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OBGYN > STIs > Flashcards

STIs Flashcards

1
Q

What are the vaginal defences to STIs?

A

Stratified squamous epithelium
Ph< 4.5
lactobacilli

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2
Q

What is PID?

A

A spectrum of disorders of the upper genital tract
including
-endometritis
-salpingitis
-oophoritis
-parametritis
-tubo-ovarian abscess
-pelvic peritonitis
(peri-hepatitis)

Traditionally salpingitis due to STIs

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3
Q

What is the incidence of PID?

A

Incidence increasing: 2% will be affected

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4
Q

Who is the incidence of PID higher in?

A

Younger (15-24)
Lower SEC
Nulliparous

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5
Q

What are the microbiology causes of PID?

A

Chlamydia (up to 35%) & gonorrhoea account for majority of cases.

Less commonly:
STIS: Mycoplasma genitalium
Gut Flora: E Coli, clostridium, bacteroides
Vaginal flora: G. Vaginalis, Actinomyces israelii
Skin flora: strep pyogenes, Staph aureus

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6
Q

What is the pathology of PID? (As in where did this infection come from)

A

Ascending infection:
- from vagina/cervix
-Direct inoculation (ERPC, TOP, lap + dye, IUD)

Descending:
-transperitoneal (appendix, diverticulitis)
-haematogenous (classically TB)

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7
Q

What are the risk factors for PID?

A

Sexual behaviour

Recent instrumentation

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8
Q

What are the protective factors against PID? (4)

A

Pregnancy

Sterilisation

OCP

Barrier contraception

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9
Q

What are the clinical features of PID on history?

A

Often asymptomatic
-late presentation with subfertility or menstrual problems

Symptoms include
-Bilateral lower abdo pain
-Deep Dyspareunia
-Secondary dysmenorrhoea

-fever (> 38)
-vaginal bleeding (menstrual irreg, post coital)
-vaginal/cervix discharge
-nausea and vomiting

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10
Q

What are the clinical features on exam in PID?

A

NEWs chart: HR, BP, Temp

Abdominal: bilat lower abdo tenderness

Pelvic:
bimanual: bilat adnexal tenderness (or mass)
cervical excitation
speculum: purulent vaginal discharge

Very frequently less clear and confused with appendix, ovarian cysts and ectopic pregnancy (all unilateral)

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11
Q

What are the DDx for PID? (7)

A

● ectopic pregnancy

● complications of an ovarian cyst, such as rupture or torsion
● endometriosis

● Appendicitis
● irritable bowel syndrome (and less commonly, other gastrointestinal disorders)

● urinary tract infection/stones

● functional pain (pain of unknown physical origin)

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12
Q

What are the DDx or any acute pain in OBGYN?

A
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13
Q

What investigations would you do for PID? (5)

A

Endocervical/Urethral swabs (chlamydia and gonorrhoea):
-negative does not exclude
-note absence of endocervical or vaginal pus cells o/r
PID (95% predictive value)

Urine: Pregnancy test/Urinalysis

Bloods: FBC, ESR, CRP (can assess severity, but can be normal in mild-mod disease), blood cultures, LFTs

Pelvic Ultrasound: ? Abscess/hydrospalpinx ? Other cause

Laparoscopy + BX (fimbrial)

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14
Q

where are the different swabs taken from?

A
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15
Q

What is the management of PID? (4)

A

‘Pelvic rest’

Analgesics

Antibiotics
IV->if severe disease: fever, peritonitis,
abscess
Remove IUCD if severe disease (Abx first)

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16
Q

What are the BASHH guidelines 2019 for PID?

A

Mild to moderate PID no difference in outcomes between inpatient or outpatient management.

Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected.

Outpatient regimens:
First line:
IM ceftriaxone stat 1gr
+ doxycycline 100mg bd
+ metronidazole 400mg bd
x 14/7

Other regimens
Ofloxacin + metronidazole
Moxifloxacin

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17
Q

How should more complex cases of PID be managed?

A

Admit febrile patients and treat them with IV antibiotics
ceftriaxone 2g daily, doxycycline 100mg twice daily.
->Then oral doxycycline 100mg twice daily + oral
metronidazole 400mg twice daily x 14/7

Review diagnosis if no improvement in 24 hours and perform a laparoscopy
Pelvic abscess may require drainage (under USS guidance or laparoscopically)

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18
Q

What are the short term complications of PID? (3)

A

Abscess
(Pyosalpinx, ovarian, pelvic)

Peritonitis

Fritz-Hugh-Curtis syndrome (RUQ pain, perihepatitis, 10-20%)

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19
Q

What are the long term complications of PID? (5)

A

Recurrent disease

Chronic pelvic pain

Ectopic pregnancy (x8)

Infertility (x1: 13%, x3: 75%)

Adhesions

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20
Q

How should someone with PID be followed up?

A

Review at 72 hours and Further review 2-4 weeks after therapy may be useful to ensure:
● compliance with oral antibiotics

●adequate clinical response to treatment

● awareness of the significance of PID and its complications

● screening and treatment of sexual contacts

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21
Q

What causes chronic PID?

A

No or inadequate abx

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22
Q

What are the clincial features of chronic PID? (4)

A
  • Dense adhesions
  • Hydro or pyosalpinx
  • Chronic pain, infertility, abnormal menstruation/discharge (see acute)
  • Exam: fixed retroverted uterus (see acute)
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23
Q

What investigations should be done for chronic PID? (2)

A

TVUS

Laparoscopy

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24
Q

What treatments are done for chronic PID? (3)

A

abx/analgesics if acute infection

adhesionolysis

salpingectomy

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25
Q

The following are known causes of pelvic inflammatory disease

Strep pyogenes
Mycoplasma
Chlamydia
Clostridium Welchii
Trichomonas

A

Strep pyogenes – T ->post abortion or delivery
Mycoplasma- T
Chlamydia –T (often super-infection)
Clostridium Welchii- T
Tichomonas-F

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26
Q

Which of the following is not a late complication of PID
Chronic pelvic pain
Ectopic pregnancy
Pelvic adhesions
Abscess formation
Infertility

A

Answer: abscess formation – short-term

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27
Q

What is tested for on asymptomatic STI screening?

A

Bloods
HIV
Syphilis
Hep B & C

Swabs or Urine
Chlamydia and gonorrhoea
?HVS for trichomonas

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28
Q

What is NB to note when screening for STIs?

A

Patient:
-Screen for concurrent disease

Screen partners:
-regular
-contact trace

Statutory Notification

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29
Q

What are some facts about chlamydia?

The most common cause of STIs
Caused by a gram negative intracellular organism
Silent in over half the cases
Sensitive to metronidazole
Possible cause of pneumonia in infants

A

The most common cause of STDs - T
Caused by a gram negative intracellular organism -T
Silent in over half the cases - T
Sensitive to metronidazole -F
Possible cause of pneumonia in infants -T

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30
Q

What organism causes chlamydia?

A

Gram negative bacteria, Chlamydia trachomatis

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31
Q

What is the epidemiology of chlamydia?

A

3% of 18-24 y/o in UK. (most common STI)

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32
Q

What is the natural history of chlamydia?

A

Symptoms usually 7-21 days post exposure

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33
Q

What are the symptoms of chlamydia? (3)

A

Usually asymptomatic (70%)
Cervicitis: Discharge, PCB, IMB, dyspareunia
urethritis: dysuria
lower abdo pain

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34
Q

What are the complications of chlamydia? (4)

A

PID and its complications (see above)

bartholonitis

Reiter’s syndrome/SARA (arthritis, conjunctivitis, urethritis)

Pregnancy: miscarriage, preterm labour, neonatal conjunctivitis (5-14d) & pneumonia

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35
Q

How is chlamydia diagnosed?

A

1) Vulvovaginal> Endocervical swabs (+/- urethral) & NAAT

2) Urine for NAAT: EMU (1st void: less sensitive)

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36
Q

What is the treatment of chlamydia?

A

Doxycycline 100mg bd po for 7/7

or

azithromycin (1g, then 500mg od po x 2/7) or erythromycin

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37
Q

what is the cervical appearance with chlamydia?

A
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38
Q

What are some facts about gonorrhea?

Infects the vaginal epithelium
May cause arthritis
May be symptomless
Is diagnosed by a serological test
Crosses the placenta

A

Infects the vaginal epithelium
- F glandular epithelium in cervix and urethra
May cause arthritis
-T blood borne spread (septic arthritis)
May be symptomless
- T 50%
Is diagnosed by a serological test
- F unreliable-> swabs or urine
Crosses the placenta
- F but can cause neonatal opthalmia

39
Q

What is the causative organism in gonorrhoea?

A

Neisseria gonorrhoea, Gram neg diplococcus

40
Q

What is the epidemiology of gonorrhoea?

A

Increased incidence. Higher prevalence MSM.

41
Q

What is the natural history of gonorrhoea?

A

Symptoms: Usually 2-7 days post-exposure

42
Q

What are the signs and symptoms of gonorrhoea? (5)

A

Commonly asymptomatic (50%).

Fever

Cervicitis: Discharge, IMB, PCB, deep dyspareunia.

urethritis: dysuria

Lower abdo pain

43
Q

What are the complications of gonorrhoea?

A

PID, Bartholinitis, Reiters/SARA

More aggressive: urethral stricture, bacteraemia, septic arthritis, polyarthralgia, rash, inflammation anus (d/c + pain), oropharynx(usually asymptomatic)
pregnancy: miscarriage, preterm labour, neonatal opthalmia (2-7 days PN)

44
Q

How is gonorrhoea diagnosed?

A

1) vulvovaginal swabs +NAAT> endocervical swab & NAAT (+urethral swab),

2) Urine: NAAT on EMU (less sensitive)

3) gram stain (accurate in men but less accurate in women)

45
Q

What is the treatment for gonorrhoea?

A

Ceftriaxone 1g stat

Test of cure recommended (2 weeks after treatment)

46
Q

what is the cervical appearance of gonorrhoea?

A
47
Q

Case

A
48
Q

What is this?

A

Genital warts

49
Q

What is the medical term for gential warts?

A

Condyloma acuminata

50
Q

What organism causes genital warts?

A

Human papilloma virus (6,11 -90% of genital warts. 16/18? )

51
Q

What is the epidemiology of genital warts?

A

Effect approx 1%

52
Q

What are the signs and symptoms of genital warts?

A

3 month incubation

90% disappear spontaneously within 2yrs

Warts (flat – papilliform), itch, irritation

25% have another STD.

53
Q

What are the complications of genital warts?

A

(of HPV infection) : Cervical cancer Vaccine

54
Q

What is the treatment for genital warts?

A

Topical podophyllin, imiquimod, Tricholoracetic acid

Cryotherapy, Diathermy/laser/excision (resist/keratinised)

condoms for 3/12 post treatment.

55
Q

Case

A
56
Q

Case

A
57
Q

What organism causes genital herpes?

A

Double stranded DNA virus. Herpes Simplex V Type 2>1

58
Q

What are the clinical presentations of genital herpes? (5)

A

can be asymptomatic

  • Primary: (incubation 3days to 2 weeks)
    vesicles and ulcers at introitus. (secondary bacterial infection)
  • Lymphadenopathy, dysuria (retention)
  • systemic symptoms, aseptic meningitis
  • Recurrent: 75%. Less severe – tingling prior and < pain .
  • Neonatal: encephalitis (C-section)
59
Q

What are the ways to diagnose gential herpes?

A

Swab-NAAT (or cell culture).

serology (distinguish primary from recurrent)

60
Q

How is genital herpes treated?

A

Oral acyclovir (400mg tds x 5/7)/valciclovir (severe infections, decrease duration of symptoms-within 5 days). Analgesia. Tx secondary infections.

61
Q

NEONATAL INFECTION & DISEASE
RARE BUT FATAL DISEASE. MAY ARISE FROM VERTICAL OR HORIZONTAL CONTACT. TRANSMISSION AT DELIVERY 85%; IN UTERO 5%; EARLY POST-NATAL 10%
MANIFESTATIONS OF NEONATAL DISEASE
SEM – SKIN, EYES AND MOUTH VESICULAR LESIONS 83%
PRESENT AT ABOUT 10 DAYS.
CNS – CNS LESIONS WITH OR WITHOUT SEM 63%
PRESENT WITH CNS MANIFESTATIONS ABOUT 17-19DAYS.
DISEMINATED DISEASE – MULTIPLE ORGAN INFECTION 58%

A
62
Q

What is this?

A

Genital herpes

63
Q

Case

A
64
Q

What is the organism causing trichomonas vaginalis?

A

A flagellate protozoan

65
Q

What is the natural history of trich?

A

Symptoms 5-28 days post exposure

66
Q

What are the signs and symptoms of Trich? (4)

A

10-50% asymptomatic
Vagina: Discharge: smelly, Green/Grey, watery,
frothy

cervix: ‘strawberry’ red cervix

Vulval irritation: sore and itch. Sup dyspareunia

Dysuria, +/- increased frequency.
67
Q

How is trich diagnosed?

A

Wet film microscopy. Swab and culture or swab and NAAT (later highest sensitivity)

68
Q

How is trich treated?

A

Metronidazole 500 b.d 7 days

69
Q

What is this?

A

Trich

70
Q

What is the causative organism of HIV/AIDS?

A

Human Immunodeficiency V

71
Q

What are the signs and symptoms of HIV?

A

seroconversion: flu like illness, rash, adenopathy

72
Q

What are the signs and symptoms of AIDS?

A

opportunistic infections (PCP, candida,
kaposi’s sarcoma) or CD4< 200. yearly smears.

73
Q

How are pregnant women with HIV/AIDS managed?

A

ART (antenatal, intra-partum, post-partum)

Delivery: vaginal possible with low viral load<400 copies/ml and on adequate ART

Avoid breast feeding

74
Q

How is HIV/AIDS monitored?

A

CD4 count

Viral load

75
Q

What is the treatment of HIV/AIDS?

A

HAART

76
Q

HIV CAN BE TRANSMITTED IN UTERO (30%), OR IN THE PERIPARTUM PERIOD (DURING LABOUR AND DELIVERY, OR THROUGH BREASTFEEDING) (70%).
THE OVERALL RISK OF TRANSMISSION IN UNTREATED WOMAN VARIES FROM 20-40%
WITH IMPROVEMNTS IN MEDICATION THE RISK OF TRANSMISSION IN TREATMENT-COMPLIANT WOMEN IS <0.1%
INCREASED RISK OF TRANSMISSION ASSOCIATED WITH HIGH MATERNAL VIRAL LOAD (SEROCONVERSION DURING PREGNANCY OR ADVANCED DISEASE); LOW MATERNAL CD4; CO-EXISTING OTHER STIs;
PROLONGED RUPTURE OF MEMBRANES; INVASIVE MONITORING DURING LABOUR; BREASTFEEDING AND PREMATURITY.

A

GENERAL PRINCIPLES OF MANAGEMENT
WHERE CD4 COUNTS <350 X 106/L START ANTI RETROVIRAL (ARV) THERAPY.
USUALLY A COMBINATION OF 2 NEUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs) AND A BOOSTED PROTEASE INHIBITOR.
ZIDOUVIDINE (ZDV/AZT) A NRTI IS MAINSTAY AS IT CROSSES PLACENTA.
MULTIPLE PROTOCOLS IN PLACE FOR MATERNAL ANTENATAL, PERIPARTUM AND NEONATAL TREATMENT DEPENDING ON DISEASE STATUS e.g. “ELITE CPNTROLLERS” AS WELL AS WOMEN WITH CO-EXISTING HIV AND HEPATITIS B OR C.
ELECTIVE LSCS WHERE MOTHER HAS HIGH VIRAL LOAD (i.e. > 400 copies/ml) , IS ON NO ARV THERAPY OR ZDV MONOTHERAPY.
BATH INFANT AFTER DELIVERY. CLEAN EYES WITH SALINE.
NO BREASTFEEDING ( ARVs will reduce but not eliminate transmission). WHERE SAFE ALTERNATIVES AVAILABLE AVOID BF.
MOTHER WHO TAKES ARV TO STOP PERIPARTUM TRANSMISSION MAY STOP POST DELIVERY.
FOUR WEEK ZDV OR ZDV TRIPLE THERAPY FOR INFANTS DEPENDING ON MATERNAL STATUS.

77
Q

What is the causative organism of syphilis?

A

Treponema pallidum (spirochete)

78
Q

What are the clinical features of syphilis?

A

Primary: painless ulcer (chancre): 10-90 days post-exposure (av: 21d)

Secondary: Rash, influenza like sx, condyloma:
lata. (possible vasculitis)

Latent phase

Tertiary syphilis: Aortic regurg, dementia,
tabes dorsalis, gummata.

in pregnancy: IUGR/IUD/pre-term labour/hutchinsons triad

79
Q

How is syphilis diagnosed?

A

1) Dark ground microscopy (primary and secondary) (NAAT can also be used)

2) Serology: VDRL (-ve when treated), TPHA, FTA tests

80
Q

What is the treatment of syphilis?

A

early IM Benzathine penicillin single dose

latent/tertiary: variable regimens

81
Q

** CONGENITAL SYPHILIS (Treponema pallidum)**

NOTIFIABLE DISEASE IN OWN RIGHT
PREVENTABLE.
DURING FIRST YEAR OF MATERNAL INFECTION THERE IS 80-90% CHANCE OF TRANSMISSION TO FETUS.
50% RISK IN 2* SYPHILIS, 40% RISK WITH LATENT SYPHILIS, 10% RISK WITH TERTIARY.
25-30% AFFECTED FETUSES DIE IN UTERO: IUGR, NON-IMMUNE HYDROPS.
25-30% AFFECTED NEONATES DIE
EARLY CONGENITAL SYPHILIS
<2 YEARS. HEPATOSPLENOMEGALY, LYMPHADENOPATHY, SYPHILIS RASH, PERSISTENT RHINITIS, OSTEOCHONDRITIS, PNEUMONIA, PAROT PSEUDOPARALYSIS, BULGING FONTANELLE, SEIZURES.
LATE CONGENITAL SYPHILIS
MANIFESTS >2 YEARS. USUALLY NEAR PUBERTY: HUTCHINSONS TRIAD – PEG-SHAPED INCISOR TEETH, EIGHTH NERVE DEAFNESS, INTERSTITIAL KERATITIS. SADDLE NOSE, TIBIAL BOWING. STERILE JOINT EFFUSIONS.

A
82
Q

What is this?

A

Syphilis

83
Q

What are causes of vaginal discharge?

A
  • physiological
  • foreign body
  • malignancy
  • infection:
    Candida
    Bacterial Vaginosis
    STI – chlamydia/gonorrhoea/trichomonas
    Other – beta haemolytic strep
84
Q

What is seen in primary syphilis?

A

Painless ulcer (chancre)

85
Q

What is seen in secondary syphilis? (4)

A
  • rash
  • influenza like Sx
  • condyloma lata
  • possible vasculitis
86
Q

What is seen in tertiary syphilis? (4)

A
  • aortic regurgitation
  • dementia
  • tabes dorsalis
  • gummata
87
Q

What can syphilis cause in pregnancy? (4)

A
  • IUGR
  • IUD
  • preterm delivery
  • hutchinsons triad
88
Q

What STIs can cause PID? (3)

A
  • chlamydia (35%)
  • gonorrhea
  • mycoplasma genitalium
89
Q

What gut flora can cause PID? (3)

A
  • E. coli
  • clostridium
  • bacteroids
90
Q

What vaginal flora can cause PID? (2)

A
  • G. Vaginalis
  • actinomyces israelii
91
Q

What skin flora can cause PID? (2

A
  • strep pyogenes
  • staph aureus
92
Q

What is hutchinsons triad?

A

Presentation of congenital syphilis =

  • keratitis
  • malformed teeth
  • eighth nerve deafness
93
Q

What is hutchinsons triad?

A

Presentation of congenital syphilis =

  • keratitis
  • malformed teeth
  • eighth nerve deafness

OBGYN (25 decks)

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