TEALE FENNING

farha · Century Club Joined: 18 May 2007 Posts: 154

A 34 yrs old para 5 who is currently 28weeks gestation presented with some painful blisters at her vulval area which she never had before.

a)What is your most likely diagnosis and how do you confirm that?(4 marks)

Most likely diagnosis in this case is genital herpes which is a sexually transmitted infection caused by a virus herpes simplex type1 and 2 which occur in pregnancy due to relative immunosuppressive nature of pregnancy. Diagnosis will be confirmed by collection of swab from genital lesions or by debribing roof of blisters and collecting fluid for viral culture or PCR for herpes virus DNA and type specific serology for IgG and IgM against same virus isolated from genital swab.

b) What is your immediate management of this lady? (6marks) 18 lines

Immediate manage ment of this lady is to admit her and give her symptomatic treat ment including antipyretics if she is febrile and and analgesics to relieve her pain .Antibiotics and hygiene will be maintained Isolation is not required will be given to reduce the risk of secondary bacterial infection .Saline bathing will be advised as it will have soothing effect. If there is urinary retention then bladder will be catheterized. Genitourinary physician will be involved in her management who will give advice regarding dose and duration of acyclovir therapy which is an antiviral agent and reduces the severity duration and also helps in the healing of lesion and reduces viral shedding. Screening for other sexually transmitted disease will also be done along with the screening of partner. As there is a risk of preterm labour so she will be told and watched for the sign and symptoms of preterm labour and will be managed on the same principle as women without genital herpes

At 36 weeks she presented to you with similar episodes

c)Justify your management for this lady. (4 marks)10 lines

She will be reassured that risk of neonatal herpes is very low (3%) in view of recurrent nature of the and even if lesion are present at term or in labour as neutralizing antibodies are already formed in maternal serum and will protect her baby .Virus culture in last 4 weeks to determine viral shedding is no longer recommended by RCOG.Suppressive doses of acyclovir in last 4 week although reduces viral shedding at term but there is insufficient evidence to recommend it, However if woman decides for CS in case if lesions are present at term then she can be given suppressive doses of acyclovir to reduce viral shedding .Her view regarding mod of delivery will be explored respected and documented Further appointment will be given.

d) At 38 weeks she presented to you with full dilatation. Justify your subsequent management.

Aim of management at this stage will be safe and sound delivery without increasing risk of transmission of herpes to the neonate and depends presentation and lie of fetus, whether membrane are ruptured and if ruptured then duration of rupture , presence of active genital lesion, feasibility and willingness of woman to undergo vaginal delivery . Vaginal delivery is recommended in this as risk of neonatal herpes is very low in view recurrent nature of herpes even if active lesions are present at this time. If woman is willing and vaginal delivery is planned and there is no obstetrical indication which favors CS, then invasive monitoring like fetal blood sampling and fetal scalp electrode will be avoided to reduce the risk of transmission of herpes. .Labour will be expedited and operative delivery will be avoided. Analgesia will be provided as per protocol. Neonatalogist will be present at the time of delivery .Acyclovir is rarely recommended in recurrent herpes but advise will be sought from GUM physician After delivery neonatologist will examine the baby and breast feeding is not contraindicated until and unless there is herpetic whitlow or herpes ulcer on breast. Mother will be advised to inform pediatrician if neonate is sick, feverish or devolpe lesion

farha · Century Club Joined: 18 May 2007 Posts: 154

Hi NICK AND RAJ I amm waiting for ur comments on my answer for herpes

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

hi farah,

a good attempt, liked it. a few points that i will like to expand on / clarify ------

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

farha · Century Club Joined: 18 May 2007 Posts: 154

Thanks raj
BUT tell me amm i pass in it or not? :? :?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

this is a sure pass. it's a guideline based question, and as Nick says these are the ones that will tend to have a high pass mark, you should aim to score on these, helps compensate for the odd difficult / obscure question.

ok, am setting a non guideline based essay, give that a try.

r
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region