Partner notification:

Treat male partner empirically

Abstain from sex

Signpost to ‘sexwise’ website

83
Q

trichomonas complications

A

Pre-term delivery

Low birth weight

Enhanced HIV transmission

84
Q

4 stages of genital herpes

A

Red papules

Blisters

Painful popping of blisters

Crust over and heal

85
Q

signs/symptoms of genital herpes

A

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

First infection bilateral, recurrence unilateral

Necritising on cervix

86
Q

how long do syptoms last in primary herpes infection

A

3 weeks

87
Q

diagnosis of genital herpes

A

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.

Full STI screen

Syphilis serology

HIV antibody test

88
Q

HSV1

A

Orofacial

Up to 80% seropositivity

0-1 recurrences per year

Recurrences after year 1 unusual

89
Q

HSV2

A

Genital

7% seropositivity

4 recurrences per year

90
Q

management of genital herpes

A

aciclovir
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

91
Q

primary genital herpes mx

<28 weeks gestation

A

aciclovir during initial infection
regular prophylactic aciclovir after 36 weeks gestation
vaginal delivery if asymptomatic at delivery and >6 weeks since initial infection

92
Q

primary genital herpes mx

>28 weeks gestation

A

aciclovir during infection
regular prophylactic aciclovir immediately afer
c section

93
Q

HpV immunisation

A

Introduced in 2008

Protects against subtypes 6,11,16,18

12-13 year old girls

Reepat dose at 6-12months after 1st

MSM <45 eligible if attending SHS/HIV services since 2018

94
Q

complications of genital herpes

A

Urinary retention

Adhesions

Meningism

Emotional distress

Recurrences

95
Q

HIV spread

A

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

96
Q

Examples of AIDS-defining illnesses

A

Kaposi’s sarcoma

Pneumocystis jirovecii pneumonia (PCP)

Cytomegalovirus infection

Candidiasis (oesophageal or bronchial)

Lymphomas

Tuberculosis

Cryptococcal meningitis

97
Q

Screening for HIV

A

Can take up to 3 months for antibodies to develop to infection
repeat testing is needed
verbal consent needed

98
Q

Risk factors for someone undergoing testing:

A

High HIV prevalence coutry

Blood transfusion, or other risk-prone procedures in countries who don’t have strong screening for HIV

Paid for sex or been paid for sex

Rape/ sexual assault by those from above

Babies with mothers who have untreated HIV

MSM: bleeding during anal sex

99
Q

Indications for HIV testing

A

MSM/ transgender

Female sexual contacts of MSM/ tansgender

Black african

Injecting drug use

STI diagnosis

Sex workers

HIV positive sexual partners

HIV infection entering differential diagnosis:

Recurrent or severe shingles

Recurrent bacterial pneumonia

100
Q

How often should indicated patients be tested for HIV

A

Every 3 months for MSM

101
Q

Annual HIV test indications

A

Heterosexuals who have changed sexual partners

IVDU

Sex worker

Black african men and women having UPSI with new or casual partners

102
Q

Types of HIV tests

A

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.

Window period 45 days

103
Q

CD4 count in HIV

A

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

How immunosuppressed they area

Indication of how advanced the disease is

104
Q

viral load HIV

A

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.

105
Q

prevention of HIV

A

Safe sex, condom use

Screening and regular testing

Treatment as prevention

U=U, undetectable = untransmissable

Post-exposure prophylaxis

Pre-exposure prophylaxis

106
Q

HAART HIV medication

A

Protease inhibitors (PIs):
Always co-prescribed with a booster
Darunavir plus ritonovir

Integrase inhibitors (IIs): 
Raltegavir, dolutegravir, bictegravir

Nucleoside reverse transcriptase inhibitors (NRTIs):
Tenofovir, abacavir, emtricitabine, lamivudine
Backbone

Non-nucleoside reverse transcriptase inhibitors (NNRTIs): 
Efavirenz, doravarine  
Entry inhibitors (EIs)
107
Q

additional management of HIV

A

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.

108
Q

Preventing HIV transmission during birth

A

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

109
Q

Prophylaxis for baby with HIV positive mother

A

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

110
Q

Breast feeding HIV

A

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 a

111
Q

Post-exposure prophylaxis

A

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.

112
Q

Pre-exposure prophylaxis

A

High risk patients eligible

Truvada either daily or event-based

Reduces risk of acquisition of HIV by at least 86% but likely much more

Doesn’t protect against other STIs/ BBI

113
Q

HepC disease course

A

1 in 4 fights off the virus and makes a full recovery

3 in 4 it becomes chronic

Complications: liver cirrhosis and associated complications and hepatocellular carcinoma

114
Q

management of hepC

A

Have a low threshold for screening patients that are at risk of hepatitis C

Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases

Refer to gastroenterology, hepatology or infectious diseases for specialist management

Notify Public Health (it is a notifiable disease)

Stop smoking and alcohol

Education about reducing transmission and informing potential at risk contacts

Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma

Antiviral treatment with direct acting antivirals (DAAs) is tailored to the specific viral genotype. They successfully cure the infection in over 90% of patients. They are typically taken for 8 to 12 weeks

Liver transplantation for end-stage liver disease

115
Q

HepC transmission

A

Parenteral:
Needle stick
Transfusion
Haemodialysis

Vertical Transmission
Hepatitis C is passed from infected mothers to their babies about 5 – 15% of the time. Hepatitis C antivirals are not recommended in pregnancy and there are no additional measures that are known to reduce the risk of transmission.
Babies and children tend not to have any symptoms or pathology associated with hepatitis C infection. It is very unlikely that children will pass on hepatitis C to others as they do not engage in sexual activity or IV drug use. Parents should be educated about hepatitis C and the modes of transmission.

Sexual transmission very low risk:
Higher risk if HIV co-infected
MSM

116
Q

Prevention of hepC

A

Risk modification

No immunoglobulin

No PEP

No vaccine

Testing can reduce the risk of transmission to others- early identification -> RF modification and treatment

No intervention that reduces MTCT:

Consider HepB vaccine for baby

117
Q

advice for hepC patients

A

HepC curable

Check for other hepatitis infections- vaccinated against HepB

do not donate blood, semen or organs

Discuss routes of transmission and risk reduction

Screen for STIs

Detailed explanation of condition and long term complications

Acute hepatitis is notifiable

118
Q

management of hepC

A

Evaluate if patient is stable

Any signs of acute or chronic liver failure?

Liver function (clotting, platelelts, albumin)

Liver inflammation (enzymes- ALT)

Refer to hepatology for further ix/rx

Direct acting anti-virals for hepC;

Harvoni

Prevents virus completing cell cycle

Curable infection with shorter treatment and less AE

119
Q

management of hepC in children

A

Babies to hepatitis C positive mothers are tested at 18 months of age using the hepatitis C antibody test. Breastfeeding has not been found to spread hepatitis C, so mothers are free to breastfeed their babies. If nipples become cracked or bleed breastfeeding should temporarily stop whilst they heal.

Children often clear the virus spontaneously. Chronic infection with hepatitis C does not usually cause issues in childhood. Infected children will require regular specialist follow up to monitor their liver function and hepatitis C viral load.

Medical treatment may be considered in children over 3 years. Treatment in childhood involves pegylated interferon and ribavirin, which are less effective and well tolerated compared with the adult treatments.

Treatment is typically delayed until adulthood unless the child is significantly affected, because children are usually asymptomatic and newly available treatment for adults is highly effective.

120
Q

hepB transmission

A

Parenteral

Vertical

Sexual:

MSM higher risk

Multiple partners, condomless anal intercourse

Heterosexual SI

Sporadic:

RF- in LD institutions and geographical areas of high prevalence

121
Q

incubation of hepB

A

40-160 days

Virtually all children with acute infection have no symptoms

Acute infection asymptomatic in 10-50% adults

Chronic carries usually no sx

If symptomatic in acute phase, usually similar to hepA with prodrome/ icteric phase but more prolonged

122
Q

HbsAg

A

active infection

123
Q

HBeAg

A

markers of viral replication and implies high infectivitiy

124
Q

HbcAb

A

core antibody

implies past or current infection

125
Q

HbsAb

A

surface antibody

implies vaccination or past or current infection

126
Q

Primary prevention on hepB

A 
Advice to pt: 
Inform GP/dentist 
Don’t donate 
Dont share needles 
Cover wounds 
Clean blood spills thoroughly 
Condoms

Pregnancy:
Antivirals for mother if high viral load
Vaccinate neonate
Consider HBIG if HR

Sexual contacts:
Vaccination
HBIG if recent
Condoms/ dental dams until immature

Household contacts:

Vaccination

Don’t share razors/ toothbrushes

127
Q

management of hepB

A

Have a low threshold for screening patients that are at risk of hepatitis B.

Screen for other blood borne viruses (hepatitis A and B and HIV) and other sexually transmitted diseases

Acute infection is notifiable

Acute infection is self-limiting

Refer persistent infection to hepatologist

Vaccinate against hepA if not already immune

Refer to gastroenterology, hepatology or infectious diseases for specialist management

Notify Public Health (it is a notifiable disease)

Stop smoking and alcohol

Education about reducing transmission and informing potential at risk contacts

Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma

Antiviral medication can be used to slow the progression of the disease and reduce infectivity:

Peg interferon alpha 2a

Entecavir, tenofovir

Liver transplantation for end-stage liver disease

128
Q

post-exposure prophylaxis hepB

A 
HIV: 
Truvada/ raltegavir 
Start within 72 hours 
Duration 28 days 
Can discontinue if source tests negative

HepB:
May need booster
May need HBIG if inadequate immunity and patient HbsAg positive

HepC:
No prophylaxis available

Gynaecology (10 decks)

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