VAGINAL DISCHARGE
A
19-year-old woman presents
with a vaginal discharge. She is currently 9 weeks preg- nant in her first
pregnancy. The discharge started about 3 weeks ago
and is non-itchy and creamy in colour.
It is not profuse but
she feels it has a strong odour
and is embarrassed about it. There is no bleeding or abdominal pain.
She has had
two or three
previous sim- ilar episodes
before the pregnancy that resolved spontaneously.
She
has been with
her partner for
3 years and
neither of them
have had any
other sexual partners. They have always
used condoms until
3 months ago. She has never had a cer- vical smear test.
The
external genitalia appear
normal. On speculum examination a small
amount of smooth grey discharge is seen coating
the vagina walls.
There is a small cervical
ectropion that is not bleeding.
·
What is the likely
diagnosis and the differential diagnosis?
·
How
would you further
investigate and manage this patient?
·
If
your diagnosis is confirmed, what are the implications for the pregnancy?
The
history suggests that the woman
is not at risk of a sexually
transmitted infection as a
cause for her discharge (although this can never
be ruled out
entirely as the
reported sex- ual history
can be inaccurate). She has an ectropion, which
can cause a clear discharge. A non-offensive, non-itchy discharge is normal in pregnancy.
The
salient feature in this case is that the discharge has an offensive odour. Offensive
odour is usually due to either trichomonas or bacterial vaginosis (BV).
Trichomonas causes a profuse,
sometimes frothy discharge
with cervicitis, whereas
BV causes a smooth,
mild discharge, if any discharge at all.
The
woman should have swabs taken
for sexually transmitted infection as well as BV and
candida.
A
diagnosis of BV can be made, finding
a typical thin
grey discharge with
a fishy odour and a vaginal pH of 6–7.
More formal criteria for diagnosis are
the Amsel (discharge, clue cells on microscopy, high pH and
fishy odour with
potassium hydroxide) or Hay/Ison cri- teria (relative lactobacilli to anaerobe proportions on Gram-stained vaginal
smear). Microbiological culture is not helpful
as many of the anaerobes associated with BV are
also found as commensals.
Spontaneous onset and remission is typical with BV, and 50 per cent of women
are asymptomatic. General advice should be given for avoiding BV
including avoidance of vaginal
douching, shower gel, and antiseptic agents or shampoo in the bath, as these interfere with the normal
flora (lactobacilli) and allow an increase in BV organisms.
Specific treatment is with
metronidazole for 5–7 days.
Late miscarriage, preterm birth,
preterm premature rupture
of membranes, and postpartum
endometritis have all been associated with BV, and so any pregnant
woman with BV should be treated with metronidazole.
In contrast, non-pregnant women only require treatment if symptomatic.
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