Genital Tract Infections

If you want to give your Obstetrics and Gynaecology preparation a quick boost, then read this blog post on Genital Tract Infections! 

The burden of untreated infections is especially high for women because sometimes these infections are asymptomatic or in other cases the symptoms are not recognizable. But not anymore because we have outlined everything you need to know in the paragraphs below!

Let’s learn more about Genital Tract Infections, a critical topic for your OBGYN preparation.

Asherman Syndrome 

Etiology

• Overzealous Curettage done For
  • AUB (Abnormal Uterine bleeding),
  • MTP
  • Secondary PPH
  • Such curettage injures basal lamina causing scarring & Fibrosis of endometrium . This then leads to secondary amenorrhea.
• Endometrial TB also causes Asherman Syndrome

Important information Max chances of occurrence of Asherman’s syndrome is when curettage was done for: Secondary PPH

Treatment

• Hysteroscopic Adhesiolysis
• Followed with High dose Estrogens & Progesterone: for cyclical withdrawal

Tubercular PID

• Incidence → 20-25% of women in India

Pathogenesis

• Endometritis Menorrhagia
  ↓
  Endometrial destruction
  ↓
  Asherman Syndrome→ Oligomenorrhea
  Hypomenorrhea 
  Amenorrhea
• Fallopian Tube
  • Calcific, beaded, rigid tube
  • Hydrosalpinx: Tobacco Pouch Hydrosalpinx
  • Retort Shaped Hydrosalpinx

Treatment

• 4 Drugs for 2 months & 3 Drugs for 4 months
• Do not stop the Rx in 1^st trimester

Pelvic Inflammatory Disease 

Causes

• Chamydia: Most prevalent; Indolent
• Gonorrhea: Most common in OPD
• Mycoplasma
• TB
• Ureaplasma
• Bacteroids
• Pepto streptococcus
• Bacterial vaginosis [important cause]
• Streptococcus

Important information MC cause if PID in India is Chlamydia, and not TB

Clinical Features 

Symptoms

• Pain abdomen
• Congestive dysmenorrhea
• Dysparunia
• Fever 

Signs

• Fever
  • Admit IF
    • Temp > 38°C/ 100.4°F
    • Severe Symptoms
    • Suspicious Pelvic Abscess
    • Unreliable/ Non Compliant Patient
    • Uncertain Diagnosis
• ↑ CRP
• Leucocytosis
• On P/v
  • cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness

Important information Cervical motion Tenderness is seen In Ruptured Ectopic Pregnancy as well as PID

Additional Criteria

• Culture & Sensitivity Of
  • Endometrial Biopsy
  • Vaginal swab
  • Cervical Swab
  • Culture Medias For
    • Gonorrhea: Thayer martin media
    • Chlamydia: Mc coy cell lines [PCR Preferred]
• ↑ ESR/ CRP
• ↑ TLC
• Fever > 100.4°F [38°C]

Elaborate Criteria

• Diagnostic Laparoscopy
  • Gives direct evidence
  • Laparoscopy “IF DONE” is the best way to diagnose PID
• USG: Documents pelvic/tuboovarian abscess

Discharge Criteria: Temperature < 99.5°F

Treatment

• Centre for disease control of atlanta In patient regimes
  • Out patient regimes
• Broad Spectrum Antibiotics

OPD Regime

• Cefoxitine 2gm iv or Cefotaxime 1gm iv
• Doxycycline 100 gm BD x 14 Days: For chlamydia
• Metronidazole 500 mg BD x 14 Days
  • For anaerobes
  • For bacterial vaginosis
• Azithromycin can be given instead of Doxycycline
• Clindamycin can be given instead of Metronidazole

Important information It is very important to treat Bacterial Vaginosis - metro is always given in all regimes. Untreated BV is important cause of relapse

Vaginitis

• Ph of Vagina
• Candidiasis → can occur in acidic ph of 4.5
• Bacterial vaginosis can occur in Alkaline PH
• Trichomoniasis Alkalinity Shift also predisposes [5.5 or 6...]

Amsel’s Criteria

• Useful in Dx of Bacterial vaginosis
• ≥ 3 out of 4 are required
  • Creamy discharge
  • Whiff Test ⊕
  • Fishy odour
  • Clue Cells

Acidic ph	Alkaline ph > 7
Candidiasis	Bacterial vaginosis	Trichomoniasis
Dimorphic Fungi Blastospores [Spreads] Mycelia [Invasion & adherence] Curdy white discharge plaque on vaginal wall on removal causes Petechiae Out of proportion Pruritus Complicated / uncomplicated Uncomplicated Seen in Ⓝ women Good prognosis a/w albicans  Complicated In immunocompromised [in DM, TB, pregnancy etc] Recurrent, Severe a/w non-albicans	Hemphilus vaginalis aka Gardenella vaginalis AMSEL’S >/= 3 out of 4 Creamy discharge Whift Test: +ve Secretion + 10% KOH → amines Fishy odour Clue Cells: vaginal epithelium with embeded bacteria No Pruritis	by Trichomonas vaginalis Flagellate protozoan  Motile organism cause severe irritation & severe pruritis Colpitis Macularis [Strawberry Vagina] Greenish yellow, Frothy discharge
Treatment Azoles Oral Fluconazole Rx both male & female	Treatment METRONIDAZOLE Rx the Women [no sexual transmission]	Treatment METRONIDAZOLE Rx both man & women

Important informationMC Vaginitis: Bacterial Vaginosis

Bacterial Vaginosis can cause

• PID
• Relapse of PID
• Chorioamnionitis [PID in pregnancy]
  • Abortion
  • IU Death
  • Puerperal sepsis
• Vault cellulitis
• Whiff test can also be positive in trichomoniasis
  • As both Bacterial vaginosis & Trichomoniasis CO-Exists
  • Classical For Bacterial vaginosis
• Rx the male partner also in Trichomoniasis
• Rx the male partner also in candidiasis
• Rx only women in B Vaginosis (as not STTD)

Q. Which of the following is the drug of choice for bacterial vaginosis in pregnancy? 

• Metronidazole
• Clindamycin
• Erythromycin
• Rovamycin

Q. A sexually active lady came with profuse yellowish frothy discharge with intense itching. On local examination of the vagina a ‘strawberry’ like cervix is revealed. What condition she is likely suffering from? 

• Candidiasis
• Trichomonas vaginitis
• Bacterial vaginosis
• Gonorrhea

Q. Green frothy discharge is seen in? 

• Herpes simplex
• Candida albicans
• Trichomonas vaginalis
• Normal vaginal flora

Q. A HSG is suggestive of Asherman syndrome. The woman suffering from this syndrome is likely to have which of the following presentations? 

• Amenorrhea
• Oligomenorrhea
• Menorrhagia
• Dysmenorrhea

Q. A woman presents with secondary amenorrhoea since 3 months since she had a curettage for missed abortion. FSH is 7 IU/L. A UPT is negative. What is the most likely diagnosis?

• Pituitary failure
• Ovarian failure
• Uterine synechiae
• Pregnancy

Q. A 28 year old woman was suspected to have genital tuberculosis. What is the percentage that fallopian tube would be involved in this case? 

• 100
• 80
• 60
• 50

Q. 18 year old girl comes to gynae OPD presenting with 6 months of amenorrhea, with h/o low grade fever, weight loss, pain abdomen, generalized weakness. On examination pelvic mass felt on left side with features of ascites. Diagnosis? 

• TB pelvis with tubo ovarian mass
• Ectopic pregnancy
• Granulosa cell tumour
• Fibroid degeneration

And that is everything you need to know about Genital Tract Infections for your Obstetrics and Gynecology preparation! For more informative posts like this, keep following PrepLadder’s blog.