RANZCOG q

Question 1

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)

Answer 1

•	Herpes simplex virus
•	Syphilis
•	Chancroid
•	Donovanosis
•	HIV ulcer
Behcetts 

• Lymphogranuloma venerum
• Drug reaction
• Trauma

Question 2

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)

Answer 2

• 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%)

Question 3

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)

Answer 3

• 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