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Gynecological infections Gebre K. Tseggay, M. D..

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1 Gynecological infections Gebre K. Tseggay, M. D.

2 Normal Vaginal Flora Dominated by lactobacilli Dominated by lactobacilli Lactobacilli convert glucose to lactic acid, to maintain an acidic vaginal pH of 3.8 to 4.2. This acidic environment inhibits the overgrowth of bacteria and other organisms with pathogenic potential. Lactobacilli convert glucose to lactic acid, to maintain an acidic vaginal pH of 3.8 to 4.2. This acidic environment inhibits the overgrowth of bacteria and other organisms with pathogenic potential. Some lactobacilli also produce hydrogen peroxide (H 2 O 2 ), a potential microbicide. Some lactobacilli also produce hydrogen peroxide (H 2 O 2 ), a potential microbicide. After onset of sexual activity, increase in Gardnerella vaginalis, lactobacilli, mycoplasmas, ureaplasmas is seen. After onset of sexual activity, increase in Gardnerella vaginalis, lactobacilli, mycoplasmas, ureaplasmas is seen.

3 BACTERIA ENDOGENOUS TO THE LOWER GENITALTRACT GRAM POSITIVEGRAM NEGATIVE Lactobacillus acidophilusEscherichia coli CorynebacteriumsppEnterobacter cloacae Gardnerella vaginalis Staphylococcus epidermidisKlebsiella Streptococci Morganella Enterococcus faecalisProteus PeptococcusBacteroides PeptostreptococcusFusobacterium Prevotella modified from Schlossberg,CTID 2001

4 Vaginitis Most common causes include: Vulvovaginal Candidiasis (VVC) Vulvovaginal Candidiasis (VVC) Bacterial Vaginosis (BV) Bacterial Vaginosis (BV) Trichomoniasis Trichomoniasis *In some cases the etiology may be mixed *In some cases the etiology may be mixed

5 VAGINITIS SYMPTOMS Often non-specific: Often non-specific: Abnormal discharge Abnormal discharge Vulvovaginal irritation Vulvovaginal irritation Vulvar itching Vulvar itching Odor Odor

6 VAGINITIS DIAGNOSIS History History Visual inspection Visual inspection Appearance of vaginal discharge: color, viscosity, adherence to vaginal walls, odor Appearance of vaginal discharge: color, viscosity, adherence to vaginal walls, odor Collection of specimen Collection of specimen Diagnostic tests: Diagnostic tests: Vaginal pH : determine vaginal pH with narrow-range pH paper Vaginal pH : determine vaginal pH with narrow-range pH paper Whiff test : assessment of a fishy odor after application of 10% KOH to wet mount Whiff test : assessment of a fishy odor after application of 10% KOH to wet mount KOH (wet mount): wet mount of discharge with 10% KOH KOH (wet mount): wet mount of discharge with 10% KOH NaCl (wet mount): wet mount of discharge with 0.9% normal saline NaCl (wet mount): wet mount of discharge with 0.9% normal saline

7 VAGINITIS DIAGNOSIS Other tests: Cultures: not used routinely, but are available for both T. vaginalis and Candida spp. Cultures: not used routinely, but are available for both T. vaginalis and Candida spp. New tests for BV (commercially available) : New tests for BV (commercially available) : Fem Exam Test Card™: pH and amines Fem Exam Test Card™: pH and amines Fem Exam vaginalis PIP Activity Test Card™: detects enzyme breakdown from G. vaginalis Fem Exam vaginalis PIP Activity Test Card™: detects enzyme breakdown from G. vaginalis DNA probe for 3 organisms (T. vaginalis, C. albicans, and G. vaginalis): sensitivity, specificity, and clinical utility are under investigation. DNA probe for 3 organisms (T. vaginalis, C. albicans, and G. vaginalis): sensitivity, specificity, and clinical utility are under investigation.

8 VULVOVAGINAL CANDIDIASIS Not considered to be STD Not considered to be STD Caused by overgrowth of Candida species ( Candida species are normal flora of vagina ) Caused by overgrowth of Candida species ( Candida species are normal flora of vagina ) 80-90% caused by C. albicans. 80-90% caused by C. albicans. Non-albicans candida play increasing role Non-albicans candida play increasing role

9 VULVOVAGINAL CANDIDIASIS RISK FACTORS Uncontrolled DM Corticosteroid therapy Antimicrobial therapy (oral, parental, topical) Poor hygiene Estrogen therapy High-dose estrogen contraceptives Pregnancy IUD HIV infection  Sponge  Nonoxynol-9 (?)  Diaphragm (?)  Increased frequency of coitus  "Candy binge“  Women frequenting STD clinics Tight-fitting synthetic underclothing But, most episodes of vulvovaginal candidiasis occur in the absence of a recognizable precipitating factors

10 CLASSIFICATION VULVOVAGINAL CANDIDIASIS CLASSIFICATION UncomplicatedComplicated Sporadic, infrequentRecurrent Mild-to-moderateSevere Likely C albicansNon-albicans Non-immunocomprisedDiabetes, pregnancy, immunosuppression

11 VULVOVAGINAL CANDIDIASIS MANIFESTATIONS Vulvar pruritis is most common symptom Vulvar pruritis is most common symptom Thick, white, curdy vaginal discharge ("cottage cheese-like") Thick, white, curdy vaginal discharge ("cottage cheese-like") Erythema, irritation, occasional erythematous "satellite" lesion Erythema, irritation, occasional erythematous "satellite" lesion External dysuria and dyspareunia External dysuria and dyspareunia

12 V DIAGNOSIS V ULVOVAGINAL CANDIDIASIS DIAGNOSIS Clinical Clinical pH normal (<4.5) pH normal (<4.5) Whiff test negative Whiff test negative Fungal stain positive Fungal stain positive 30% may have a negative fungal stain 30% may have a negative fungal stain Severity does not depend on No. yeasts present Severity does not depend on No. yeasts present

13 Regimens for the Treatment of Vulvovaginal Candidiasis Intravaginal agents: Intravaginal agents: Butoconazole 2% cream, 5 g intravaginally for 3 days† Butoconazole 2% cream, 5 g intravaginally for 3 days† Butoconazole 2% sustained release cream, 5 g single intravaginally application Butoconazole 2% sustained release cream, 5 g single intravaginally application Clotrimazole 1% cream 5 g intravaginally for 7-14 days† Clotrimazole 1% cream 5 g intravaginally for 7-14 days† Clotrimazole 100 mg vaginal tablet for 7 days Clotrimazole 100 mg vaginal tablet for 7 days Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application Miconazole 2% cream 5 g intravaginally for 7 days† Miconazole 2% cream 5 g intravaginally for 7 days† Miconazole 100 mg vaginal suppository, 1 suppository for 7 days† Miconazole 100 mg vaginal suppository, 1 suppository for 7 days† Miconazole 200 mg vaginal suppository, 1 suppository for 3 days† Miconazole 200 mg vaginal suppository, 1 suppository for 3 days† Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days Tioconazole 6.5% ointment 5 g intravaginally in a single application† Tioconazole 6.5% ointment 5 g intravaginally in a single application† Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 0.8% cream 5 g intravaginally for 3 days Terconazole 0.8% cream 5 g intravaginally for 3 days Terconazole 80 mg vaginal suppository, 1 suppository for 3 days Terconazole 80 mg vaginal suppository, 1 suppository for 3 days Oral agent: Oral agent: Fluconazole 150 mg oral tablet, 1 tablet in a single dose Fluconazole 150 mg oral tablet, 1 tablet in a single dose Note: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom product labeling for further information. † Over-the-counter (OTC) preparations

14 RECURRENT RECURRENT VULVOVAGINAL CANDIDIASIS Four or more symptomatic episodes/year Usually NOT from resistance to antifungals Diabetes mellitus or immunosuppression should be considered in refractory/ recurrent cases Simultaneous Rx of sex partners has no effect on recurrence (but 3-10% of sex partners may have balanitis) Vaginal culture useful to confirm diagnosis and identify unusual species Treatment Initial regimen of 7-14 days topical therapy Fluconazole 150 mg (repeat 72 hrs) Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole For Non-albicans VVC: Longer duration of therapy Non-azole regimen may even be needed 600 mg boric acid in gelatin capsule vaginally once a day for 14 days

15 Treatment in Pregnancy VULVOVAGINAL CANDIDIASIS Treatment in Pregnancy Only topical intravaginal regimens recommended (usually for 7 days) Only topical intravaginal regimens recommended (usually for 7 days)

16 Management of Sex Partners VULVOVAGINAL CANDIDIASIS Management of Sex Partners Treatment not recommended Treatment not recommended Treatment of male partners does not reduce frequency of recurrences in the female Treatment of male partners does not reduce frequency of recurrences in the female But, male partners with balanitis may benefit from treatment But, male partners with balanitis may benefit from treatment

17 BACTERIAL VAGINOSIS Not a classical STD Not a classical STD Overgrowth of vaginal normal flora with anaerobic bacteria and decrease or loss of protective lactobacilli (Disturbed vaginal ecosystem) Overgrowth of vaginal normal flora with anaerobic bacteria and decrease or loss of protective lactobacilli (Disturbed vaginal ecosystem) Gardrenella vaginalis (GV) & other microrganisms in high titers Gardrenella vaginalis (GV) & other microrganisms in high titers But, GV found in 50% of vaginal cultures in asymptomatic women too. But, GV found in 50% of vaginal cultures in asymptomatic women too. BV linked to: premature rupture of membranes, premature delivery and low birth-weight delivery, acquisition of HIV, development of PID, and post-operative infections after gynecological procedures BV linked to: premature rupture of membranes, premature delivery and low birth-weight delivery, acquisition of HIV, development of PID, and post-operative infections after gynecological procedures Male sex partners may be colonized but asymptomatic Male sex partners may be colonized but asymptomatic

18 BACTERIAL VAGINOSIS Gray, homogenous discharge w foul (fishy) odor reported mostly after vaginal intercourse and after completion of menses Gray, homogenous discharge w foul (fishy) odor reported mostly after vaginal intercourse and after completion of menses Without obvious vaginal inflammation Without obvious vaginal inflammation Clue cells present Clue cells present pH>4.5 pH>4.5 Positive Whiff test (KOH) Positive Whiff test (KOH)

19 NOT a clue cell Clue cells NOT a clue cell

20 BV Diagnosis: Amsel Criteria Amsel Criteria: Must have at least three of the following findings:  Vaginal pH >4.5  Presence of >20% per HPF of "clue cells" on wet mount examination  Positive amine or "whiff" test  Homogeneous, non-viscous, milky-white discharge adherent to the vaginal walls

21 BACTERIAL VAGINOSIS Other Diagnostic Tools Culture not recommended ; Do not Rx a positive GV vaginal culture in asymptomatic women Culture not recommended ; Do not Rx a positive GV vaginal culture in asymptomatic women Newer diagnostic modalities include: Newer diagnostic modalities include: FemExam™ FemExam™ PIP Activity TestCard™ PIP Activity TestCard™ DNA probe DNA probe

22 BACTERIAL VAGINOSIS TREATMENT Metronidazole 500 mg twice daily x 7 days Metronidazole 500 mg twice daily x 7 days Metronidazole gel 0.75%, 5 g intravaginally once daily x 5 days Metronidazole gel 0.75%, 5 g intravaginally once daily x 5 days Clindamycin cream 5%, 5 g intravaginally qhs x 7 days Clindamycin cream 5%, 5 g intravaginally qhs x 7 days Alternative regimens Metronidazole 2 gm in a single dose Metronidazole 2 gm in a single dose Clindamycin 300 mg twice daily x 7 days Clindamycin 300 mg twice daily x 7 days Clindamycin ovules 100 g intravaginally qhs x 3 days Clindamycin ovules 100 g intravaginally qhs x 3 days

23 BACTERIAL VAGINOSIS Treatment in Pregnancy Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes Do not use of topical agents in pregnancy Do not use of topical agents in pregnancy Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatal visit; optimal regimen not established

24 BACTERIAL VAGINOSIS Treatment in Pregnancy Metronidazole 250 mg three times daily for 7 days or Clindamycin 300 mg twice daily for 7 days

25 BACTERIAL VAGINOSIS Management of Sex Partners Not recommended Not recommended Woman’s response to therapy and the likelihood of relapse or recurrence not affected by treatment of sex partner Woman’s response to therapy and the likelihood of relapse or recurrence not affected by treatment of sex partner

26 TRICHOMONIASIS Etiologic agent Etiologic agent Trichomonas vaginalis – a flagellated protozoa Trichomonas vaginalis – a flagellated protozoa

27 Trichomoniasis and other vaginal infections — Initial visits to physicians’ offices: United States, 1966–2003 SOURCE: National Disease and Therapeutic Index (IMS Health)

28 TRICHOMONIASIS Estimated 7.4 million cases annually in the U.S. Estimated 7.4 million cases annually in the U.S. Almost always sexually transmitted Almost always sexually transmitted Causes urethritis in men (usu. asymptomatic) Causes urethritis in men (usu. asymptomatic) Transmission between female sex partners has been documented Transmission between female sex partners has been documented Fomite transmission rare Fomite transmission rare Possible association with Possible association with Pre-term rupture of membranes and pre-term delivery Pre-term rupture of membranes and pre-term delivery Increased risk of HIV acquisition Increased risk of HIV acquisition

29 TRICHOMONIASIS DIAGNOSIS Copious, yellow-green or gray frothy discharge, adherent to vaginal walls, w foul odor. Copious, yellow-green or gray frothy discharge, adherent to vaginal walls, w foul odor. Vulvovaginal erythema Vulvovaginal erythema Punctate cervical microhemorrhages seen in 25%: ‘strawberry cervix’ Punctate cervical microhemorrhages seen in 25%: ‘strawberry cervix’ Saline smear 80% sensitive, highly specific (motile trichomonads) Saline smear 80% sensitive, highly specific (motile trichomonads) Liquid culture, Diamond’s medium, done in persistent cases Liquid culture, Diamond’s medium, done in persistent cases Gram stain & Pap smear are not sensitive or specific Gram stain & Pap smear are not sensitive or specific Whiff test (KOH) +/- Whiff test (KOH) +/-

30 TRICHOMONIASIS TREATMENT Recommended regimen Metronidazole 2 gm orally in a single dose Alternative regimen Alternative regimen Metronidazole 500 mg twice a day for 7 days Pregnancy Metronidazole 2 gm orally in a single dose

31 TRICHOMONIASIS TREATMENT FAILURE Re-treat with metronidazole 500 mg twice daily for 7 days Re-treat with metronidazole 500 mg twice daily for 7 days If above fails, Rx with metronidazole 2 gm single dose x 3-5 days If above fails, Rx with metronidazole 2 gm single dose x 3-5 days In repeated failure: In repeated failure: Confirm diagnosis with culture Confirm diagnosis with culture consider metronidazole susceptibility testing through the CDC consider metronidazole susceptibility testing through the CDC Trial of tinidazole Trial of tinidazole

32 TRICHOMONIASIS TRICHOMONIASIS Other management issues No alcohol for the duration of treatment and for at least 24 h after the last dose. Trich is an STD, so: GC and Chlamydia testing should be done, & Syphilis, HIV, and hepatitis B serologic testing should be considered

33 TRICHOMONIASIS Management of Sex Partners Sex partners should be treated, even if asymptomatic Sex partners should be treated, even if asymptomatic Avoid intercourse until therapy is completed and patient and partner are asymptomatic Avoid intercourse until therapy is completed and patient and partner are asymptomatic.

34 VAGINITIS DIFFERENTIATION NormalTrichomoniasisCandidiasis Bacterial Vaginosis Symptom presentation discharge, itch, 50% asymptomatic Itch, discomfort, dysuria, thick discharge Odor, discharge, itch Vaginal discharge Clear to white Frothy, gray or yellow-green; malodorous Thick, clumpy, white “cottage cheese” Homogenous, adherent, thin, milky white; malodorous “foul fishy” Clinical findings Cervical petechiae “strawberry cervix” Inflammation and erythema Vaginal pH 3.8 - 4.2 > 4.5 Usually < 4.5 > 4.5 KOH “whiff” test Negative Often positive NegativePositive NaCl wet mount Lacto- bacilli Motile flagellated protozoa, many WBCs Few WBCs Clue cells (> 20%), no/few WBCs KOH wet mount Pseudohyphae

35 NON-INFECTIOUS VAGINITIS Vaginal foreign bodies, especially in prepubescent girls, may present with a heavy white discharge but would be unaccompanied by vulvar erythema or the microscopic appearance of hyphae. Atrophic vaginitis is commonly found in postmenopausal women and is distinguished from candidal vaginitis by mucosal dryness, atrophy, dyspareunia, minimal discharge, and itching. Contact dermatitis, local irritation secondary to tight- fitting underwear, and contact dermatitis from toiletry items, latex condoms, diaphragms, spermicides

36 MUCOPURULENT CERVICITIS Largely caused by Chlamydia trachomatis and Neiserria Gonorrheae Largely caused by Chlamydia trachomatis and Neiserria Gonorrheae

37 Chlamydia trachomatis

38 Chlamydia — Rates: United States, 1984–2003

39 Chlamydia — Rates by sex: United States, 1984–2003 CDC

40 Chlamydia trachomatis Estimated 3 million cases in the U.S. annually Estimated 3 million cases in the U.S. annually Women: bartholinitis, cervicitis, urethritis, PID, perihepatitis, conjunctivitis Women: bartholinitis, cervicitis, urethritis, PID, perihepatitis, conjunctivitis Men: urethritis, epididymitis Men: urethritis, epididymitis M&W: LGV M&W: LGV Infants: conjunctivitis, pneumonia Infants: conjunctivitis, pneumonia Complications: PID, perihepatitis, Reiter’s syndrome, infertility, ectopic pregnancy, chronic pelvic pain, increased risk for HIV Complications: PID, perihepatitis, Reiter’s syndrome, infertility, ectopic pregnancy, chronic pelvic pain, increased risk for HIV Incubation period is 7-21 days. Incubation period is 7-21 days.

41 Chlamydia trachomatis Risk factors Adolescence Adolescence Cervical epithelial cells are developmentally immature (ectopy) making them more susceptible to infection. Cervical epithelial cells are developmentally immature (ectopy) making them more susceptible to infection. Risky behaviors also contribute to susceptibility. Risky behaviors also contribute to susceptibility. New or multiple sex partners New or multiple sex partners History of past STD infection History of past STD infection Presence of another STD Presence of another STD Oral contraceptive use (contributes to cervical ectopy, & OCP users less likely to use barrier protection) Oral contraceptive use (contributes to cervical ectopy, & OCP users less likely to use barrier protection) Lack of barrier contraception Lack of barrier contraception

42 Chlamydia trachomatis Cervicitis Majority of cervical infections are asymtpomatic-70% to 80%. Majority of cervical infections are asymtpomatic-70% to 80%. When symptomatic, S+S may be non-specific: When symptomatic, S+S may be non-specific: spotting, or mucopurulent cervicitis, with mucopurulent endocervical discharge, edema, erythema, and friability w easily induced bleeding within the endocervix or any zones of ectopy. spotting, or mucopurulent cervicitis, with mucopurulent endocervical discharge, edema, erythema, and friability w easily induced bleeding within the endocervix or any zones of ectopy.Urethritis 50% of infected women yield chlamydia from both urethra and cervical sites 50% of infected women yield chlamydia from both urethra and cervical sites Usually asymptomatic Usually asymptomatic May cause the “dysuria-pyuria” syndrome mimicking acute cystitis. On urinalysis, pyuria present but few bacteria. May cause the “dysuria-pyuria” syndrome mimicking acute cystitis. On urinalysis, pyuria present but few bacteria.

43 Chlamydia trachomatis DIAGNOSIS Chlamydia trachomatis DIAGNOSIS Culture: high specificity BUT labor-intensive, expensive, labor-intensive, expensive, variable sensitivity (50%-80%), variable sensitivity (50%-80%), not suitable for widespread screening not suitable for widespread screening Non-culture methods: Serology: not very useful Serology: not very useful EIA, DFA, DNA probe : less sensitive(50-75%), nonspecific EIA, DFA, DNA probe : less sensitive(50-75%), nonspecific Nucleic acid amplification tests (NAAT): PCR, LCR: Nucleic acid amplification tests (NAAT): PCR, LCR: more sensitive than culture (>80%-90%) more sensitive than culture (>80%-90%) highly specific (>99%) highly specific (>99%) can use first void urine can use first void urine can use self-obtained vaginal swab can use self-obtained vaginal swab

44 Chlamydia trachomatis Treatment Azithromycin 1 gm single dose or Doxycycline 100 mg bid x 7d

45 Chlamydia trachomatis Alternative regimens Erythromycin base 500 mg qid for 7 days or Erythromycin ethylsuccinate 800 mg qid for 7 days or Ofloxacin 300 mg twice daily for 7 days or Levofloxacin 500 mg for 7 days

46 Chlamydia trachomatis Treatment in Pregnancy Recommended regimens Erythromycin base 500 mg qid for 7 days or Amoxicillin 500 mg three times daily for 7 days Alternative regimens Erythromycin base 250 mg qid for 14 days or Erythromycin ethylsuccinate 800 mg qid for 14 days or Erythromycin ethylsuccinate 400 mg qid for 14 days or Azithromycin 1 gm in a single dose

47 Chlamydia trachomatis Screening Annual screening of sexually active women < 25 yrs Annual screening of sexually active women < 25 yrs Annual screening of sexually active women > 25 yrs with risk factors Annual screening of sexually active women > 25 yrs with risk factors Sexual risk assessment may indicate need for more frequent screening for some women Sexual risk assessment may indicate need for more frequent screening for some women Screen pregnant women in the first trimester Screen pregnant women in the first trimester Re-screen women 3-4 months after treatment due to high prevalence of repeat infection Re-screen women 3-4 months after treatment due to high prevalence of repeat infection

48 GONORRHEA

49 Gonorrhea — Rates: United States, 1970–2003 and the Healthy People 2010 target Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

50 GONORRHEA Caused by Neisseria gonorrhoeae, a gram-neg intracellular diplococcus. Caused by Neisseria gonorrhoeae, a gram-neg intracellular diplococcus. Estimated 700,00-800,000 persons infected annually in the US. Estimated 700,00-800,000 persons infected annually in the US. Manifestations in women may include: Manifestations in women may include: cervicitis, PID, urethritis, pharyngitis, proctitis, disseminated (bacteremia,arthritis, tenosynovitis) cervicitis, PID, urethritis, pharyngitis, proctitis, disseminated (bacteremia,arthritis, tenosynovitis) Accessory gland infection (Bartholin’s glands, Skene’s glands) Accessory gland infection (Bartholin’s glands, Skene’s glands) Fitz-Hugh-Curtis Syndrome (Perihepatitis ) Fitz-Hugh-Curtis Syndrome (Perihepatitis )

51 Gonorrhea Cervicitis Gonorrhea Cervicitis Clinical Manifestations Symptoms are non-specific : abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia Symptoms are non-specific : abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding 50% of women with clinical cervicitis are asymptomatic 50% of women with clinical cervicitis are asymptomatic Incubation period unclear, but symptoms may occur within 10 days of infection Incubation period unclear, but symptoms may occur within 10 days of infection

52 Bartholin’s Abscess Gonorrhea Cervicitis

53 GONORRHEA LAB DIAGNOSIS Culture (selective media-Thayer Martin, needs CO2) Culture (selective media-Thayer Martin, needs CO2) Non-culture tests: DNA probe, nucleic acid amplification Non-culture tests: DNA probe, nucleic acid amplification Gram-stain, less sensitive in cervicitis ( most sensitive for symptomatic urethritis in men ) Gram-stain, less sensitive in cervicitis ( most sensitive for symptomatic urethritis in men )

54 Gonorrhea: Gram Stain of Urethral Discharge Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

55 Neisseria gonorrhoeae ( Cervix, Urethra, Rectum) Cefixime 400 mg or Ceftriaxone 125 IM or 1 Ciprofloxacin 500 mg or 1 Ofloxacin 400 mg or 1 Levofloxacin 250 mg PLUS Chlamydial therapy if infection not ruled out 1 Contraindicated in pregnancy and children. Not recommended for infections acquired in California, Asia, or the Pacific, including Hawaii.

56 Neisseria gonorrhoeae (Cervix, Urethra, Rectum) Alternative regimens Spectinomycin 2 grams IM in a single dose or Single dose cephalosporin (cefotaxime 500 mg) or Single dose quinolone (gatifloxacin 400 mg, lomefloxacin 400 mg, norfloxacin 800 mg) PLUS Chlamydial therapy if infection not ruled out

57 Neisseria gonorrhoeae Treatment in Pregnancy Cephalosporin regimen Cephalosporin regimen Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM Women who can’t tolerate cephalosporin regimen may receive 2 g spectinomycin IM No quinolone or tetracycline regimen No quinolone or tetracycline regimen PLUS Erythromycin or amoxicillin for presumptive or diagnosed chlamydial infection

58 Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2003 Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

59 Neisseria gonorrhoeae Antimicrobial Resistance Surveillance is crucial for guiding therapy recommendations Surveillance is crucial for guiding therapy recommendations No significant resistance to ceftriaxone No significant resistance to ceftriaxone Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California, Washington. Fluoroquinolone resistance in SE Asia, Pacific, Hawaii, California, Washington. FQ resistance 15% in MSM. FQ resistance 15% in MSM.

60 GONORRHEA TREATMENT ISSUES Fluoroquinolones are no longer recommended for therapy for gonorrhea acquired in Asia, the Pacific Islands (including Hawaii), and California. Fluoroquinolones are no longer recommended for therapy for gonorrhea acquired in Asia, the Pacific Islands (including Hawaii), and California. CDC no longer recommends fluoroquinolones as a first-line therapy for gonorrhea in MSM CDC no longer recommends fluoroquinolones as a first-line therapy for gonorrhea in MSM If symptoms persist, perform culture for N. gonorrhoeae. If symptoms persist, perform culture for N. gonorrhoeae. Any gonococci isolated should be tested for antimicrobial susceptibility Any gonococci isolated should be tested for antimicrobial susceptibility Co-infection with Chlamydiae in up to 50% of pts, hence anti-Chlmydia Rx added. Co-infection with Chlamydiae in up to 50% of pts, hence anti-Chlmydia Rx added. Note : A test of cure is not recommended, if a recommended regimen is administered. Note : A test of cure is not recommended, if a recommended regimen is administered.

61 GONORRHEA Partner Management Evaluate and treat all sex partners for N. gonorrhoeae and C. trachomatis infections if contact was within 60 days of symptoms or diagnosis. Evaluate and treat all sex partners for N. gonorrhoeae and C. trachomatis infections if contact was within 60 days of symptoms or diagnosis. If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated. If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated. Avoid sexual intercourse until therapy is completed and both partners no longer have symptoms. Avoid sexual intercourse until therapy is completed and both partners no longer have symptoms.

62 PELVIC INFLAMMATORY DISEASE (PID)

63 PELVIC INFLAMMATORY DISEASE Estimated about 1 million annual cases in the US Estimated about 1 million annual cases in the US Endometritis, salpingitis, tuboovarian abscess, & pelvic peritonitis. Endometritis, salpingitis, tuboovarian abscess, & pelvic peritonitis. Ascending infection from or via cervix Ascending infection from or via cervix Most cases of PID are polymicrobial: Chlamydia, GC, vaginal organisms, anaerobes, enteric GNR, GPC). Most cases of PID are polymicrobial: Chlamydia, GC, vaginal organisms, anaerobes, enteric GNR, GPC). May be unrelated to STD. May be unrelated to STD. Most common pathogens: Most common pathogens: N. gonorrhoeae: recovered from cervix in 30%-80% of women with PID N. gonorrhoeae: recovered from cervix in 30%-80% of women with PID C. trachomatis: recovered from cervix in 20%-40% of women with PID C. trachomatis: recovered from cervix in 20%-40% of women with PID N. gonorrhoeae and C. trachomatis are present in combination in approximately 25%-75% of patients N. gonorrhoeae and C. trachomatis are present in combination in approximately 25%-75% of patients

64 PELVIC INFLAMMATORY DISEASE PELVIC INFLAMMATORY DISEASE RISK FACTORS Adolescence (in sexually active teens 3x more than 25-29 yr olds) Adolescence (in sexually active teens 3x more than 25-29 yr olds) History of PID History of PID GC or chlamydia, or a history of GC or chlamydia GC or chlamydia, or a history of GC or chlamydia Male partners with GC or chlamydia Male partners with GC or chlamydia Multiple partners Multiple partners Current douching Current douching Insertion of IUD (especially within 4 mos after insertion) Insertion of IUD (especially within 4 mos after insertion) Bacterial vaginosis Bacterial vaginosis Demographics (lower socioeconomic status) Demographics (lower socioeconomic status) Oral contraceptive use, in some cases (by avoidance of barrier precautions?) Oral contraceptive use, in some cases (by avoidance of barrier precautions?)

65 PID Classification Overt 40% CDC

66 PELVIC INFLAMMATORY DISEASE Minimum Diagnostic Criteria Uterine/adnexal tenderness or cervical motion tenderness Additional Diagnostic Criteria Oral temperature >38.3 CElevated ESR Cervical Chlamydia or GCElevated CRP WBCs/saline microscopy Cervical Discharge

67 Pelvic Inflammatory Disease More Specific Criteria Endometrial biopsy: histopathologic evidence of endometritis Endometrial biopsy: histopathologic evidence of endometritis Imaging Studies: Transvaginal sonography or MRI (showing thickened fluid-filled tubes) Imaging Studies: Transvaginal sonography or MRI (showing thickened fluid-filled tubes) Laparoscopy: abnormalities consistent with PID Laparoscopy: abnormalities consistent with PID

68 PELVIC INFLAMMATORY DISEASE MANAGEMENT Antibiotics Antibiotics Bed rest Bed rest Reevaluation within 72 hrs of treatment Reevaluation within 72 hrs of treatment All male sex partners should be evaluated for STD and empirically treated with regimen effective for GC/Chlmydia All male sex partners should be evaluated for STD and empirically treated with regimen effective for GC/Chlmydia

69 Hospitalize, if: Surgical emergencies not excluded (e.g., appendicitis, ectopic pregnancy..) Surgical emergencies not excluded (e.g., appendicitis, ectopic pregnancy..) Pregnant patient Pregnant patient Pelvic abscess is suspected Pelvic abscess is suspected Adolescent Adolescent Severe illness Severe illness If unable to tolerate outpt regimen If unable to tolerate outpt regimen If f/up within 72 hrs after starting abx cannot be arranged If f/up within 72 hrs after starting abx cannot be arranged Non-response to oral therapy Non-response to oral therapy HIV infection with low CD4 count HIV infection with low CD4 count PELVIC INFLAMMATORY DISEASE MANAGEMENT

70 Pelvic Inflammatory Disease Parenteral Regimen A Cefotetan 2 g IV q 12 hours or Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg orally/IV q 12 hrs

71 PELVIC INFLAMMATORY DISEASE Parenteral Regimen B Clindamycin 900 mg IV q 8 hours PLUS Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.

72 PELVIC INFLAMMATORY DISEASE Alternative Parenteral Regimens Ofloxacin 400 mg IV q 12 hours or Levofloxacin 500 mg IV once daily WITH OR WITHOUT Metronidazole 500 mg IV q 8 hours or Ampicillin/Sulbactam 3 g IV q 6 hrs PLUS Doxycycline 100 mg orally/IV q 12 hrs

73 PELVIC INFLAMMATORY DISEASE Oral Regimen A Ofloxacin 400 mg twice daily for 14 days or Levofloxacin 500 mg once daily for 14 days WITH OR WITHOUT Metronidazole 500 mg twice daily for 14 days

74 PELVIC INFLAMMATORY DISEASE Oral Regimen B Ceftriaxone 250 mg IM in a single dose or Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently PLUS Doxycycline 100 mg twice daily for 14 days WITH or WITHOUT WITH or WITHOUT Metronidazole 500 mg twice daily for 14 days

75 SUSPECTED TUBOOVARIAN ABSCESS Cultures Cultures Broad spectrum antibiotics Broad spectrum antibiotics 85% of abscesses w a diameter of 4-6 cm (& only 40% of those >10 cm) respond to abx alone 85% of abscesses w a diameter of 4-6 cm (& only 40% of those >10 cm) respond to abx alone Surgery for failure to respond to abx. Surgery for failure to respond to abx.

76 PELVIC INFLAMMATORY DISEASE SEQUELAE Ectopic pregnancy Ectopic pregnancy 7-fold increase in risk after a single episode of PID 7-fold increase in risk after a single episode of PID Infertility: Infertility: 13% of women after one episode of PID 13% of women after one episode of PID 25-35% after 2 episodes, 50-75% after 3 or more episodes 25-35% after 2 episodes, 50-75% after 3 or more episodes 2/3 unable to conceive after Rx for TOA 2/3 unable to conceive after Rx for TOA Dyspareunia Dyspareunia Pelvic adhesions Pelvic adhesions Chronic pelvic pain Chronic pelvic pain

77 PELVIC INFLAMMATORY DISEASE Management of Sex Partners Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptoms Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptoms Sex partners should be treated empirically with regimens effective against CT and GC Sex partners should be treated empirically with regimens effective against CT and GC

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79 Genital herpes — Initial visits to physicians’ offices: United States, 1966–2003 SOURCE: National Disease and Therapeutic Index (IMS Health)

80 Genital HSV Infection More than one in five Americans (45 million people)-are estimated infected with genital herpes more common in women than men, infecting approximately one out of four women, versus one out of five men. ---Silent epidemic--- In a national house-hold survey, less than 10 percent of people who tested positive with herpes knew they were infected (Fleming, 1997). ---Silent epidemic--- Genital herpes is a recurrent, lifelong viral infection. Genital herpes is a recurrent, lifelong viral infection. Most sexual transmission occurs while source case is asymptomatic). Asymptomatic shedding occurs (Most sexual transmission occurs while source case is asymptomatic). Incubation period is 2-12 days (average is 4 days). Incubation period is 2-12 days (average is 4 days). Can be transmitted between sex partners, from mothers to newborns, and can increase a person's risk of becoming infected with HIV

81 Estimated Annual Incidence of Selected STDs in the U.S., 2000 Trichomoniasis 7.4 million Trichomoniasis 7.4 million Human Papillomavirus (HPV) 6.2 million Human Papillomavirus (HPV) 6.2 million Chlamydia 2.8 million Chlamydia 2.8 million Herpes Simplex Virus (HSV) Type 2 : 1.6 million Herpes Simplex Virus (HSV) Type 2 : 1.6 million Gonorrhea 718,000 Gonorrhea 718,000 Syphilis 37,000 Syphilis 37,000

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83 HSV Serologic Tests Type-Specific HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1 HSV-specific glycoprotein G2 for HSV 2 infection and glycoprotein G1 for HSV 1 Available gG type-specific assays- POCkit HSV-2, HerpeSelect HSV1/2 IgG ELISA and HerpeSelect 1/2 immunoblot IgG Available gG type-specific assays- POCkit HSV-2, HerpeSelect HSV1/2 IgG ELISA and HerpeSelect 1/2 immunoblot IgG Sensitivity 80-98%, Specificity > 96% Sensitivity 80-98%, Specificity > 96% Confirmatory testing may be indicated in some settings Confirmatory testing may be indicated in some settings

84 Genital Herpes First Clinical Episode Acyclovir 400 mg tid Acyclovir 400 mg tid or or Famciclovir 250 mg tid Famciclovir 250 mg tid or or Valacyclovir 1000 mg bid Valacyclovir 1000 mg bid Duration of Therapy 7-10 days Duration of Therapy 7-10 days

85 Genital Herpes Episodic Therapy Acyclovir 400 mg three times daily x 5 days or Acyclovir 800 mg twice daily x 5 days or Famciclovir 125 mg twice daily x 5 days or Valacyclovir 500 mg twice daily x 3-5 days or Valacyclovir 1 gm orally daily x 5 days

86 Genital Herpes Daily Suppression Acyclovir 400 mg bid Acyclovir 400 mg bidor Famciclovir 250 mg bid Famciclovir 250 mg bidor Valacyclovir 500-1000 mg daily Valacyclovir 500-1000 mg daily

87 Genital Herpes in HIV Infection May have prolonged or severe episodes with extensive genital or perianal disease May have prolonged or severe episodes with extensive genital or perianal disease Episodic or suppressive antiviral therapy often beneficial Episodic or suppressive antiviral therapy often beneficial For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary For severe cases, acyclovir 5-10 mg/kg IV q 8 hours may be necessary

88 Genital Herpes HIV Infection/Episodic Therapy Acyclovir 400 mg three times daily Acyclovir 400 mg three times dailyor Famciclovir 500 mg twice daily Famciclovir 500 mg twice dailyor Valacyclovir 1 gm twice daily Valacyclovir 1 gm twice daily Duration of Therapy 5-10 days Duration of Therapy 5-10 days

89 Genital Herpes HIV Infection/Daily Suppression Acyclovir 400-800 mg twice to three times daily or Famciclovir 500 mg twice daily or Valacyclovir 500 mg twice daily

90 Genital Herpes Antiviral Resistance Persistent or recurrent lesions on antivirals Persistent or recurrent lesions on antivirals Obtain viral isolate for viral susceptability Obtain viral isolate for viral susceptability 5% immunocomprised patients 5% immunocomprised patients Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir Acyclovir resistant isolates-resistant to valacyclovir, most resistant to famciclovir Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days) Alternatives: Foscarnet 40 mg/kg IV q 8 or topical cidofovir gel 1% (daily x 5 days)

91 Herpes in Pregnancy Risk for transmission to neonate from infected mother is : high (30%-50%) among women who acquire genital herpes near the time of delivery, but low (<1%) in women with histories of recurrent herpes at term or who acquire genital HSV during the first half of pregnancy. high (30%-50%) among women who acquire genital herpes near the time of delivery, but low (<1%) in women with histories of recurrent herpes at term or who acquire genital HSV during the first half of pregnancy. Prevention of neonatal herpes depends on avoiding acquisition of HSV during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery. Prevention of neonatal herpes depends on avoiding acquisition of HSV during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery. Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally

92 Genital Herpes Treatment in Pregnancy Acyclovir may be used with first episode or severe recurrent disease Acyclovir may be used with first episode or severe recurrent disease Available data do not indicate an increased risk of major birth defects (first trimester) Available data do not indicate an increased risk of major birth defects (first trimester) The safety of acyclovir, valacyclovir, and famciclovir therapy in pregnant women has not been established. The safety of acyclovir, valacyclovir, and famciclovir therapy in pregnant women has not been established.

93 Genital Herpes Counseling Natural history of infection, recurrences, asymptomatic shedding, transmission risk Natural history of infection, recurrences, asymptomatic shedding, transmission risk Individualize use of episodic or suppressive therapy Individualize use of episodic or suppressive therapy Abstain from sexual activity when lesions or prodromal symptoms present Abstain from sexual activity when lesions or prodromal symptoms present Risk of neonatal infection Risk of neonatal infection

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96 HUMAN PAPILLOMAVIRUS 6.2 million Americans get a new genital HPV infection each year. 6.2 million Americans get a new genital HPV infection each year. May cause cancer of cervix, vulva, vagina, or anus May cause cancer of cervix, vulva, vagina, or anus the most common sources of genital warts--HPV types 6 and 11--are rarely associated with malignancy the most common sources of genital warts--HPV types 6 and 11--are rarely associated with malignancy the high-risk HPV types 16 and 18 have been found in more than 90% of cervical cancers the high-risk HPV types 16 and 18 have been found in more than 90% of cervical cancers They appear an average of 3 months after exposure, the latency period can be much longer. They appear an average of 3 months after exposure, the latency period can be much longer. Infection can be clinically apparent, subclinical, or latent Infection can be clinically apparent, subclinical, or latent Frequency of spontaneous regression is unclear. A few studies indicate a regression rate of 10%-30% within 3 months. Frequency of spontaneous regression is unclear. A few studies indicate a regression rate of 10%-30% within 3 months. Persistence of infection occurs, but frequency and duration is unknown. Persistence of infection occurs, but frequency and duration is unknown. Recurrences after treatment are common (20%-50% recurrence rate at 3-6 months). Recurrences after treatment are common (20%-50% recurrence rate at 3-6 months). Symptoms Symptoms Genital warts usually cause no symptoms other than the warts themselves. Genital warts usually cause no symptoms other than the warts themselves. Vulvar warts can cause dyspareunia, pruritis, and burning discomfort. Vulvar warts can cause dyspareunia, pruritis, and burning discomfort. Urethral meatal warts occasionally cause hematuria or impairment of urinary stream. Urethral meatal warts occasionally cause hematuria or impairment of urinary stream. Vaginal warts occasionally cause discharge, bleeding, or obstruction of birth canal (due to increased wart growth in pregnancy). Vaginal warts occasionally cause discharge, bleeding, or obstruction of birth canal (due to increased wart growth in pregnancy).

97 HUMAN PAPILLOMAVIRUS Risk for Malignancy Externa genital warts Externa genital warts HPV types 6, 11. HPV types 6, 11. Minimal risk for malignancy Minimal risk for malignancy Flat warts Flat warts HPV 16,18, 31, 45… HPV 16,18, 31, 45… Associated with cancer of cervix, vagina, vulva, anus, penis Associated with cancer of cervix, vagina, vulva, anus, penis Most women with persistent HPV infection do not develop cervical cancer precursors or cervical cancer. Most women with persistent HPV infection do not develop cervical cancer precursors or cervical cancer. Over 99% of cervical cancers have HPV DNA detected within the tumor. Over 99% of cervical cancers have HPV DNA detected within the tumor. Persistent infection with a high-risk HPV type is necessary but not sufficient for the development of cervical cancer. Persistent infection with a high-risk HPV type is necessary but not sufficient for the development of cervical cancer.

98 HUMAN PAPILLOMAVIRUS DIAGNOSIS Inspection usually diagnostic of external warts:, biopsy if in doubt Inspection usually diagnostic of external warts:, biopsy if in doubt Pap smear, biopsy for flat warts of cervix Pap smear, biopsy for flat warts of cervix HPV-DNA studies, PCR, hybrid capture HPV-DNA studies, PCR, hybrid capture HPV cannot be cultured, and serologic tests are not available to test for HPV antibodies HPV cannot be cultured, and serologic tests are not available to test for HPV antibodies Subclinical infections may be detected by applying 3% to 5% acetic acid solution for 5 to 10 minutes. The lesions then become visible, and can be further visualized via colposcopy. Subclinical infections may be detected by applying 3% to 5% acetic acid solution for 5 to 10 minutes. The lesions then become visible, and can be further visualized via colposcopy.

99 HUMAN PAPILLOMAVIRUS Treatment Primary goal for treatment of visible warts is the removal of symptomatic warts Primary goal for treatment of visible warts is the removal of symptomatic warts Therapy may reduce but probably does not eradicate infectivity Therapy may reduce but probably does not eradicate infectivity Difficult to determine if treatment reduces transmission Difficult to determine if treatment reduces transmission No laboratory marker of infectivity No laboratory marker of infectivity Variable results utilizing viral DNA Variable results utilizing viral DNA

100 HUMAN PAPILLOMAVIRUS Choice of therapy guided by preference of patient, experience of provider, resources Choice of therapy guided by preference of patient, experience of provider, resources No evidence that any regimen is superior No evidence that any regimen is superior Locally developed/monitored treatment algorithms associated with improved clinical outcomes Locally developed/monitored treatment algorithms associated with improved clinical outcomes Acceptable alternative may be to observe; possible regression/uncertain transmission Acceptable alternative may be to observe; possible regression/uncertain transmission

101 PAPILLOMAVIRUS Patient-applied Podofilox 0.5% solution or gel Podofilox 0.5% solution or gel Imiquimod 5% cream Imiquimod 5% creamProvider-administered Cryotherapy Cryotherapy Podophyllin resin 10-25% Podophyllin resin 10-25% Trichloroacetic or Bichloroacetic acid 80-90% Trichloroacetic or Bichloroacetic acid 80-90% Surgical removal Surgical removal

102 HUMAN PAPILLOMAVIRUS Treatment in Pregnancy Imiquimod, podophyllin, podofilox should not be used in pregnancy Imiquimod, podophyllin, podofilox should not be used in pregnancy Many specialists advocate wart removal due to possible proliferation and friability Many specialists advocate wart removal due to possible proliferation and friability HPV types 6 and 11 can cause respiratory papillomatosis in infants and children HPV types 6 and 11 can cause respiratory papillomatosis in infants and children Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction

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105 CHORIOAMNIONITIS RISK FACTORS Nulliparity Nulliparity Length of labor Length of labor Preterm labor Preterm labor PROM PROM Meconium stained amniotic fluid Meconium stained amniotic fluid Internal fetal or uterine monitoring Internal fetal or uterine monitoring Presence of GU pathogens (GBS, GC,BV) Presence of GU pathogens (GBS, GC,BV) No of vag exams in women w ruptured membrane No of vag exams in women w ruptured membrane Underlying Host Factors No. of lactobacilli, IgA, Chronic diseases Immunosuppression Nutritional disorders Drug abuse.

106 CHORIOAMNIONITIS DIAGNOSIS Maternal fever >38C(>100.4) AND at least 2 of the following: Maternal fever >38C(>100.4) AND at least 2 of the following: Maternal leukocytosis (>15,000 cells/cubic mm) Maternal leukocytosis (>15,000 cells/cubic mm) Maternal tachycardia (>100 beats/min) Maternal tachycardia (>100 beats/min) Fetal tachycardia (>160 beats/min) Fetal tachycardia (>160 beats/min) Uterine tenderness Uterine tenderness Foul odor of the amniotic fluid Foul odor of the amniotic fluid AMNIOTIC FLUID ANALYSIS: AMNIOTIC FLUID ANALYSIS: Gram stain: bacteria & leukocytes (> 6 leukocytes/hpf) Gram stain: bacteria & leukocytes (> 6 leukocytes/hpf) Glucose (<15mg/dl abnormal) Glucose (<15mg/dl abnormal) WBC (Abnormal >30 cells/cc) WBC (Abnormal >30 cells/cc) Leukocyte esterase (strips) + Leukocyte esterase (strips) + Abnormal glu + wbc + Leuk/esterase= sensitivity 90%, specificty 80% for pos culture MICROBIOLOGY: Organisms from vaginal flora, anaerobes, mycoplasma, GBS, E.coli. Organisms from vaginal flora, anaerobes, mycoplasma, GBS, E.coli. Usually polymicrobial Usually polymicrobial

107 CHORIOAMNIONITIS MANAGEMENT 1. Antibiotics Amp/gent/clinda. Amp/gent/clinda. Other broad-spectrum regimen Other broad-spectrum regimen 2. Delivery (Note: C-section should be performed only for accepted obstetric indications)

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109 POSTPARTUM ENDOMETRITIS DIAGNOSIS Fever, usually on 1 st or 2 nd postpartum day. Fever, usually on 1 st or 2 nd postpartum day. Lower abdominal pain Lower abdominal pain Uterine tenderness Uterine tenderness Leukocytosis Leukocytosis Bimanual exam should be done Bimanual exam should be done Microbiologic diagnosis: Transvaginally obtained cultures are controversial (contaminants) Transvaginally obtained cultures are controversial (contaminants) Blood cultures should be done (10-20% have bacteremia) Blood cultures should be done (10-20% have bacteremia) Chlamydia testing (culture, antigen, PCR) should be done for high risk pts & with late-onset PPE. Chlamydia testing (culture, antigen, PCR) should be done for high risk pts & with late-onset PPE.

110 POSTPARTUM ENDOMETRITIS PREDISPOSING FACTORS C-section, especially after labor or rupture of membranes is the main predictor C-section, especially after labor or rupture of membranes is the main predictor Incidence after vaginal delivery 0.9-3.9 % Incidence after vaginal delivery 0.9-3.9 % Incidence after C-section 10-50% Incidence after C-section 10-50% Other predictors: Other predictors: Duration of labor Duration of labor Rupture of membranes Rupture of membranes Presence of BV Presence of BV Number of vag. Exams during labor Number of vag. Exams during labor Use of internal fetal monitoring. Use of internal fetal monitoring.

111 POSTPARTUM ENDOMETRITIS (PPE) MICROBIOLOGY Polymicrobial (GBS, enterococci, G. vaginalis, E. coli, Prevotella bivia, Bacteroides spp, peptostreptococci, Ureoplasma urealyticum, Mycoplasma hominis) Polymicrobial (GBS, enterococci, G. vaginalis, E. coli, Prevotella bivia, Bacteroides spp, peptostreptococci, Ureoplasma urealyticum, Mycoplasma hominis) Chlamydia trachomatis may cause a late form of PPE (>2days to 6 wks postpartum, after vag delivery) Chlamydia trachomatis may cause a late form of PPE (>2days to 6 wks postpartum, after vag delivery) Group A Strep PPE is rare Group A Strep PPE is rare of exogenous source, usually caregiver. of exogenous source, usually caregiver. Major epidemiologic significance: HCW screening (all at the delivery & those who did vag exam before delivery should be screened w cultures of nares, throat, vagina, rectum, skin. If culture + should refrain from patient care for the 1 st 24h of abx therapy) Major epidemiologic significance: HCW screening (all at the delivery & those who did vag exam before delivery should be screened w cultures of nares, throat, vagina, rectum, skin. If culture + should refrain from patient care for the 1 st 24h of abx therapy)

112 POSTPARTUM ENDOMETRITIS MANAGEMENT Antibiotics (broad-spectrum) Antibiotics (broad-spectrum) until pt is afebrile, pain-free, & with normal wbc count. until pt is afebrile, pain-free, & with normal wbc count. FAILURE TO RESPOND may indicate: multi-drug resistant bacteria, multi-drug resistant bacteria, inadequate regimen, inadequate regimen, abscess, abscess, puerperal ovarian vein thrombosis, puerperal ovarian vein thrombosis, non-infectious fever (e.g., drug-fever, breast engorgement) non-infectious fever (e.g., drug-fever, breast engorgement)PROPHYLAXIS: Abx prophylaxis for any c-section after labor or rupture of membranes of any duration Abx prophylaxis for any c-section after labor or rupture of membranes of any duration

113 PUERPERAL OVARIAN VEIN THROMBOSIS Acute postpartum thrombosis of ovarian veins Acute postpartum thrombosis of ovarian veins Rare, incidence 1/2000 deliveries or 1-2/100 pts w postpartum infection Rare, incidence 1/2000 deliveries or 1-2/100 pts w postpartum infection Can occur after c-section or vaginal delivery. Can occur after c-section or vaginal delivery. Usually associated with post-c-section endometritis. Previously diagnosed w “PPE failing to respond to abx” Usually associated with post-c-section endometritis. Previously diagnosed w “PPE failing to respond to abx” Onset mostly 2-4 days after delivery. Onset mostly 2-4 days after delivery. Acute onset, pt appears ill, febrile/chills, lower abd pain (usually rt sided), tachycardia disproportionately elevated c/w temp. Acute onset, pt appears ill, febrile/chills, lower abd pain (usually rt sided), tachycardia disproportionately elevated c/w temp. EXAM: tenderness, tender sausage-shaped mass may be palpable (1/2- 2/3). EXAM: tenderness, tender sausage-shaped mass may be palpable (1/2- 2/3). If PE has occurred may have respiratory complaints too. If PE has occurred may have respiratory complaints too. Usually a diagnosis of exclusion. Usually a diagnosis of exclusion. Sono, CT, or MRI may confirm diagnosis Sono, CT, or MRI may confirm diagnosis Rx: Abx, anticoagulation ( usually x 7-10d, in absence of PE) Rx: Abx, anticoagulation ( usually x 7-10d, in absence of PE)


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