17: Upper GT infections

Question 1

Endomyometritis occurs most commonly after ?

Answer 1

a delivery or instrumentation of the endometrial cavity

Question 2

Diagnosis of endomyometritis is made how?

Answer 2

clinically with findings of uterine tenderness, fever, and elevated WBC count.

Question 3

endomyometritis treatment

Answer 3

if unrelated to pregnancy, treat same as PID
if related to pregnancy use broad-spec abx such as IV clindamycin 900 mg q8h and gentamicin loaded with 2 mg/kg IV and then maintained with 1.5 mg/kg IV q8h or IV cephalosporins (cefoxitin 2 g IV q6h)

Question 4

what % of patients with PID will become infertile?

Answer 4

12%

-because of seriousness of this disease, patients are often hospitalized and treated with IV antibiotics.

Question 5

Minimal diagnosis criteria for PID consists of ?

Answer 5

pelvic or lower abdominal pain, plus uterine, adnexal, or cervical motion tenderness.
-can lead to TOAs or TOCs

Question 6

Diagnosis of TOA or TOC is most likely when there is ?
difference betweent TOA and TOC?
Confirmation is usually achieved with ?

Answer 6

an adnexal mass in the setting of PID symptoms.

TOC (complex) are not walled off like the true abscess and are thus more responsive to antimicrobial therapy

an imaging study such as pelvic ultrasound or CT

Question 7

TOA treatment includes ?

Answer 7

hospitalization and broad-spectrum IV abx:

• cefotetan 2 g IV q12h or cefoxitin 2 g IV q6h plus doxycycline (100 mg PO or IV q12h
• Clindamycin 900 mg q8h plus gentamicin (loading dose of 2 mg/kg, followed by 1.5 mg/kg IV q8h or 5 mg/kg IV q24h) with or without ampicillin (3 g IV q6h)

Question 8

TSS treatment

Answer 8

hospitalized and treated with IV antibiotics and, if necessary, hemodynamic support (fluids, pressors)

Question 9

risk factors for PID

Answer 9

RPOCs, STIs, intrauterine foreign bodies or growths, instrumentation of the intrauterine cavity
nonwhite and non-Asian ethnicity, multiple partners, recent history of douching, prior history of PID, and cigarette smoking
IUD insertion with current G/C or chlamydial infection

Question 10

chronic endometritis

Answer 10

• often asymptomatic
• polymicrobial
• Mtb a cause in developing countries, may lead to infertility
• s/s: chronic irregular bleeding, discharge, and pelvic pain
• dx: EMB showing plasma cells

Question 11

chronic endometritis treatment

Answer 11

doxycycline 100mg PO BID x10-14

Question 12

PID includes ?

Answer 12

any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
-incidence highest in the 15- to 25-year-old age group

Question 13

symptoms/sequelae of PID

Answer 13

chronic pelvic pain, increased vaginal discharge, abnormal odor, abnormal bleeding, GI disturbances, and UT symptoms, (fever in 20%), dyspareunia, and pelvic adhesions, infertility, 7-10x risk ectopic pregnancy

Question 14

Additional diagnostic criteria that supports the diagnosis of PID

Answer 14

fever (>38.3°C), abnormal cervical or vaginal mucopurulent discharge, abundant WBC on saline microscopy of vaginal secretions, elevated ESR, elevated CRP, cervical G/C or Chlamydia infections

Question 15

definitive diagnosis of PID made by ?

Answer 15

laparoscopy, endometrial biopsy, or pelvic imaging with PID findings.

Question 16

Fitzhugh-Curtis syndrome

Answer 16

perihepatitis from the ascending infection resulting in RUQ pain and tenderness and LFT elevations.

Question 17

PID organisms

Answer 17

N. gonorrhoeae and C. trachomatis;

polymicrobial: such as Bacteroides spp. Gardnerella, Escherichia coli, Haemophilus influenzae, and streptococci.

Question 18

inpatient PID treatment

Answer 18

broad-spectrum cephalosporin, such as cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h plus doxycycline 100 mg IV or PO q12h
-if allergic to cephs: IV clindamycin and gentamicin (also choice for preggos)

Question 19

outpatient PID treatment

Answer 19

single dose of ceftriaxone 250 mg IM or cefoxitin 2 g IM plus 1 g of probenecid PO along with doxycycline 100 mg PO BID x14 is used with close follow-up for resolution of symptoms

Question 20

TOA symptoms

Answer 20

abdominal and/or pelvic pain (90%) and fever and leukocytosis (60% to 80%). WBC count is usually elevated with a left shift and elevated ESR

Question 21

if TOA not responsive to abx?

curative therapy for TOA ?

Answer 21

if not responsive to abx, surgical drainage of TOA is recommended.
Unilateral salpingo-oophorectomy
For bilateral TOAs, often a TAH and bilateral salpingo-oophorectomy (TAHBSO) may be necessary

Question 22

Nonmenstrual-related TSS has been associated with ?

Answer 22

vaginal infections, vaginal delivery, cesarean section, postpartum endometritis, miscarriage, and laser treatment of condylomata.

Question 23

TSS symptoms

Answer 23

high fever (>38.9°C or 102°F), hypotension, diffuse erythematous macular rash, desquamation of the palms and soles 1 to 2 weeks after the acute illness, and multisystem involvement 3+ organ systems, GI (abd pain, V/D), myalgias, mucous membrane hyperemia, increased BUN and creatinine, platelet count less than 100,000, and alteration in consciousness
-Cx may be negative (exotoxin is absorbed)

Question 24

TSS abx therapy

Answer 24

reduces risk of recurrence
empiric: clindamycin plus vancomycin
MRSA TSS: clindamycin plus vancomycin or linezolid
MSSA TSS: clindamycin plus nafcillin or oxacillin
duration: x10-14

Question 25

HIV is initially asymptomatic (latent stage) which can last for ? years

Answer 25

5-7 years

Question 26

AIDS-related complex includes

Answer 26

lymphadenopathy, night sweats, malaise, diarrhea, weight loss, and unusual recurrent infections such as oral candidiasis, varicella zoster, or herpes simplex

Question 27

“pre-exposure prophylaxis” among sexually active adults without HIV to reduce their risk of becoming infected

Answer 27

tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC)

Question 28

nucleoside analogs

Answer 28

zidovudine (AZT), lamivudine (3TC), abacavir, didanosine, and stavudine—act to inhibit reverse transcriptase and interfere with viral replication

Question 29

Protease inhibitors

Answer 29

(lopinavir, atazanavir, indinavir, saquinavir, ritonavir) interfere with the synthesis of viral particles and have been effective in increasing CD4 counts and decreasing viral load.

Question 30

With no treatment, approximately ?% of infants born to HIV-infected mothers will become infected with HIV. Increased transmission can be seen with ?

Answer 30

25%
higher viral burden or advanced disease in the mother, ROM, and invasive procedures during labor and delivery that increase neonatal exposure to maternal blood.

Question 31

how to reduce the risk of perinatal transmission by two-thirds in women

Answer 31

three-part regimen of zidovudine (ZDV) administered during pregnancy and labor and to the newborn

Question 32

? has been shown to lower transmission rates by roughly two-thirds compared to vaginal delivery in patients on no therapy and particularly without onset of labor or ROM or in the setting of high viral load (>1000 copies/mL)

Answer 32

Cesarean delivery

Question 33

when to screen preggos for HIV

Answer 33

all pregnant women at their first prenatal visit and again in the third trimester if the woman has specified risk factors for HIV infection

Question 34

breastfeeding in HIV+ moms?

Answer 34

breastfeeding is contraindicated in HIV-infected woman as virus is found in breast milk and is responsible for HIV transmission to the infant

Question 35

high incidence of what gyne condition with HIV?

Answer 35

invasive cervical cancer (HPV)

• routine Pap smears at initial evaluation and 6 months later.
• if negative, annual Paps unless documentation of previous HPV infection, squamous intraepithelial lesion, or symptomatic HIV disease, in which case indicates 6-month intervals.

Question 36

when to start HAART in HIV+ pregnant patients

Answer 36

second trimester with goal for viral suppression by third trimester