Gynecology
SGD Group 9
Case
A 20-year-old female college student G2P2 comes to see you because of a
persistent vaginal discharge and also seeking contraceptive advice. She and
her boyfriend have been sexually active for 6 months. They use condoms
“most of the time”, but she is interested in using something with a lower
failure rate for birth control. She has regular menses and no significant past
medical or gynecologic history. She describes as yellowish discharge and also
notes mild vulvar irritation. On physical exam, she has normal external female
genitalia without lesions or erythema, a gray/yellow discharge on the vaginal
walls and pooled in the posterior fornix. Her cervix grossly normal but bleeds
easily with manipulation. The bimanual exam is unremarkable.
Laboratory testing reveals vaginal fluid pH of 7 and vaginal wet prep positive
for mobile flagellated organism.
01
Differential Diagnoses
Patient’s
Bacterial vaginosis
Chlamydia
Age
20 yo
✔
✔
Signs
and
sympto
ms
Persistent yellowish
vaginal discharge
Increased white
discharge, increased
odor (musty or fishy)
– Usually asymptomatic
– Abnormal vaginal
discharge
– Burning sensation
when urinating
– Pain during
intercourse
– Pruritus
– Erythema
– Edema
–Fissuring/Excoriation
– External dysuria
– Vulvar burning &
dyspareunia
Sexually
Not sexually
Transmitted
Mild vulvar irritation
Rare - vulvar irritation
MOT
PE
Gray/yellow discharge
on the vaginal wall and
pooled in the posterior
fornix
Cervix grossly normal
but bleeds easily with
manipulation
Thin, whitish gray,
– Cervical friability
homogeneous discharge, – Cloudy, yellow
cocci, sometimes frothy
mucoid discharge from
the cervical os
Candida Vaginitis
✔
– Abnormal vaginal
discharge;white,
whitish gray
curdy/cottage cheese
discharge
Lab
Vaginal
pH
7
>4.5
Wet
mount
Mobile flagellated
organisms
Clue cells
Amine odor after
adding potassium
hydroxide to wet
mouth
>4.5
-
<4.5
*cervicitis
NAAT
Culture
– Hyphae or
pseudohyphae
Comprehensive gynecology 8th
02
What is the most likely
diagnosis?
Clinical Impression
Trichomoniasis
●
A pear-shaped protozoan flagellate
●
Most prevalent noviral, nonchlamydial
STI of women
●
Sexually transmitted
●
Highly contagious
●
Strawberry Cervix
●
pH >4.5
●
Frothy discharge
●
Positive
for
visualization
organism
upon
03
What is your
management plan for
this patient?
● 2 gram single oral dose of metronidazole or 500 mg oral metronidazole twice
daily for 7 days or tinidazole
● Sexual partner must be treated simultaneously
● individuals undergoing treatment should avoid unprotected intercourse.
● Abstinence from alcohol use when taking metronidazole is necessary.
● follow-up examination of patients with trichomoniasis for test of cure is often
advocated.
04
What are the
additional issues you
would want to
discuss with this
patient?
How to prevent STIs
Abstinence
-Get vaccinated
-Fewer sexual partners
-Practice mutual monogamy
-Use condoms
-
Methods of contraception
●
Combination hormonal methods: pills, patches and rings
Advantages
●
●
Cycle control
on-contraceptive benefits
Disadvantages
b. “Nuisance” side effects – bloating, H/A, breast tenderness, nausea
c. No STD protection
d. Need to remember daily, weekly, month
e. Seizure medications may decrease effectiveness
2. Depo-provera: a progestin-only injectables administered via deep IM injection.
Advantages
●
●
4 shots per year
Highly effective
Disadvantages
●
●
●
Irregular bleeding
Weight gain
No STD protection
3. IUD: An IUD is a small plastic device inserted into a woman's uterine cavity to prevent pregnancy
Advantages
●
●
●
Long Term contraception with single act motivation
Highly effective
Does not interfere with sexual intercourse
Disadvantages
●
●
No STD protection
Menstrual irregularities
4. Condoms
05
What contraceptive
options would be
appropriate for this
patient?
1.A variety of contraceptive methods may be appropriate to
achieve effective contraception in this patient including oral
contraceptives, patches, ring or injection.
2. She is not a good candidate for sterilization (due to age), IUD
(due to STI history) and condom/diaphragm/spermicide (due to
non-compliance).
3.The effectiveness, precautions, contraindications and
method administration should be discussed with the patient so
that she can make an informed choice.
06
Would you
recommen screening
for additional
sexually transmitted
infections in this
patient and if so,
how?
● Yes; with serologic testing for Hepatitis B, Syphilis, HIV and cervical
cultures for Gonorrhea and Chlamydia.
● She should also have cervical cytology if not done recently.
Gynecology
SGD Group 9
Case
A 16-year-old G1P1, LMP one week ago, present with one-week history of lower abdominal pain. Pain is
constant, bilateral and accompanied by fever and chills, She had some nausea and several episodes of
vomiting. She has been sexually active for 3 years and has had unprotected intercourse with several
partners. She denies irregular bleeding, dysmenorrhea or dyspareunia. Past medical history is
negative except for childhood illness. Past surgical history is remarkable for tonsillectomy as a child
and an uncomplicated vaginal delivery a year ago.
Physical exam, reveals ill appearing 16-year-old who is afebrile and has a pulse of 94 bpm, BP 124/82,
and respiratory rate 22 cpm. On examination of the abdomen, there is bilateral lower abdominal
tenderness and the abdomen is slightly distended with rebound, negative psoas and Murphy’s sign.
Pelvic exam reveals the BUS negative and vaginal pink, moist. There is a purulent discharge from the
cervical os and the cervix appears indurated. The uterus is in the midline position and is soft and
tender to palpation. There is bilateral adnexal fullness and moderate tenderness.
Laboratory evaluation includes positive GC, negative RPR, and WBC 17.6 with a left shift. Urinalysis is
remarkable for few WBCs, no bacteria, 3+ ketones and negative urine hCG.
01
Differential Diagnoses
Salpingitis
Rule ins:
1.
Lower abdominal pain(LLO/RLQ)
2.
Rebound tenderness
3.
Fever/Nausea
4.
Highest prevalence in groups aged 16-24 yrs
5.
Leukocytosis
6.
Vaginal discharges
Rule out:
1.
Negative papas sign
2.
Bilateral pain
3.
3+ ketones
4.
Indurated cervix
5.
Murphy’s sign
Ectopic
Pregnancy
Rule ins:
1.
Lower abdominal pain
2.
Nausea and vomiting
3.
Abdominal tenderness
4.
Cervical tenderness
5.
Adnexal tenderness
Rule out:
1.
Negative neck and shoulder pain
2.
Unilateral pain
3.
Negative for urine hCG
02
What is the most likely
diagnosis?
Acute Pelvic inflammatory disease
Comprehensive gynecology 8th edition pg 535
Acute pelvic inflammatory disease
Comprehensive gynecology 8th edition pg 535
03
What are the
most likely
organisms
responsible for
this condition
-Chlamydia
-Gonorrhea
-Herpes simplex
-Trichomonas vaginalis
-Candida Albicans
04
What are the
common presenting
signs and symptoms
for this condition?
The clinical criteria necessary for the diagnosis of PID include:
●
Abdominal tenderness +/-rebound
●
Adnexal tenderness
●
Cervical motion tenderness
●
Plus one or more of the following: Gram stain of endocervix positive for Gram negative intracellular
diplococci, temperature >38 degrees C, WBC>10,000, pus on culdocentesis or laparoscopy, pelvic
abscess on bimanual exam or ultrasound
05
What is the definitive
diagnostic tool for
equivocal cases
1.Cervical Gram stain
● The cervical Gram stain is a potentially useful
● The finding of 10 or more white cells per oil immersion field is
diagnostic for mucopurulent cervicitis and PID.
● the finding of gram negative intracellular diplococci identified
within three or more neutrophils on Gram stain
● has a 68 percent sensitivity and a 98 percent specificity
2. Pelvic ultrasonography
●
●
●
●
●
●
distension and dilation of the fallopian tubes;
enlargement of the ovaries,tubes,and ligaments.
fluids in the cul -de-sa
the appearance of a complex, multiloculated mass with cystic and solid elements in
uterus.
obesity, or uncooperativeness precludes an adequate pelvic examination.
highly accurate method for detecting pelvic abscesses (93 percent sensitivity and 99
percent specificity).
3. Laparoscopy
❖
❖
❖
❖
Laparoscopy is the criterion standard for the diagnosis of PID.
It is significantly more specific and sensitive than are clinical criteria alone.
Laparoscopy with direct visualization of the internal female organs improves
diagnostic accuracy and presents an opportunity for direct culture of purulent
material.
The minimum criteria for diagnosing PID laparoscopically include findings of tubal
wall edema, visible hyperemia of the tubal surface, and the presence of exudate on
the tubal surfaces and fimbriae.
4. Endometrial biopsy
❖ Endometrial biopsy can be used to determine the histopathologic
diagnosis of endometritis, a condition that is uniformly associated
with salpingitis.
❖ The procedure is performed with an endometrial suction pipette or
curette and is well tolerated.
06
WHAT CRITERIA WOULD
YOU USE TO DETERMINE
INPATIENT VS OUTPATIENT
TREATMENT ?
INPATIENT MANAGEMENT
● Sex partners of PID patients should be examined and
treated.
● Partners should be treated empirically for N.gonorrhoeae
and C.trachomatis.
● Without treatment of infected partners, risk of
reinfection is high.
Outpatient Management
Follow-Up
❖ Clinical improvement should be apparent within
72 hours of initiation of therapy
❖ If patient is responding, she should be
examined 4-6 weeks after therapy
❖ If no improvement within 72 hours after outpatient IM/oral
therapy,Consider:
– Hospitalization,
– Assessment of the antimicrobial regimen
– Consideration of diagnostic laparoscopy
❖ All diagnosed with chlamydial or gonococcal should be
retested 3 months after treatment
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