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Section II: Topics in Gynecology
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(3 7 days) About 1% hydrocortisone may be used to relieve external irritative symptoms When is oral fluconazole contraindicated During pregnancy A 7-day course of topical antifungal therapy is recommended for pregnant patients No Candidiasis is not typically a sexually transmitted disease
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Does the patient s sexual partner need to be treated as well
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Trichomonas Vaginalis
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What is trichomoniasis A sexually transmitted vaginal infection caused by the flagellated protozoan, T vaginalis There is a strong association with BV Malodorous, purulent, greenish, frothy, profuse watery discharge; vulvovaginal erythema and irritation, dyspareunia, dysuria; punctate hemorrhages on the cervix ( strawberry cervix ) pH of vaginal secretions >50 Microscopic examination of a wet saline prep of vaginal fluid reveals motile trichomonads What are some complications of trichomoniasis Increased HIV transmission; increased risk of PID; preterm delivery; premature rupture of membranes; low birth weight infants Oral metronidazole Pregnant patients should receive oral metronidazole (category B drug) All sexual partners should be treated What other tests should be considered Tests for N gonorrhoeae, C trachomatis, syphilis, HIV
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How is the diagnosis usually made
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Desquamative Inflammatory Vaginitis
What are the three characteristics of desquamative inflammatory vaginitis Diffuse, exudative vaginitis Vaginal-epithelial cell exfoliation Profuse and purulent vaginal discharge
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What causes inflammatory vaginitis
Replacement of normal lactobacilli with gram-positive cocci (usually streptococci) Premenopausal women with normal estrogen levels With a purulent vaginal discharge, vulvovaginal burning, dyspareunia, vaginal erythema, and a vulvovaginal-cervical spotted rash Vaginal secretion pH >45 Increased number of parabasal cells Gram-positive cocci (usually streptococci) on Gram-staining
What type of patients present with desquamative inflammatory vaginitis How do these patients typically present
What are some laboratory findings
What is the treatment
2% clindamycin cream intravaginally 7 days
Atrophic Vaginitis
Which women are more likely to be affected by atrophic vaginitis What causes atrophic vaginitis Postmenopausal women Thinning of the vaginal epithelium because of a reduction of endogenous estrogen Reduction of lactobacilli and lactic acid increases the vaginal pH and leads to an overgrowth of non-acidophilic organisms Mild vaginal atrophy is usually asymptomatic Advanced vaginal atrophy can present with vaginal soreness, purulent vaginal discharge, dysparenuia, and postcoital irritation and bleeding Atrophy of external genitalia, loss of vaginal folds, thin and diffusely erythematous vulvovaginal mucosa with some ecchymoses, and watery or serosanguineous discharge pH >50 70 Increased number of leukocytes and parabasal epithelial cells Increased gram-negative rods What is the treatment Topical estrogen vaginal cream
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What does a physical examination reveal
What do laboratory tests of the vaginal secretions reveal
Section II: Topics in Gynecology
Noninfectious Causes of Vaginitis
What are some causes of noninfectious vaginitis Topical antimycotic drugs Spermicides Mini-pads/pantyliners and other feminine products Soaps Povidone-iodine Latex condoms Seminal fluid What are the symptoms of noninfectious vaginitis With what disease can noninfectious vaginitis be confused How is the diagnosis made What is the treatment Pruritus, irritation, burning, soreness, and variable discharge (similar to infectious vaginitis) Acute Candida vaginitis Based upon symptoms and exclusion of all infectious etiologies Removal of causative agent Local relief by sodium bicarbonate, sitz baths, and topical vegetable oils
OTHER GYNECOLOGIC INFECTIONS Postoperative Pelvic Infection
What are some gynecologic postoperative infections Cuff and pelvic cellulitis Salpingitis Suppurative pelvic thrombophlebitis TOA with and without rupture What are the five major causes of fever in the postoperative gynecology patient The five W s: Wind = pulmonary atelectasis or pneumonia Water = urinary tract infection Walk = deep vein thrombosis (DVT) or superficial phlebitis Wound = infection from the abdominal incision or from a pelvic source Weird drugs = drug-causing fevers
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On what postoperative day does fever because of pelvic infection commonly occur What should one think of if fevers continue and there is no clinical response to antibiotics
Between postoperative day (POD) 2 4
Pelvic abscess
Toxic Shock Syndrome
What is toxic shock syndrome (TSS) An acute illness characterized by high fevers which may quickly lead to hypotensive shock and multisystem failure Preformed exotoxins produced by Staphylococcus aureus Menstruating women between ages 12 24 who use superabsorbent tampons Postpartum women Women who use a diaphragm In both men and women following surgical procedures What are the major clinical findings in TSS Abrupt onset of high fevers, vomiting, and diarrhea Within 48 hours, signs of shock occur (temperature 1022 F, dehydration, tachycardia, hypotension) and a diffuse sunburn-like rash appears over the face, trunk, and proximal extremities Desquamation (particularly affecting the palms and soles) may occur 1 2 weeks after the onset of illness Involvement of three or more organ systems (GI, CNS, renal, mucous membrane, skin, cardiac, hepatic) is essential for diagnosis What information should be sought during the H&P that is pertinent to this diagnosis Ask the patient if she is menstruating or using tampons!!! You must perform a vaginal examination and remove the tampon immediately if one is present Complete panel of blood tests
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