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Obstetrics and Gynaecology > GUM medicine - done > Flashcards

GUM medicine - done Flashcards

1
Q

What is BV?

A

Overgrowth of bacteria in the vagina, specifically anaerobic bacteria – not an STI

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2
Q

What is BV caused by?

A

Loss of lactobacilli “friendly bacteria” in the vagina

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3
Q

What risk does BV put women in?

A

Developing STIs

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4
Q

What are lactobacilli? What its function?

A

The main component of the healthy vaginal bacterial flora - produces lactic acid which keeps the vaginal pH low (under 4.5)

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5
Q

What does the acidic environment in the vagina do?

A

Prevents other bacteria from overgrowing

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6
Q

What happens when the pH of the vagina rises?

A

More alkaline environment enables anaerobic bacteria to multiply

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7
Q

Which examples of anaerobic bacteria are there?

A

Gardnerella vaginalis (most common)

Mycoplasma hominis

Prevotella species

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8
Q

What are the risk factors for BV?

A

Multiple sexual partners (although it is not sexually transmitted)

Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)

Recent antibiotics

Smoking

Copper coil

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9
Q

What to ask when taking a history for BV?

A

Use of soaps to clean the vagina

Vaginal douching

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10
Q

What is the presenting feature of BV?

A

Fishy-smelling watery grey or white vaginal discharge (half of women are asymptomatic)

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11
Q

What would suggest a diagnosis other than BV?

A

Itching, irritation and pain are not associated with BV and suggest an alternative cause

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12
Q

How can the typical discharge of BV be confirmed?

A

Speculum examination – high vaginal swab can be done

Examination is not always required where the symptoms are typical and the woman is low risk of STIs

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13
Q

What are the investigations for BV?

A

Vaginal pH can be tested using a swab and pH paper

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14
Q

What is the normal pH of the vagina?

A

3.5-4.5 (BV occurs with a pH above 4.5)

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15
Q

What type of swab is used for BV?

A

Standard charcoal swab – high vaginal swab

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16
Q

How does BV appear on microscopy?

A

“Clue cells” – epithelial cells from the cervix that have bacteria stuck inside them – usually Gardnerella vaginalis

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17
Q

What is the management of BV?

A

Asymptomatic BV doesn’t usually require treatment

Symptomatic BV treated with metronidazole

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18
Q

How is metronidazole given?

A

Orally or by vaginal gel

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19
Q

What is an alternative to metronidazole for BV?

A

Clindamycin an alternative but less optimal antibiotic choice

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20
Q

How to avoid BV?

A

Avoid vaginal douching or cleaning with soaps

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21
Q

What advice to give when prescribing metronidazole?

A

Avoid alcohol for the duration of treatment as it causes a “disulfiram-like reaction” with nausea and vomiting, flushing and sometimes shock and angioedema

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22
Q

What complications is BV associated with in pregnant women?

A

Miscarriage

Preterm delivery

Premature rupture of membranes

Chorioamnionitis

Low birth weight

Postpartum endometritis

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23
Q

What is the other name for “thrush”

A

Vaginal candidiasis

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24
Q

What is vaginal candidiasis?

A

Vaginal infection with a yeast of the candida family – most commonly candida albicans

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25
Q

What are some risk factors for thrush?

A

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)

Poorly controlled diabetes

Immunosuppression (e.g. using corticosteroids)

Broad-spectrum antibiotics

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26
Q

How does vaginal candidiasis present?

A

Thick white discharge which doesn’t typically smell

Vulval and vaginal itching, irritation or discomfort

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27
Q

What can severe vaginal candidiasis lead to?

A

Erythema

Fissures

Oedema

Pain during sex (dyspareunia)

Dysuria

Excoriation

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28
Q

What are the investigations for thrush?

A

Often treatment for thrush is started impirically, based on presentation

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29
Q

How can the pH of a vaginal differentiate between different infections?

A

BV and Trichomonas (pH > 4.5)

Candidiasis (pH < 4.5)

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30
Q

What can confirm the diagnosis of thrush?

A

Charcoal swab with microscopy

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31
Q

What are the management options for thrush?

A

Antifungal medications:

Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator

Antifungal pessary (i.e. clotrimazole)

Oral antifungal tablets (i.e. fluconazole)

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32
Q

What are the different options for doses / regimes of antifungal medications?

A

A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night

A single dose of clotrimazole pessary (500mg) at night

Three doses of clotrimazole pessaries (200mg) over three nights

A single dose of fluconazole (150mg)

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33
Q

What is canesten duo?

A

Over the counter treatment for thrush, containing:

Single fluconazole tablet

Clotrimazole cream to use externally for symptoms

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34
Q

What advice needs to be given to women using antifungal creams and pessaries?

A

Can damage condoms and prevent spermicides from working – alternative contraception is needed for at least 5 days after use

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35
Q

What type of bacteria is chlamydia trachomatis?

A

Gram-negative bacteria

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36
Q

How does chlamydia replicate?

A

Enters and replicates within cells before rupturing the cell and spreading to others (intracellular organism)

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37
Q

What is the National Chlamydia Screening Programme?

A

A programme aimed to screen every sexually active person under 25 years of age for chalamydia annually or when they change their sexual partner – everyone who tests positively should have a re-test three months after treatment to ensure they have not contracted chlamydia again, rather than to check that the treatment has worked

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38
Q

What are patients tested for when they attend a GUM clinic ?

A

Chlamydia

Gonorrhoea

Syphilis (blood test)

HIV (blood test)

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39
Q

What are the two kinds of swabs used for sexual health screening?

A

Charcoal swabs

Nucleic acid amplification test (NAAT) swabs

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40
Q

What type of testing do charcoal swabs allow for?

A

Microscopy (looking at sample under a microscope), culture (growing the organism) and sensitivities (testing which antibiotics are effective)

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41
Q

What do charcoal swabs look like?

A

Long cotton bud which go into a tube with a black transport medium at the end (amines transport medium – keeps microorganisms alive during transport)

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42
Q

What does microscopy involve?

A

Gram staining and examination under a microscope

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43
Q

Where are samples taken from for charcoal swabs?

A

Endocervical swabs

High vaginal swabs

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44
Q

What infections can charcoal swabs confirm?

A

Bacterial vaginosis

Candidiasis

Gonorrhoeae (specifically endocervical swab)

Trichomonas vaginalis (specifically a swab from the posterior fornix)

Other bacteria, such as group B streptococcus (GBS)

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45
Q

What infection is NAAT specifically testing for?

A

Chlamydia and gonorrhoea - testing directly for the DNA or RNA of the organism

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46
Q

What samples can NAAT testing use?

A

Endocervical swab

Vulvovaginal swab (self taken)

First-catch urine sample

(in order of preference)

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47
Q

What samples can be taken from men for NAAT testing?

A

First-catch urine

Urethral swab

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48
Q

What swabs can be taken to diagnose chlamydia in the rectum and throat?

A

Rectal and pharyngeal NAAT swabs

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49
Q

How to confirm a diagnosis of gonorrhoea after a positive NAAT test?

A

Endocervical charcoal swab is required for microscopy, culture and sensitivities

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50
Q

What presentations suggest chlamydia in women?

A

- Abnormal vaginal discharge

  • Pelvic pain
  • Abnormal vaginal bleeding (intermenstrual or postcoital)
  • Painful sex (dyspareunia)
  • Painful urination (dysuria)
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51
Q

What presentation suggests chlamydia in a man?

A
  • Urethral discharge
  • Painful urination (dysuria)
  • Epididymo-orchitis
  • Reactive arthritis
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52
Q

How would rectal chlamydia and lymphogranuloma venereum present?

A

Anorectal symptoms - discomfort, discharge, bleeding and change in bowel habits

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53
Q

What are the examination findings in chlamydia?

A
  • Pelvic or abdo tenderness
  • Cervical motion tenderness (cervical excitation)
  • Inflamed cervix (cervicitis)
  • Purulent discharge
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54
Q

What tests are used to diagnose chlamydia?

A

Nucleic acid amplification tests (NAAT)

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55
Q

Where are samples for NAAT testing for chlamydia taken from?

A

Vulvovaginal swab

Endocervical swab

First-catch urine sample (in women or men)

Urethral swab in men

Rectal swab (after anal sex)

Pharyngeal swab (after oral sex)

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56
Q

What is the first line treatment for uncomplicated chlamydia?

A

Docycycline 100mg twice a day for 10 days

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57
Q

Why is a single dose of 1g of azathioprine no longer recommended first line for chlamydia?

A

Mycoplasma genitalium resistance to azithromycin and

Less effective for rectal chlamydia infection

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58
Q

What medications can be given to pregnant women with chlamydia?

A

Azithromycin 1g stat then 500mg once a day for 2 days

Erythromycin 500mg four times daily for 7 days

Erythromycin 500mg twice daily for 14 days

Amoxicillin 500mg three times daily for 7 days

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59
Q

When is a test of cure used for clamydia?

A
  • Rectal cases of chlamydia
  • Pregnancy
  • Symptoms persist
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60
Q

What should form part of management after testing positive for chlamydia?

A

Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection

Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners

Test for and treat any other sexually transmitted infections

Provide advice about ways to prevent future infection

Consider safeguarding issues and sexual abuse in children and young people

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61
Q

What are the possible complications from infection with chlamydia?

A

Pelvic inflammatory disease

Chronic pelvic pain

Infertility

Ectopic pregnancy

Epididymo-orchitis

Conjunctivitis

Lymphogranuloma venereum

Reactive arthritis

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62
Q

What are the pregnancy related complications after infection with chlamydia?

A

Preterm delivery

Premature rupture of membranes

Low birth weight

Postpartum endometritis

Neonatal infection (conjunctivitis and pneumonia)

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63
Q

What is lymphogranuloma venereum?

A

Condition affecting the lymphoid tissue around the site of infection with chlamydia - most common in MSM

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64
Q

How many stages are there of Lymphogranuloma Venereum?

A

3 stages

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65
Q

What is the primary stage of LGV?

A

Painless ulcer (primary lesion) - occuring on the penis in men, vaginal wall in women or rectum after anal sex

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66
Q

What is the second stage of LGV?

A

Involves lymphadenitis - swelling, inflammation and pain in the lymph nodes infected with the bacteria (inguinal or femoral)

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67
Q

What is the 3rd stage of LGV?

A

Inflammation of the rectum (proctitis) and anus

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68
Q

What may proctocolitis in the 3rd stage of LGV lead to?

A
  • Anal pain
  • Change in bowel habits
  • Tenesmus
  • Discharge
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69
Q

What is tenesmus?

A

Feeling of needing to empty the bowels even after completing a bowel motion

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70
Q

What is the first line treatment for LGV?

A

Doxycycline 100mg twice daily for 21 days

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71
Q

What are alternatives to Doxy for LGV?

A

Erythromycin

Azithromycin

Ofloxacin

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72
Q

How does chlamydial conjunctivits occur?

A

When genital fluid comes into contact with the eye

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73
Q

How does chlamydial conjunctivitis present?

A

Chronic erythema

Irritation

Discharge lasting more than 2 weeks

Usually unilateral

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74
Q

What can present similarily to chlamydial conjunctivitis?

A

Gonococcal conjunctivitis

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75
Q

What type of bacteria is Neisseria Gonorrhoeae?

A

Gram negative diplococcus bacteria

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76
Q

Where does gonorrhoea infect?

A

Infects mucous membranes with a columnar epithelium e.g. endocervix, urethra, rectum, conjunctiva and pharynx

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77
Q

What increases the risk of gonorrhoea?

A

Being:

Young

Sexually active

Having multiple partners

Having other STIs

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78
Q

What is the problem with treating gonorrhoea?

A

High level of antibiotic resistance - traditionally ciprofloxacin or azithromycin was used to treat gonorrhoea - there are now high levels of abx resistance

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79
Q

How does Gonorrhoea present in women?

A

More likely to be symptomatic than infection with chlamydia:

Odourless purulent discharge, possibly green/yellow

Dysuria

Pelvic pain

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80
Q

How does gonorrhoea present in men?

A
  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Testicular pain or swelling (epididymo-orchitis)
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81
Q

How does rectal infection with gonorrhoea present?

A

Anal or rectal discomfort and discharge - often asymptomatic

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82
Q

How does pharyneal infection with gonorrhoea present?

A

Possible sore throat but otherwise asymptomatic

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83
Q

How does prostatitis caused by gonorrhoea present?

A

Perineal pain, urinary symptoms and prostate tenderness

84
Q

How is gonorrhoea diagnosed?

A

NAAT testing to detect the RNA or DNA of gonorrhoea

85
Q

Where are samples taken from for the diagnosis of gonorrhoea?

A

Endocervical, vulvovaginal or urethral swabs or in first catch urine sample

86
Q

What samples for gonorrhoea are advised in MSM?

A

Rectal and pharyngeal in all MSM and in those with risk factors (e.g. anal and oral sex)

87
Q

Why are endocervical swabs taken for MSC for gonorrhoea?

A

To provide information on the specific bacteria, antibiotic sensitivities and resistance

88
Q

What is included in the management of patients who test positive for gonorrhoea?

A

Referre to GUM clinics to coordinate testing, treatment and contact tracing - management depends on whether antibiotic sensitivities are known

89
Q

What are the antibiotics of choice for gonorrhoea?

A

Uncomplicated:

  • Single dose of intramuscular ceftriaxone 1g if the sensitivites are NOT known
  • Single dose of oral ciprofloxacin 500mg if the sensitivites are known
90
Q

What follow up should patients with gonorrhoea have?

A

Follow-up test of cure - with NAAT testing if they are symptomatic or cultures where they are symptomatic:

  • 72 hours after treatment for culture
  • 7 days after treatment for RNA NATT
  • 14 days after treatment for DNA NATT
91
Q

What are the other factors to consider around gonorrhoea?

A
  • Abstain from sex for 7 days to reduce re-infection
  • Test for and treat other STIs
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people
92
Q

What are some complications of gonorrhoea?

A

Pelvic inflammatory disease

Chronic pelvic pain

Infertility

Epididymo-orchitis (men)

Prostatitis (men)

Conjunctivitis

Urethral strictures

Disseminated gonococcal infection

Skin lesions

Fitz-Hugh-Curtis syndrome

Septic arthritis

Endocarditis

93
Q

What is a key complication to remember of gonorrhoea in pregnancy?

A

Gonococcal conjunctivitis in a neonate - contracted from the mother during birth - called ophthalmia neonatorum - medical emergency and associated with sepsis, perforation of the eye and blindness

94
Q

What is disseminated gonococcal infection?

A

Complication of untreated gonococcal infection where the bacteria spreads to the skin and joints

95
Q

What does disseminated gonococcal infection cause?

A
  • Various non-specific skin lesions
  • Polyarthralgia (joint aches and pains)
  • Migratory polyarthritis (arthritis which moves between joints)
  • Tenosynovitis
  • Systemic symptoms such as fever and fatigue
96
Q

What is mycoplasma ginitalium (MG)?

A

A bacteria which causes non-gonococcal urethritis - STI

97
Q

What is a concern with mycoplasma genitalium?

A

Developing problems with antibiotic resistance, particularly with azithromycin

98
Q

How does MG present?

A

Many cases do not cause symptoms - urethritis is a key feature

99
Q

What complications may infection with mycoplasma genitalum lead to?

A

Urethritis

Epididymitis

Cervicitis

Endometritis

Pelvic inflammatory disease

Reactive arthritis

Preterm delivery in pregnancy

Tubal infertility

100
Q

What are the investigations for mycoplasma genitalium?

A

Traditional cultures are not helpful in isolating MG as it is a very slow growing organism. Therefore testing involves nucleic acid amplification tests (NAAT) to look specifically for the DNA or RNA of the bacteria

101
Q

What samples are recommended for testing for MG?

A
  • First urine sample in the morning for men
  • Vaginal swabs (can be self taken) for women
102
Q

What else should positive samples be tested for?

A

Macrolide resistance and performing a test of cure after treatment

103
Q

What is the management for MG?

A

Course of doxycycline followed by azithromycin for uncomplicated genital infections

  • Doxycycline 100mg twice daily for 7 days then;
  • Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
104
Q

What can be used to treat complicated infections of MG?

A

Moxifloxacin

105
Q

What is used to treat MG in pregnancy and breastfeefing?

A

Azithromycin alone (doxycyclin is contraindicated)

106
Q

What is PID?

A

Inflammation and infection of the organs of the pelvis caused by infection spreading up through the cervix

107
Q

What can PID result in?

A

Tubular infertility and chronic pelvice pain

108
Q

What is endometritis?

A

Inflammation of the endometrium

109
Q

What is salpingitis?

A

Inflammation of the fallopian tubes

110
Q

What is oophoritis?

A

Inflammation of the ovaries

111
Q

What is parametritis?

A

Inflammation of the parametrium (connective tissue around the uterus)

112
Q

What is peritonitis?

A

Inflammation of the peritoneal membrane

113
Q

What are the causes of PID?

A

Neisseria gonorrhoeae tends to produce more severe PID

Chlamydia trachomatis

Mycoplasma genitalium

114
Q

What else can PID be caused by?

A

Gardnerella vaginalis (associated with bacterial vaginosis)

Haemophilus influenzae (a bacteria often associated with respiratory infections)

Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)

115
Q

What are the risk factors for PID?

A

Not using barrier contraception

Multiple sexual partners

Younger age

Existing sexually transmitted infections

Previous pelvic inflammatory disease

Intrauterine device (e.g. copper coil)

116
Q

How does PID present?

A

Pelvic or lower abdominal pain

Abnormal vaginal discharge

Abnormal bleeding (intermenstrual or postcoital)

Pain during sex (dyspareunia)

Fever

Dysuria

117
Q

What are the examination findings of PID?

A

Pelvic tenderness

Cervical motion tenderness (cervical excitation)

Inflamed cervix (cervicitis)

Purulent discharge

(Fever and other signs of sepsis)

118
Q

What are the investigations for PID?

A

Testing for causative organisms and other STIs:

NAAT swab for gonorrhoea and chlamydia

NAAT swab for mycoplasma genitalium

HIV test

Syphilis test

High vaginal swab for BV, candidiasis and trichomonias

Microscope for pus cells on swabs from vagina or endocervix

Pregnancy test to exclude ectopic pregnancy

Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis

119
Q

What is the management of PID?

A

Refer patients to GUM specialist service for contact tracing

Start antibiotics empirically (according to guidelines)

An example regieme:

  • Single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
  • Doxycycline 100mg twice daily for 10 days (to cover chlamydia and mycoplasma genitalium)
  • Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as gardnerella vaginalis)

Ceftriaxone and doxy will cover other bacteria e.g. H. influenzae and E.Coli

120
Q

When may PID patients require admission for IV abx / managment?

A

Signs of sepsis

Pregnant

Drainage of pelvic abscess

121
Q

What are some complications of PID?

A

Sepsis

Abscess

Infertility

Chronic pelvic pain

Ectopic pregnancy

Fitz-Hugh-Curtis syndrome

122
Q

What is Fitz-Hugh-Curtis syndrome?

A

Complication of PID caused by inflammation and infection of the liver capsule (Glisson’s capsule) leading to adhesions between the liver and peritoneum

123
Q

How does Fitz-Hugh-Curtis syndrome happen?

A

Bacteria spreads from pelvis via peritoneal cavity, lymphatic system or blood

124
Q

What are the symptoms of Fitz-High-Curtis syndrome?

A

Right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation

125
Q

How is Fitz-Hugh-Curtis syndrome treated?

A

LAparoscopy to visualise and treat adhesions by adhesiolysis

126
Q

What is trichomonas vaginalis?

A

Type of parasite spread through sexual intercourse - classed as a protozoan and is a single celled organism with flagella

127
Q

What are flagella and there are they on trichomonas?

A

Appendages stretching from the body, similar to limbs

Four flagella at the front and a single flagellum at the back giving a characteristic appearance to the organism

128
Q

What are the flagella used for in trichomonas?

A

Attaching to tissues and causing damage

129
Q

Where does trichomonas live?

A

Urethra of men and women and vagina

130
Q

What does trichomonas increase the risk of?

A

Contracting HIV by damaging the vaginal mucosa

Bacterial vaginosis

Cervical cancer

Pelvic inflammatory disease

Pregnancy-related complications such as preterm delivery.

131
Q

How does trichomonas infection present?

A

50% of cases are asymptomatic, when they do occur:

  • Vaginal discharge
  • Itching
  • Dysuria (painful urination)
  • Dyspareunia (painful sex)
  • Balanitis (inflammation to the glans penis)
132
Q

How is the vaginal discharge in trichomonas?

A

Frothy and yellow-green (may have fishy smell)

133
Q

How does the cervix appear in trichomonas?

A

“Strawberry cervix” (aka colpitis macularis) - cervicitis

Tiny haemorrhages across surface of the cervix, giving the appearance of a strawberry

134
Q

What is the pH like in trichomonas?

A

Raised pH (above 4.5) similar to BV

135
Q

How is a diagnosis of trichomonas made?

A

Standard charcoal swab with microscopy (examination under a microscope)

Swabs taken from the posterior fornix of the vagina (behind the cervix) in women

Self taken low vaginal swab may be used as an alternative

Urethral swab or first-catch urine is used in men

136
Q

What is the treatment of trichomonas infection?

A

Metronidazole

137
Q

What does the herpes simplex virus cause?

A

Both cold sores (herpes labialis) and genital herpes

138
Q

What are the two main strains of the herpes virus?

A

HSV-1

HSV-2

(many people are infected without any symptoms)

139
Q

Where does the virus remain latent after initial infection?

A

Associated sensory nerve ganglia - typically the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes

140
Q

What other things can the herpes simplex virus cause?

A

Aphthous ulcers

Herpes keratitis (inflammation of the cornea of the eye)

Herpetic whitlow (a painful skin lesion on a finger or thumb)

141
Q

How is the herpes simplex virus spread?

A

Through direct contact with affected mucous membranes or viral shedding in mucous secretions - virus can be spread even when no symptoms are present

142
Q

When is asymptomatic shedding of HSV most common?

A

In first 12 months of infection and where recurrent symptoms are present

143
Q

Which form of the virus typically causes genital herpes?

A

HSV-2

144
Q

How does genital herpes present?

A

Initial presentation is the most severe:

  • Ulcers or blistering lesions affecting the genital area
  • Neuropathic type pain (tingling, burning or shooting)
  • Flu-like symptoms (e.g. fatigue and headaches)
  • Dysuria (painful urination)
  • Inguinal lymphadenopathy
145
Q

Up to how long can an initial infection of genital herpes last?

A

3 weeks - recurrent episodes are usually milder

146
Q

How is a diagnosis of herpes made?

A

Can be made clinically based on the history and examination findings

Viral PCR swab from a lesion can confirm the diagnosis and causative organism

147
Q

What is the management of genital herpes?

A

Referal to a genitourinary medicine specialist service

Aciclovir to treat geniral herpes (alternatives are valaciclovir and famciclovir)

148
Q

What are some additional measures for treating genital herpes?

A

Paracetamol

Topical lidocaine 2% gel (e.g. Instillagel)

Cleaning with warm salt water

Topical vaseline

Additional oral fluids

Wear loose clothing

Avoid intercourse with symptoms

149
Q

Does genital herpes cause pregnancy-related issues or complications of congenital abnormalities?

A

Not known to

150
Q

What is the main issue to genital herpes during pregnancy?

A

Risk of neonatal herpes simplex infection contracted during labour and deliver - high morbidity and mortality (however passive immunity to the virus as antibodies can cross the placenta into the fetus)

151
Q

What is the management of genital herpes based upon?

A

Whether it is primary infection or recurrent genital herpes

152
Q

Is aciclovir harmful in pregnancy?

A

Not known to be

153
Q

How is primary genital herpes contracted before 28 weeks gestation?

A

Aciclovir during the initial infection then followed by regular prophylactic aciclivir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labout and delivery

154
Q

How will having genital herpes during pregancy affect the management?

A

Asymptomatic at delivery can have a vaginal delivery (provided > 6 weeks after initial infection)

C-Section is recommended when symptoms are present

155
Q

How is primary genital herpes which is contracted after 28 weeks during pregnancy treated?

A

Aciclovir during the initial infection followed immediately by regular prophylactic aciclovir

C-Section is recommended in all cases to reduce the risk of neonatal infection

156
Q

How is recurrent genital herpes treated in pregnancy?

A

Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery

Carries a low risk of neonatal infection (0-3%) even if the lesions are present suring delivery

157
Q

What does HIV stand for?

A

Human immunodeficiency virus

158
Q

What does AIDS stand for?

A

Acquired immunodeficiency syndrome

159
Q

What is AIDS now referred to as?

A

Late-stage HIV

160
Q

What type of virus is HIV?

A

RNA retrovirus

161
Q

What is the most common type of HIV?

A

HIV-1 (HIV-2 is rare outside West Africa)

162
Q

What cells does HIV affect?

A

CD4 T-helper cells of the immune system

163
Q

How does an infection with HIV present?

A

Initial seroconversion flu-like illness within the first few weeks of infection - then asymptomatic until the condition progresses to immunodeficiency - where AIDS-definiing illnesses and oppourtunic infections occur - potentially years after the initial infection

164
Q

How is HIV transmitted?

A

Unprotected anal, vaginal or oral sexual activity

Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)

Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye

165
Q

What are some AIDS definining illnesses?

A

Kaposi’s sarcoma

Pneumocystis jirovecii pneumonia (PCP)

Cytomegalovirus infection

Candidiasis (oesophageal or bronchial)

Lymphomas

Tuberculosis

166
Q

How is HIV screened for?

A

Everyone admitted to hospital with an infectious disease is tested for HIV

Up to 3 months to develop antibodies to the virus after infection

HIV antibody tests can be negative for three months following exposure

167
Q

Do patients still require formal counselling or education before a test for HIV?

A
168
Q

What testing is typical for HIV?

A

Antibody testing - simple blood test

Testing for the p24 antigen can give a positive result earlier in the infection

PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood giving a viral load

169
Q

How is HIV disease monitored?

A

CD4 count

Viral load

170
Q

What does the CD4 count tell you about the HIV infection?

A

These cells are destroyed by the virus

500-1200 cells/mm3 is the normal range

<200 cells/mm3 is considered end stage HIV and puts the patient at high risk of opportunistic infections

171
Q

How is the viral load used to monitor HIV?

A

Number of copies of HIV RNA per ml of blood

“Undetectable” refers to a viral load below the lab’s recordable range (usually 50-100 copies / ml)

Can be in the hundreds and thousands in untreated HIV

172
Q

Who manage patients with HIV?

A

Specialist HIV, infectious disease or GUM centres manage patients with HIV

173
Q

How is HIV treated with antiretroviral therapy?

A

ART is offered to everyone with a diagnosis of HIV irrespective or viral load or CD4 count

Specialist blood tests can establish the resistance or each HIV strain to different medications

174
Q

What is HIV treatment aimed at?

A

Achieve a normal CD4 count and undetectable viral load

175
Q

How would you treat physical health problems (e.g. routine chest infection) on patients with normal CD4 and an undetectable viral load on ART?

A

As you would a HIV negative patient - check for medication interactions

176
Q

What are the different classes of HAART medications which work slightly different on the virus?

A

Protease inhibitors (PIs)

Integrase inhibitors (IIs)

Nucleoside reverse transcriptase inhibitors (NRTIs)

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Entry inhibitors (EIs)

177
Q

What forms part of the additional managment for a patient with diagnosed HIV?

A
  • Prophylactic co-trimoxazole (septrin) is given to patients with a CD4 of under 200/mm3 to protect against PCP
  • Patients with HIV have increased risk of developing CVD so close monitoring of risk factors and blood lipids - appropriate treatment (e.g. statins) may be required to reduce their risk of developing CVD
  • Yearly cervical smears for women with HIV as it predisposes patients to developing HPV and cervical cancer
  • Vaccinations up to date, including influenza, pneumococcal, hep A and B, tetanus, diptheria and poli vaccines - patients should avoid live vaccines
178
Q

If both partners are HIV positive, do they still need to use condoms?

A

Yes for vaginal and anal sex and dams for oral sex

If the viral load is undetectable then transmission through unprotected six is unheard of - even in extensive studies - infection is not impossible

179
Q

How may patients who are HIV positive concieve safely?

A

Techniques like sperm washing and IVF

180
Q

How may a HIV positive mother give birth?

A

The mother’s viral load will determine the mode of delivery:

Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml

Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml

IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml

181
Q

What prophylaxis against HIV for newborns is there?

A

Depends on mothers viral load:

Low-risk babies, where the mother’s viral load is < 50 copies per ml, are given zidovudine for four weeks

High-risk babies, where the mother’s viral load is > 50 copies / ml, are given zidovudine, lamivudine and nevirapine for four weeks

182
Q

Can HIV be transmitted during breast feeding?

A

Yes, even if the mother’s viral load is undetectable

183
Q

What is the window of oppourtinity for post-exposure prophylaxis for HIV?

A

Less than 72 hours - it’s not 100% effective

Risk assessment of probability of developing HIV balanced against the side effects of PEP

184
Q

What does PEP for HIV involve?

A

Combination of ART therapy, current regime:

  • Truvada (emtricitabine and tenofovir) and raltegravir for 28 days
185
Q

Post HIV exposure, when are HIV tests done?

A

Immediately and also a minimum of three months after exposure to confirm a negative status - individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative

186
Q

What bacteria causes syphillis?

A

Treponema pallidum

187
Q

What type of bacteria is treponema pallidum?

A

Spirochete - type of spiral-shaped bacteria - gets in through skin or mucous membranes, replicates and then disseminates throughout the body

Mainly an STI

188
Q

How long is the incubation period for syphillis?

A

21 days on average

189
Q

How can syphillis be contracted?

A

Oral, vaginal or anal sex involving direct contact with an infected area

Vertical transmission from mother to baby during pregnancy

Intravenous drug use

Blood transfusions and other transplants (although this is rare due to screening of blood products)

190
Q

Whar are the different stages / types of syphillis?

A

Primary

Secondary

Latent

Tertiary

Neurosyphilis

191
Q

What is primary syphilis?

A

Painless ulcer called a chancre at the original site of infection (usually on the genitals)

192
Q

What is secondary syphilis?

A

Systemic symptoms, particularly of the skin and mucous membranes - symptoms can result after 3-12 weeks and the patient can enter the latent stage

193
Q

What is latent syphilis?

A

Latent syphilis occurs after the secondary stage of syphilis where symptoms disappear and the patient becomes asymptomatic despite still being infected

194
Q

When does early latent syphilis occur?

A

Within 2 years of the initial infection and late latent syphilis occurs from 2 years after the initial infection onwards

195
Q

What is tertiary syphilis?

A

Occurs many years after the initial infection, affects many organs of the body particularly with the development of the gummas and cardiovascular and neurological complications

196
Q

What is neurosyphillis, when does it occur?

A

If the infection involves the CNS, presenting with neurological symptoms

197
Q

How does primary syphilis present?

A

A painless genital ulcer (chancre) tending to resolve over 3-8 weeks

Local lymphadenopathy

198
Q

How does secondary syphilis present?

A

Typically starts after the chancre is healed:

Maculopapular rash

Condylomata lata (grey wart-like lesions around the genitals and anus)

Low-grade fever

Lymphadenopathy

Alopecia (localised hair loss)

Oral lesions

199
Q

How does tertiary syphilis present?

A

Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)

Aortic aneurysms

Neurosyphilis

200
Q

How does neurosyphilis present?

A

Headache

Altered behaviour

Dementia

Tabes dorsalis (demyelination affecting the spinal cord posterior columns)

Ocular syphilis (affecting the eyes)

Paralysis

Sensory impairment

201
Q

What is argyll-robertson pupil?

A

A specific finding in neurosyphilis

A constricted pupil which accommodates when focusing on a near object but doesn’t react to light - often irregularly shaped - commonly called a ‘prostitutes pupil’

202
Q

How is a diagnosis of syphilis made?

A

Antibody testing for antibodies to the T.pallidum bacteria can be used as a screening test - then referred to a specialist GUM centre for further testing

Samples can be tested for T. pallidum with:

Dark field microscopy

Polymerase chain reaction (PCR)

203
Q

Which tests can be used to assess the quantity of antibodies being produced by the body to an infection with syphilis?

A

Rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) (non-specific but sensitive)

Higher number indicates a greater chance of active disease

204
Q

How do the PRP and VDRL quantify syphilis infection?

A

Tests involve introducing a sample of serum to a solution containing antigens and assessing the reaction. A more significant reaction suggests a higher quantity of antibodies

Non-specific so often produce false positives

205
Q

What does the management of a patient with syphilis involve?

A

Full screening for other STIs

Advice about avoiding sexual activity until treated

Contact tracing

Prevention of future infections

206
Q

What is the standard medication for syphilis?

A

Single deep intramuscular dose of benzathine benzylpenicillin (penicillin)

207
Q

What are alternative medications for syphilis e.g. late syphilis and neurosyphilis?

A

Ceftriaxone

Amoxicillin

Doxycycline

Obstetrics and Gynaecology (10 decks)

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