A 28-year-old female of 37 weeks’ gestation notices dampness on her underwear after coughing. She is uncertain whether it is urine but is concerned that she might have ruptured her membranes.
Which ONE of the following statements is MOST appropriate?
Answer: C: Rupture of membranes that occur prior to the onset of labour, regardless of gestation, is called premature rupture of membranes. If rupture occurs before 37 weeks’ gestation, it is termed preterm premature rupture of membranes. The majority of patients with premature rupture of membranes will go into labour within 24 hours; however, a small proportion will have prolonged rupture of membranes with the increased risk of chorioamnionitis. Ultrasound examination may show reduced liquor volume but volume can appear normal with a small leak. A sterile speculum examination is therefore indicated to confirm the presence of amniotic fluid by visualization of fluid draining through the cervical os, change of nitrazine paper to blue or presence of ferning on microscopy. At the same time cord prolapse can be excluded. Assessment of the fetal heart with a cardiotocography (CTG) is essential to determine fetal well-being; however, patients should not be discharged until obstetric consultation has been sought to determine the presence or absence of ruptured membranes and to facilitate subsequent management.
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Regarding immediate (primary) postpartum haemorrhage (PPH), which ONE of the following is TRUE?
Answer: A: PPH can be defined as bleeding from the birth canal >500 mL in the first 24 hours after vaginal delivery and >1000 mL post caesarean section. Primary PPH refers to bleeding within the first 24 hours after delivery and secondary PPH to bleeding after 24 hours. The most important aspect of the management of PPH is probably its prediction and prevention. Risk factors for PPH include antepartum haemorrhage, prior postpartum haemorrhage, over distention of the uterus from polyhydramnios, multiple pregnancy or macrosomia, prolonged labour, instrumental delivery and abnormal placentation. Active management of the third stage has been shown to reduce the risk of PPH. The most common cause of immediate PPH is uterine atony, contributing to approximately 80% of cases. If the uterus is contracted, the leading causes of primary PPH are genital tract trauma and pathologic placentation. Secondary PPH is most frequently caused by retained products, subinvolution of the uterus, and uterine infection.
Strategies to treat primary PPH first must ensure uterine contraction and then identify and repair any genital tract injuries. Uterine atony is initially managed with firm manual massage of the uterine fundus through the abdominal wall in conjunction with the administration of oxytocic agents. Medical treatment of PPH is aimed at achieving uterine contractions. These include oxytocin, ergot alkaloids and prostaglandins. Oxytocin is the most common medication used to achieve uterine contraction and therefore is the first-line agent for prevention and treatment of PPH. Oxytocin is commonly administered by an intravenous infusion, which can be prepared by adding 20–40 units of oxytocin to 1 L of crystalloid and infusing it at a rate of 200–500 mL/hr. Titrate to sustain uterine contractions and control uterine haemorrhage. Slowing of haemorrhage should be observed within minutes of administration. If an intravenous line is unavailable, administer 10 units of oxytocin intramuscularly. Administration of oxytocinin as an intravenous bolus should preferably be avoided as it may cause profound hypotension and arrhythmias.
Which ONE of the following is TRUE regarding acute vulvovaginitis?
Answer: B: The most common infectious causes of vaginitis in symptomatic women include bacterial vaginosis (22–50%), candidiasis (17–39%) and trichomonas (4–35%). Alkaline secretions from the cervix before and after menstruation, as well as semen (alkaline), reduce acidity and predispose to infection.
Bacterial vaginosis (BV) is a polymicrobial clinical syndrome caused by a change in the balance of microorganisms found in a healthy vagina. The resultant reduction of the normal hydrogen peroxide–producing Lactobacillus species in the vagina leads to overgrowth with high concentrations of anaerobic (e.g. Mobiluncus species) and other fastidious bacteria (including Gardnerella vaginalis and Atopobium vaginae), and Mycoplasma hominis. The most common symptom of bacterial vaginosis is an increase in a greyish white vaginal discharge. The discharge often has a fishy smell. The diagnosis of BV can be confirmed by examination of the discharge, including vaginal swab wet preparation and gram-stained smear. Typical features on examination of the discharge include:
Culture adds little to microscopy. Additionally, gardnerella organisms are part of the normal vaginal flora and therefore positive culture alone does not indicate infection.
Regarding pelvic inflammatory disease (PID), which ONE of the following is FALSE?
Answer: B: PID refers to a clinical syndromes resulting from infection or inflammation of the usually sterile upper genital tract. PID is usually polymicrobial and due to sexually acquired organisms. Other risk factors for PID include procedures or conditions that involve disruption of the normal cervical barrier (pregnancy termination, delivery, surgery or following insertion of an intrauterine contraceptive device). Additionally, there is an increased risk of PID early in the menstrual cycle or at the end of menses, which is attributed to low progesterone levels and coincident thinning of the cervical mucosal barrier.
Diagnosis of PID is usually based on clinical criteria with or without laboratory evidence. Adnexal tenderness alone is the single most sensitive examination finding (95%) but has a specificity of 3.8%. Other findings with high sensitivity of over 90% include lower abdominal tenderness, uterine tenderness and cervical motion tenderness. However, as isolated findings, they again lack sensitivity. The presence of white blood cells (WBCs) in the vaginal discharge is a sensitive marker for PID. The diagnosis of PID is therefore unlikely if the cervical discharge appears normal and there are no WBCs on the wet slide preparation.
A 22-year-old female presents to the ED with lower abdominal pain. She admits to having multiple sex partners. On examination she is well, presenting with a temperature of 37.6°C. The rest of her vital signs are normal. Vaginal examination confirms bilateral adnexal tenderness as well as cervical motion tenderness.
Which ONE of the following is TRUE in this setting?
Answer: C: Sexually transmitted PID is usually caused by Chlamydiae or Neisseria gonorrhoeae and antibiotic regimens traditionally were directed primarily against these organisms. However, it is now recognized that these agents are instrumental in the initial infection of the upper genital tract, causing epithelium damage that allows further entry of opportunistic infections including anaerobes, Mycoplasma genitalium and other bacteria. Polymicrobial infection is therefore common and antibiotic treatment should include antibiotics with activity against the major sexually transmitted pathogens and anaerobic bacteria. Current guidelines suggest that empiric treatment should be initiated in those women at risk who exhibit lower abdominal pain, adnexal tenderness, and cervical motion tenderness. Early empirical treatment of sexually acquired PID is important and recommended because it may reduce the risk of tubal damage, which predisposes to infertility or ectopic pregnancy. Furthermore, whereas a positive microscopy, culture or PCR result on endocervical swab retrospectively supports the diagnoses of PID, defines antibiotic sensitivities and identifies the need to treat sexual partners, the absence of microbiological evidence of infection does not exclude PID. Current Australian antibiotic recommendations for mild to moderate infection are:
Ceftriaxone 500 mg IM or IV, as a single dose (for gonorrhoea) plus
Metronidazole 400 mg orally, 12-hourly for 14 days plus
Azithromycin 1 g orally, as a single dose and
Azithromycin 1 g orally, as a single dose 1 week later, or doxycycline 100 mg orally, 12-hourly for 14 days
Azithromycin, 1 g orally as a single dose, is effective in treating Chlamydia of the lower genital tract; however, single-dose therapy is inadequate to treat a chlamydial infection of the upper female genital tract.
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