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MBBS IV - Junior Clerkship WCS > JC105 (O&G) - Obstetric and gynaecological infections > Flashcards

JC105 (O&G) - Obstetric and gynaecological infections Flashcards

1
Q

List natural immune defenses in the female genital tract

A

 Apposition of labia & vaginal walls

 Stratified squamous epithelium in lower genital tract (natural resistance to infection)

 Vaginal microbiome (especially lactobacilli)

 Vaginal acidity (pH 3.5-4.5)

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2
Q

Factors that adversely affect immune defense in the female genital tract

A

Menstrual cycle – secretions (alkaline) around menses

Pregnancy & puerperium:
 high pH
 Higher estrogen levels and higher glycogen content in vaginal secretions
 Trauma at delivery  infection in lower genital tract
 Lochia (alkaline) – heavy flow of blood and mucus that starts after delivery

Diabetes

Antibiotics

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3
Q

Non-infectious causes of vaginal discharge

A

 Physiological (hormones)
 Cervical ectropian
 Foreign bodies (IUCD, ring pessary for prolapse)
 Vulval dermatitis
 Benign and malignant tumours (cervical cancer)

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4
Q

Infectious causes of vaginal discharge

A

Non-sexually transmitted
 Bacterial vaginosis
 Candidiasis
 Group B Streptococcus

Sexually transmitted
 Chlamydia trachomatis
 Neisseria gonorrhea
 Trichomonas vaginalis

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5
Q

Outline history taking questions for vaginal discharge

A

History: Differentiate between physiological vs. pathological discharge
 Timing of discharge
 Smell, color, character

 Associated symptoms, e.g. abdominal pain, fever, pruritus
 Contraception (IUCD - non-infectious cause of vaginal discharge)

 Past health (diabetes)
 Cervical smear (up to date? Normal?)

 Previous obstetrics history

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6
Q

Top 5 STDs in Hong Kong

A
  1. Non-gonococcal urethritis/ nonspecific genital infection
  2. Genital warts/ condyloma acuminatum - HPV
  3. Gonorhoea
  4. Syphilis
  5. Herpes genitalis
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7
Q

Follow-up tests, referrals and plan of action after STI diagnosis

A

Present illness:
 Screen for other STIs (HIV, VDRL)
 Treatment (appropriate and prompt)

Sex partner:
 Partner(s) referral (to social health clinics) & treatment
 Safer sex education (e.g. barrier method)

Gynaecological:
 Special consideration during pregnancy (treat to prevent preterm labor; use safe antibiotics for babies)
 Cervical smear (opportunistic screening)
 Counselling on possible sequaelae

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8
Q

Pelvic inflammatory disease

  • Structures infected
  • Routes of infection
  • Causative organisms
A

pelvic infection:
 Infection of the uterus, fallopian tubes, adjacent parametria & overlying peritoneum
 Does not include lower genital tract (vulval/ vaginal infection)

Route of infection:

  1. Ascending – from the lower genital tract (most common)
  2. From nearby organs, e.g. acute appendicitis
  3. Haematological route

Causative organisms:
 Sexually transmitted: Chlamydia trachomatis, Neisseria gonorrhoeae
 Aerobic organisms: staphylococci, streptococci, coliforms, Haemophilus influenzae
 Anaerobic organisms: Clostridium sp., bacteroides, peptococci, streptopeptococci
 Others (less common): Mycobacterium tuberculosis, Actinomyces…etc

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9
Q

Pelvic inflammatory disease

  • Risk factors
A 
Risk factors: 
 Existing lower genital tract infection/ hematogenous infection
 Risky sexual behaviour
 Post-abortal
 Puerperium
 Following surgery
 IUCD insertion (first 2-4 weeks)
 Previous history of PID
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10
Q

Pelvic inflammatory disease

- S/S

A 
Symptoms: 
 Abdominal pain
 Fever
 Vaginal discharge/ abnormal uterine bleeding
 Urinary symptoms
 GI symptoms

Signs:
 Fever, BP, pulse (hypotension and tachycardia can indicate severe sepsis)
 Abdomen: signs of peritonitis (severe disease, or other DDx)
 Vagina: hot, discharge
 Cervical excitation tenderness
 Uterine & adnexal tenderness
 Adnexal mass (tubo-ovarian complex/abscess)

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11
Q

Describe the patient presentation that needs presumptive Dx of PID and early treatment

A

 Sexually active women experiencing pelvic/ lower abdominal pain
 In the absence of other cause
 With cervical motion/ uterine/ adnexal tenderness

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12
Q

Ddx of pelvic inflammatory disease

A

 Ectopic pregnancy
 Ovarian cyst complication
 Urinary tract infection
 Acute appendicitis

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13
Q

First-line investigations for PID

A

Blood: CBP – leukocytosis, (+/- inflammatory markers: ESR, CRP)

Microbiology:
 Endocervical swabs: Chlamydia (IF + culture), gonococcus (culture)
 High vaginal swabs: trichomonas (microscopy, culture)
 Blood: VDRL (syphilis), HIV-Ab
 MSU: UTI
 Cervical pap smear

Additional
 Pregnancy test (exclude ectopic pregnancy)
 USG or MRI pelvis: ovarian cyst complications

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14
Q

Outpatient treatment options for Pelvic inflammatory disease

A

Recommended:
1. IM ceftriaxone + oral doxycycline + oral metronidazole
Alternative:
2. Oral Ofloxacin + oral metronidazole (high ride effects)
3. Oral moxifloxacin (best against M. genitalium infection)
4. Intramuscular ceftriaxone + oral azithromycin (last-line)

Indications for adding metronidazole:
 Evidence/ suspicion of vaginitis (Trichomonas); or
 The patient underwent gynecologic instrumentation in the
preceding 2-3 weeks

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15
Q

Inpatient treatment option for PID

A

Continue intravenous antibiotic until 24 hours after clinical improvement  follow by oral therapy

First-line:
IV Ceftriaxone + Oral antibiotics
Follow by: Oral doxycycline or oral metronidazole

Alternatives:

  • IV cefoxitin
  • IV augmentin + IV doxycycline
  • IV clindamycin/ IV Gentamicin + oral clindamycin or oral metronidazole
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16
Q

Indications for inpatient treatment of PID

A 
 Cannot exclude surgical emergency
 Clinically severe disease
 Tubo-ovarian abscess complication (adnexal mass)
 PID in pregnancy
 Lack of response to oral therapy
 Intolerance to oral therapy
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17
Q

Last-resort treatment options for PID refractory to medication

A

Surgical intervention for tubo-ovarian abscess not responding to antibiotrics (image-guided drainage/ laparoscopy/ laparotomy)

Remove IUD (controversial):
 Consider if no clinical improvement occurs within 48-72 hours of treatment
 Balance against the risk of pregnancy in those who have had otherwise unprotected intercourse in the preceding 7 days

Treat male partners of women with PID empirically with doxycycline,

18
Q

Complications of PID

A

Early:
 Tubo-ovarian abscess
 Septic shock

Late: 
 Recurrent PID
 Chronic pelvic pain (15-20%): dysmenorrhoea, dyspareunia
 Fitz-Hugh-Curtis syndrome
 Ectopic pregnancy
 Subfertility (tubal obstruction)
19
Q

Prevention methods of recurrent PID

A

 Education (avoid risky sexual behavior)

 Contraception (barrier methods, e.g. condom)

 Prompt diagnosis and treatment

 Contact tracing and treatment

20
Q

List 3 Non-sexually transmitted disease that cause vaginal discharge

A

Bacterial vaginosis

Vulvovaginal candidiasis/ Candida vulvovaginitis

Group B Streptococcus(GBS) infection

21
Q

Bacterial vaginosis

  • Prevalence
  • Causative pathogens
  • Risk factors
  • Type of discharge and presentation
A

commonest cause of vaginal discharge in reproductive aged women

Pathogens: Mainly anaerobes (Gardnerella vaginalis, Prevotella sp., Mycoplasma hominis, Mobiliuncus sp.)

Risk factors: 
 Black
 IUCD
 Smokers
 Antibiotics
 Sex

Types of discharge:

  • offensive, fishy-smelling
  • Thin, white, homogeneous discharge coating vaginal wall/ vestibule
  • Not usually associated with vulvo-vaginitis
22
Q

Bacterial vaginosis

Complications

A

Infections:
 PID
 Post-TOP endometritis

Pregnancy-related:
 Late miscarriage
 Preterm labour
 PPROM (Preterm premature rupture of the membranes, pregnancy complication)
 Postpartum endometritis

Iatrogenic:
 Vaginal cuff cellulitis and abscess after vaginal hysterectomy

23
Q

Bacterial vaginosis

Diagnostic tests

A

Amsel’s criteria (3 out of 4): indicate high vaginal swab

  1. Thin, white homogeneous discharge
  2. Clue cells on microscopy
  3. pH of vaginal fluid >4.5
  4. Release of fishy odour on adding alkali (10% KOH) (‘whiff’ test positive)
24
Q

Bacterial vaginosis

  • management options
A

General:
Advice against vaginal douching/ use of shower gels/ antiseptic bath agents

Antibiotics: 
Indications:
 Symptomatic women
 Those undergoing surgery
 Pregnant women
Options: 
- Oral metronidazole (non-breastfeeding)
- Intravaginal gel (breastfeeding)
- CLindamycin cream
25
Q

Vulvovaginal candidiasis/ Candida vulvovaginitis

Causative pathogens
Risk factors
Vaginal discharge and presentation

A

Pathogen: Candida albicans

Risk factors: change defense mechanism of vagina
 Pregnancy
 Diabetes, immunosuppression
 Oral contraceptive pills
 Broad spectrum antibiotics

Presentation:

  • thick, white/yellow, cheesy
  • Vulvovaginitis: pruritus vulvae, soreness
  • Erythema of vulva, vagina
  • May cause skin fissure
26
Q

Vulvovaginal candidiasis/ Candida vulvovaginitis

Diagnostic tests

A

Vaginal swab from vaginal fornix (vaginal discharge/ scraping from vulvar lesions) for:

  1. Microscopic examination: mix with saline and wet mount
    - Slings of pseudohyphae of Candida albicans surrounded by round vaginal epithelial cells
    - Blastospores, conidia
  2. ± culture for complicated cases: severe symptoms, pregnancy, abnormal host,
    non-albicans, recurrent
27
Q

Vulvovaginal candidiasis/ Candida vulvovaginitis

Treatment options

A

asymptomatic: no need

Symptomatic
1. Genital hygiene:
 Keep genital area clean and dry
 Avoid tight fitting synthetic clothing
 Avoid local irritants in vulvovaginal area, e.g. perfumed products
 Use vulval moisturisers as soap substitute, and regular skin conditioner

  1. Antifungal agents, e.g. clotrimazole, econazole, miconazole:
     Topical, oral (e.g. clotrimazole pessary 200 mg for 3 nights)
     Vaginal route for pregnant women

Maintenance therapy for recurrent candidiasis (rare)

28
Q

Group B Streptococcus(GBS) infection of female genital tract

  • Causative pathogen
  • Vaginal discharge and presentation
  • Complications
A

Causative pathogen: Streptococcus agalactiae (primary reservoir in GIT)

Presentation: yellow or green discharge, vaginal burning and/or irritation

Complications:
Maternal risks:
 UTI
 PROM / PPROM (premature rupture of membranes = PROM before 37 weeks)
 Preterm labour
 Chorioamnionitis (associated with prolonged labor)
 Post-partum endometritis

Neonatal infection:

  • Early vertical infection: Septicaemia, pneumonia, respiratory failure, death
  • Late vertical/ horizontal infection: Meningitis, pneumonia
29
Q

GBS infection of female genital tract

  • DIagnostic tests in pregnant women
  • Indication for testing
A

Universal Group B Streptococcus screening:
- low vaginal and rectal swab at 35-37 weeks

Not required if:
 Required intrapartum antibiotic prophylaxis; or
 Planned for caesarean section

30
Q

GBS infection of female genital tract

Treatment options
Effectiveness

A

Intrapartum antibiotic prophylaxis (during labor):
- Penicillin G/ benzyl penicillin

Alternatives to penicillin:
- cefazolin/ clindamycin/ erythromycin/ vancomycin

Effectiveness:

  • Prevents early-onset GBS infection (not 100%)
  • Cannot prevent late-onset GBS infection/ horizontal infections
31
Q

Chlamydial infections in women

  • Causative pathogen
  • Risk factors
  • Incubation period
  • Presentation
A

Pathogen: Chlamydia trachomatis (obligate intracellular gram negative bacterium)

Risk factors:
 Young age
 Multisexual partners, unsafe sex, low socioeconomic class
 History of STD/ PID

Incubation: 7-21 days

Presentation: Most asymptomatic

  • Dysuria
  • Abnormal vaginal Mucopurulent discharge
  • Intermenstrual or postcoital bleeding
  • Deep dyspareunia
  • Lower abdominal pain
  • Cervicitis +/- contact bleeding

(Men: Urethritis, Dysuria, Urethral discharge, Epididymo-orchitis)

32
Q

Chlamydial infections

Complications

A

 PID
 Chronic pelvic pain

Pregnancy: 
 Increased risk of ectopic pregnancy
 Subfertility
 Preterm labour
 PPROM
 Low birth weight
 Post-partum endometritis

Syndromes:
 Reiter’s Syndrome – urethritis, conjunctivitis and arthritis
 Fitz-Hugh-Curtis Syndrome: perihepatitis/ perihepatic adhesions seen in laparotomy

Complication in babies:
 Conjunctivitis (5-12 days)
 Pneumonitis (2-3 weeks)

33
Q

Chlamydial infections

Diagnostic tests

A

Endocervical swab and/or first void urine:
 Immunofluorescence
 Culture (McCoy cell line)
 PCR, ligase chain reaction
 ELISA: Monoclonal Chlamydia-specific antibodies

34
Q

Chlamydial infections

Treatment options

A

Recommended:
- Doxycycline (100 mg bd for 7 days)

Alternative for Allergic/ intolerant/ pregnancy:

  • azithromycin (1g oral single dose, then 500mg daily for 2 days)
  • erythromycin
  • amoxicillin
  1. Screen for other STD
  2. Contact tracing and treatment
  3. Test of cure - Recommended in pregnancy (implication in newborn)
35
Q

Gonorrhea

  • Causative organism
  • Risk factors
  • Incubation period
  • Presentation
A

Neisseria gonorrhoeae:
 Gram-negative diplococci

Risk factors:
 Multisexual partners, unsafe sex, low socioeconomic class
 History of STD/ PID

Incubation period: 10 days

Presentation: 
 yellow- green vaginal discharge 
 Dysuria, frequency
 Vaginal pruritus, burning
 Post-coital bleeding
Speculum exam: 
 Vaginal erythema
 Vulval swelling/ pain – Bartholin’s abscess
36
Q

Gonorrhea

Complications in women

A

 PID
 Chronic pelvic pain
 Increased risk of ectopic pregnancy
 Subfertility

Systemic involvement:
 Arthritis, conjunctivitis, urethritis
 Pharyngitis
 Proctitis
 Endocarditis
 Meningitis
 Disseminated gonococcal infection (rare)
Pregnancy:
 Miscarriage
 Premature labour
 PPROM
 Chorioamnionitis
 SGA (small for gestational age)
 Stillbirth
 Post-partum endometritis and pelvic sepsis
Baby: 
Ophthalmia neonatorum (first few days of life)
37
Q

Gonorrhea

Diagnostic test

A

Endocervical, urethral, anal, pharyngeal swabs:

 Microscopy: Gram-negative diplococci
 Culture (Thayer-Martin medium, Martin-Lewis medium)
 PCR for DNA

38
Q

Gonorrhea

Treatment options

A
  1. Recommended within 14 days of exposure:
    IM ceftriaxone

Alternatives:

  • Ciprofloxacin if C/ST shows sensitive
  • IM ceftriaxone + azithromycin
  • IM spectinomycin + azithromycin
    • do not use quinolone due to pregnancy S/E and high resistance**
  1. Screen for other STD
  2. Contact tracing
  3. Test of cure for all cases
39
Q

Trichomoniasis

  • Causative pathogen
  • Risk factors
  • Presentation
  • Complications
A

Pathogen: Trichomonas vaginalis (flagellated protozoal parasite)

Risk factors: 
 Smokers
 Afro-Caribbean/ African race
 Lower educational level, unsafe
sex, multiple sexual partners

Presentation:

  • Foul smell, frothy, yellowish-green
  • Vaginitis: usually present with pruritus, soreness, dyspareunia
  • Post-coital bleeding (in pregnant women)

Speculum: Strawberry cervix

Pregnancy Cx:
 Preterm birth
 Low birth weight

40
Q

Trichomoniasis

Diagnostic tests

A

High vaginal swab

  • Wet mount for microscopy: motile parasites
  • Culture (7 days)
  • Rapid antigen test (immunofluorescence, enzyme immunoassay)
  • Nucleic acid amplification tests (NAAT): detect rRNA
  • PCR
41
Q

Trichomoniasis

Treatment options

A

For symptomatic women:
1. Metronidazole (oral) for 5-7 days or single high dose
(Avoid high dose if pregnant/ breast feeding)
2. Screen for other STDs
3. Screen and treat partner
4. Test of cure if symptomatic despite Tx/ recurrence

MBBS IV - Junior Clerkship WCS (131 decks)

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