RANZCOG q Flashcards

1
Q

A 28 year old woman presents to you with a recent onset of a vulval ulcer in the last 24 hours. She has recently started a new relationship.

a. List the differential diagnoses for this presentation. (4 marks)

A
•	Herpes simplex virus
•	Syphilis
•	Chancroid
•	Donovanosis
•	HIV ulcer
Behcetts 
  • Lymphogranuloma venerum
  • Drug reaction
  • Trauma
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2
Q

On examination you find a tender shallow ulcer at the introitus. You suspect herpes simplex.

b. Describe how you would confirm the diagnosis and your initial management. (5 marks)

A

• Take a viral swab from the base of the lesion for viral culture, PCR or antigen testing
o PCR most commonly used now
Management
• Explain to woman what herpes simplex virus is, that it was likely contracted by oro-genital or genital-genital contact
• Anti-viral treatment – acyclovir 200 mg 5 times a day for 5 days
o Consider IV therapy if vomiting or severely unwell
• Support measures
o Saline baths – try to pass urine in bath etc., as often more comfortable
o If unable to pass urine may need catheterisation
o Local anaesthetic gel may offer some relief
• Discuss sexual transmission
o Likely any regular sexual partner(s) has / have it
o Condoms not 100% protective against transmission
• Warn about recurrence and possible consequences if pregnant – risk of neonatal transmission
o With secondary HSV attacks in pregnancy, there is a low risk of vertical transmission (less than 3%)

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3
Q

She presents 2 years later and is 16 weeks pregnant. She has heard about the possibility of neonatal herpes infection. She generally has 3-4 attacks of genital herpes per year.

c. Justify how you would advise her about the risk of her fetus acquiring neonatal herpes and how this can be minimised. (6 marks)

A

• Avoid sex if she or partner has active oral and/or genital herpetic lesions – use condoms if having sex to try and avoid risk of further transmission (e.g. contracting HSV 1 if already has HSV 2)
• Risk of vertical infection to baby with secondary HSV is low – less than 3%
• Mode of transmission most commonly from fetal passage through the vagina, but also can be due to ascending infection (especially if membranes are ruptured for more than 4 hours pre-delivery) or postnatally
• Less likely to infect baby if only gets rare recurrences, but this woman has 3-4 attacks a year
• If no outbreaks in pregnancy – doesn’t need prophylactic aciclovir
• If multiple attacks in pregnancy – offer oral aciclovir prophylactically from 36 weeks
• If she has an outbreak in pregnancy at any time – treat with oral aciclovir
• If she has an active outbreak at the time of delivery
o Reassure that risk of transmission is low (less than 3%)
o Need to set against the risks of Caesarean section
o Some women may feel the small (but significant if it occurred) risk of transmission is worth the potential risks of Caesarean
o If rupture membranes for more than 4 hours pre-delivery, protective effective effect of Caesarean is lost
• Outbreak at other times is not an indication for Caesarean section in of itself
• Postnatally inform paediatric / neonatal team, as baby will require close observation

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