Upper reproductive tract infections

Question 1

Endometritis / endomyometritis (depending on depth of invasion)

Answer 1

Usually 2/2 instrumentation (C/S, D&E, D&C, IUD placement, but also vaginal delivery)
Probably also concomitant with most PID
Polymicrobial

Question 2

Endometritis / endomyometritis symptoms

Answer 2

Uterine tenderness, fever, elevated WBC with recent hx of instrumentation, no adnexal pain

Question 3

Endometritis / endomyometritis treatment

Answer 3

Polymicrobial - treat with clinda + gentamicin IV if severe; if chlamydia suspected, add doxy
Treat until afebrile / stable x 24-48h; no need to continue PO afterwards

Question 4

PID sequelae

Answer 4

Higher risk infertility, ectopics afterwards.

Question 5

PID symptoms

Answer 5

Abdominal / adnexal pain; can be unilat / bilat, may be absent, also vaginal discharge / bleeding / UTI sx.
Fever is actually less common (20%).

Question 6

Fitz - Hugh - Curtis syndrome

Answer 6

Perihepatitis; RUQ pain and LFT elevations too

Question 7

PID diagnosis

Answer 7

Pelvic pain + one or more of [cervical motion, uterine, or adnexal tenderness]
Fever, elevated WBC, mucopurulent cervical discharge, elevated ESR/CRP are supportive
Get cervical cultures for etiology, but usually polymicrobial (cx results don’t affect tx)
Definitive dx with laparoscopy / pelvic imaging with PID findigns / endometrial bx

Question 8

Most common organisms that cause PID

Answer 8

GC/CT are most common, but also anaerobes, E. coli, H. flu, gardnerella, strep

Question 9

PID Treatment

Answer 9

Hospitalize (esp if teenagers, nullips, noncompliant), get fluid status under control
IV abx: broad spectrum cephalosporin (e.g. cefoxitin) and doxycycline (for atypicals)
After 24h afebrile, can d/c IV abx but continue doxy. If allergic, can use clinda + gent
For o/p tx, ceftriaxone IM x1 + PO doxy +/- metronidazole x 14d

Question 10

Tubo-ovarian abscess

Answer 10

Most commonly occurs with PID.

Question 11

Symptoms of Tubo-ovarian abscess

Answer 11

PID + fever, leukocytosis with left shift, elevated ESR

Question 12

Diagnosis of Tubo-ovarian abscess

Answer 12

Dx with PID & adnexal / cul-de-sac mass

Question 13

Treatment of tubo-ovarian abscess

Answer 13

Can often avoid surgical treatment (unless peritoneal / ruptured)
Give amp + gent IV along with [clinda or metro] for anaerobes
Treat until afebrile 24-48h, pelvic exam OK. Can convert to PO for total 10-14d course
May need to drain if no response to abx in 48h; may rarely need unilateral salpingoopherectomy

Question 14

Toxic shock syndrome:

Answer 14

Now uncommon, was often 2/2 long term tampon use; 2/2 S. aureus producing TSST-1

Question 15

Symptoms of toxic shock syndrome

Answer 15

High fever, hypotension, diffuse erythematous macular rash, desquamation of palms / soles 1-2wks
Later, GI disturbances, renal failure, plts < 100k, alteration in consciousness, etc.

Question 16

Blood cultures in toxic shock syndrome

Answer 16

Blood cx often negative (toxin absorbed via vaginal mucosa)

Question 17

Treatment of toxic shock syndrome

Answer 17

Always hospitalize; fix hypotension / fluid status first.
Abx decrease risk of recurrence only (clinda + vanc) but since it’s toxin-mediated, doesn’t shorten current infection’s course.

Question 18

HIV screening/confirmation tests, work up

Answer 18

ELISA for screening → Western for confirmation; then get VL / CD4.

Question 19

Treatment of HIV

Answer 19

Get ‘em on HAART.

Question 20

HIV and cervical cancer

Answer 20

Increased risk cervical cancer - so do Pap smears initially and at 6mo, then yearly if negative.