[MDCU] Female genital tract infections

Cover core contents from - L11 : leukorrhea, STD, HIV infection - L23 : infectious disease in pregnancy

What are 5 components of vaginal secretion?

VEx TEC

• Vulvar secretion

• Exfoliated cells from cervix & vagina

• Transudate from vagina

• Endometrial / oviduct fluid

• Cervical mucous

Which hormone is responsible for glycogen formation in the vagina?

Estrogen

What are 4 principal outcome of STD therapy?

1. Microbiological eradication

2. Alleviate symptoms

3. Sequelae prevention

4. Transmission prevention

What are Amsel’s criteria for bacterial vaginosis?

1. Thin white gray homogenous discharge

2. Positive Whiff test

3. pH >4.5

4. Clue cell >20% of epithelial cells

What is the gold standard for the diagnosis of BV?

Gram stain

What is the gold standard for the diagnosis of trichomoniasis?

Culture, NAAT

Antibiotics for bacterial vaginosis

Metronidazole 500 mg oral 2 × 7

Antibiotics for trichomoniasis in affected patient

Metronidazole 500 mg oral 2 × 7

Antibiotics for trichomoniasis in sexual partner

Metronidazole 2 g oral single dose

Which disease causing abnormal vaginal discharge requires follow-up?

Trichomonas vaginalis (3 months)

After treatment, patients with trichomonas vaginalis should be retested at ___ months

3 months

Which disease causing abnormal vaginal discharge increases the risk of HIV infection?

Trichomonas vaginalis

Which disease causing abnormal vaginal discharge increases the risk of post-cesarean endometritis?

Bacterial vaginosis

Which disease causing abnormal vaginal discharge increases the risk of abnormal cervical cytology?

Bacterial vaginosis

BV and trichomoniasis can cause which complications during pregnancy?

• PROM

• Preterm labor

• Chorioamnionitis (BV)

Antibiotics for vaginal candidiasis

• Clotrimazole 100 mg suppository 1 × 7

• Fluconazole 150 mg oral single dose

• Antipruritics: CPM, hydroxyzine

Antibiotics for vaginal candidiasis in pregnancy

Clotrimazole 100 mg suppository 1 × 7

Cervicitis usually presents with which symptoms?

• Purulent exudate (WBC >10/HPF)

• Cervix that easily bleeds

Leukorrhea is a sensitive indicator for ___?

Cervical inflammation (cervicitis)

Patients with leukorrhea should be tested for which infection?

HIV and syphilis

Antibiotics for gonococcal infection in affected patient

Ceftriaxone 500 mg IM single dose + Azithromycin 1 g oral single dose

Antibiotics for gonococcal infection in sexual partner

Cefixime 400 mg oral single dose + Azithromycin 1 g oral single dose

Which pathogen causes genital ulcers that involve a superficial skin layer?

HSV

Which pathogen causes genital ulcers that involve a deep skin layer with undermined edge?

Chancroid

Which pathogen causes genital ulcers that involve a deep skin layer with smooth indurated edge?

Syphilis

Which pathogen causes genital ulcers that involve dysuria?

HSV

What is the diagnostic test for chancroid?

Culture for H.ducreyi

What is the diagnostic test for HSV genital ulcer?

PCR for HSV DNA

What are criteria for probable diagnosis of chancroid?

• Painful genital ulcers

• Regional lymphadenopathy

• Negative for syphilis

• Negative for HSV

Antibiotics for chancroid

• Ceftriaxone 250 mg IM single dose /

• Azithromycin 1 g oral single dose

Antibiotics for primary syphilis

Benzathine penicillin G 2.4 MU IM single dose

Non-treponemal test detects antibody to ___?

Cardiolipin-cholesterol-lecithin antigen

Non-treponemal test usually report as ___

Antibody titer

Treponemal test usually report as ___

Reactive / non-reactive

What are possible causes for false negative non-treponemal test?

• Prozone phenomenon

• Early infection

• Late latent infection

What are HIV treatment goal for Thailand in 2573?

• No new congenital HIV

• New cases <1,000 / year

• Access to ARV & no stigmatization

Recommended HAART regimen

TDF / TAF + Emtricitabine / Lamivudine + Dolutegravir

What is the management for pregnant woman receiving dolutegravir?

Risk of neural tube defect ↑

• Folic acid 4 mg

• Ultrasound screening

Which ARV drug should not be used with ergots?

Lopinavir / ritonavir (CYP inhibitor)

Which ARV drug, if taken with ergots, decreases their serum concentration?

Efavirenz (CYP inducer)

What is the drug regimen for pregnant woman GA >32 weeks with HIV VL >1,000?

• TAF / TDF

• Emtricitabine / Lamivudine

• Dolutegravir

• Raltegravir

Goal: ใช้ยา 4 ตัวเพื่อลดระดับไวรัสให้เร็วที่สุด

What is the delivery method for pregnant woman with HIV VL >1,000?

• Zidovudine 600 mg

• Elective C/S before labor at GA 38 weeks

• Avoid ARM & invasive monitoring

• Avoid LPV/r + ergots

What is the delivery method for pregnant woman with HIV VL 50-1,000?

• Zidovudine 600 mg

• Can try vaginal delivery

What is the delivery method for pregnant woman with HIV VL <50?

• Zidovudine is optional

• Can try vaginal delivery

Pregnant woman receiving ART before GA 20 weeks should be tested for HIV VL at GA ___

GA 32 weeks

Pregnant woman receiving ART after GA 20 weeks for >12 weeks should be tested for HIV VL at GA ___

GA 34-36 weeks

Pregnant woman receiving ART after GA 20 weeks for <12 weeks should be tested for HIV VL at GA ___

GA 36 weeks

What is the formula for daily PrEP?

TDF/FTC x 1 daily for at least 7 days

What is the formula for on-demand PrEP?

• TDF/FTC x2 2-24 hrs before SI

• x1 daily until 2 days after last SI

What is the formula for PEP?

TDF/FTC + DTG within 72 hours after SI for 28 days

When is the risk of HIV vertical transmission highest?

• 36 weeks labor

• During labor

What are risk factors of HIV vertical transmission?

• Preterm

• Prolong ROM

• Placental disruption

• Breastfeeding

• Vaginal delivery

• Invasive fetal monitoring

Which antiretroviral drug should be given to a newborn with high risk of contracting HIV?

• Zidovudine syrup 4 mg/kg q 12 hours x 4 weeks

• Lamivudine syrup 2 mg/kg q 12 hours x 4 weeks

• Nevirapine syrup 4 mg/kg q 24 hours x 4 weeks

Which antiretroviral drug should be given to a newborn with standard risk of contracting HIV?

Zidovudine 4 mg/kg q 12 hours x 4 weeks

Newborns with high risk of contracting HIV should receive HIV PCR at ___ months

1, 2, 4 months

Newborns with standard risk of contracting HIV should receive HIV PCR at ___ months

1, 2-4 months

Window period of hepatitis B infection is a state when ___ (2) are both negative

HBsAg and Anti-HBs

What is the risk factor of HBV vertical transmission?

• Absence of post-exposure prophylaxis

• Breastfeeding

What is the prophylaxis to HBV infection in infants born to mothers with HBsAg+?

• HBIG within 12 hours

• HBV vaccine at 0, 1, 6 months

Which factors are associated with failure of HBV immunoprophylaxis?

• HBeAg +

• High viral load (>200,000 units / >1,000,000 copy/ml)

When is the timing for maternal HBV antiviral therapy to be initiated?

Early 3rd trimester

→ Lamivudine, Tenofovir

Which laboratory test should be done in mother with HBsAg+?

HBeAg & ALT at GA 18-20 weeks

• HBeAg+ → TDF at 26-30 weeks

• ALT ↑ → Med

What is the management for women with HBsAg+ and HBeAg+?

Start TDF at GA 26-30 weeks

What is the postpartum management for women with HBsAg+ and HBeAg+?

• Stop TDF at 4 weeks

• ALT at 6 weeks

Which vaccines administered during pregnancy have maternal benefit?

• Pneumococcal

• Rabies

• Influenza

• Meningococcal

• Tetanus toxoid

• Hepatitis A & B

Which vaccines are contraindicated in pregnancy?

BOMVaRJ DIZ

• BCG

• OPV

• MMR

• Varicella

• Rotavirus

• JE

• Dengue

• Influenza (live-attenuated)

• Zoster

When should influenza and tetanus vaccine be administered during pregnancy?

Influenza (inactivated) x1 during 2nd / 3rd trimester

Tdap x1 : 20-32 weeks