VAGINITIS

EHSAN SARKHNPOUR
INTRODUCTUIN

• Pregnant women frequently develop increased vaginal discharge. This may

• be a physiological discharge, described in Chapter 4 (p. 54), but should be
• differentiated from symptomatic vaginitis, which is also common in
• pregnancy. Fortunately, normal vaginal flora serve to prevent vaginitis. To
• better understand this, normal vaginal microflora composition and function
• are currently being studied in the Vaginal Human Microbiome Project
• (Huang, 2014).
BACTERIAL VAGINOSIS

Diagnosis :
• Bacterial vaginosis (BV) is a maldistribution of normal vaginal flora. With BV, numbers of lactobacilli are
decreased, and anaerobic bacterial species are overrepresented. These anaerobes include Gardnerella,
Prevotella, Mobiluncus, and Bacteroides species; Atopobium vaginae; and Bvassociated bacteria,
provisionally named BVAB1, BVAB2, and BVAB3. These last three are relatively newly recognized
bacteria (Fredricks, 2005).
• Ribosomal RNA gene-sequencing techniques have identified composite communities of vaginal flora, also
called the vaginal microbiota. Five types of these composite communities exist and are referred to as
community state types (CSTs). A woman can be categorized to one of these five CSTs based on her vaginal
microbiota composition (Ravel, 2011). Researchers have begun to quantify the risk of BV associated with
these CST groups. Specifically, CSTs I, II, III, and V are rich in lactobacilli. CST IV is a heterogeneous
microbiota of strict anaerobes and is associated with BV. CSTs vary racially, and CST IV is the most
common in asymptomatic, healthy black women (Fettweis, 2014). Pregnancy-related changes in vaginal
microbiota also are being defined and may hold keys to adverse BV-related pregnancy outcomes, discussed
subsequently (Romero, 2014).
• Of childbearing-aged women in the United States, nearly 30 percent have BV. In black women, the prevalence approximates
50 percent (Allsworth, 2007). Most women are asymptomatic. In those with symptoms, a foul, thin vaginal discharge is a
typical complaint. Associated risk factors are douching, multiple partners, smoking, and altered host immunity (Desseauve,
2012; Koumans, 2007; Murphy, 2016).
• For clinical diagnosis of BV, three of the four following Amsel criteria are present: (1) vaginal pH >4.5; (2) a thin, milky,
noninflammatory vaginal discharge; (3) >20 percent clue cells seen microscopically; and (4) a fishy odor after addition of 10-
percent potassium hydroxide to a vaginal secretion sample (Amsel, 1983). The last is described as a positive “whiff test”
result. Likewise, alkalinity of seminal fluid and blood are responsible for complaints of foul odor after intercourse and with
menses in affected women. Initially, a vaginal fluid sample is mixed with saline on a glass slide for microscopic evaluation,
and this is often called a wet preparation or “wet prep.” Clue cells are vaginal epithelial cells containing many attached
bacteria, which create a poorly defined stippled cellular border (Fig. 68-5).
• Microscopically, leukocyte numbers are not increased. The higher vaginal pH stems from the diminished acid production due
to a diminished lactobacilli population. Notably, Trichomonas vaginalis infection also is associated with anaerobic
overgrowth and elaborated amines. Thus, women diagnosed with BV should have no microscopic evidence of trichomoniasis.
• The Nugent score, used primarily in research rather than clinical practice, is a system employed for diagnosing BV (Nugent,
1991). During microscopic examination of a gram-stained vaginal discharge smear, scores are calculated by assessing bacteria
staining and morphology.
• NAATs to detect the bacterial types found in women with BV have suitable accuracy and may be used for symptomatic
women (Coleman, 2018). However, these tests assess for bacteria that may also be part of normal flora in asymptomatic
women. Moreover, compared with traditional methods, molecular tests have yet to show superior health outcomes but do add
substantial cost.
 TREATMENT

• Adverse pregnancy-related health outcomes associated with BV are preterm birth, PPROM, and postpartum
endometritis (Hillier, 1995; Watts, 1990). It also increases susceptibility to STIs, including HIV (Atashili, 2008;
Brotman, 2010). For women at low risk for preterm birth, however, treatment of BV does not reduce preterm birth rates
(Brocklehurst, 2013; Carey, 2000). The American College of Obstetricians and Gynecologists (2021) and USPSTF
(2020) do not recommend routine BV screening of asymptomatic gravidas at low risk for preterm delivery. For women
with prior preterm birth, evidence of screening and treatment benefits are conflicting (Kahwati, 2020). At Parkland
Hospital, we do not routinely screen for BV among women with prior preterm birth.
• Treatment is reserved for symptomatic women (Table 68-7). Agents not listed are best avoided due to insufficient data
regarding their use in pregnancy (Workowski, 2021). It is still debated whether BV is a sexually transmitted infection,
and treatment of a male partner does not lower recurrence rates (Amaya-Guio, 2016; Schwebke, 2021).
• Preferred : metronidazole 500mg orally BD for 7 d or metronidazole 0.75% gel one applicator intravaginaly for 7 d
• Alternative : clindamycin 300mg orally BD for 7 d or clindamycin ovules 100mg intravaginaly nightly for 7 d
 TRICHOMONIASI
• Vaginitis caused by Trichomonas vaginalis is common, and its prevalence in the United States approximates 2
percent in women (Patel, 2018). The prevalence is higher in those older than 30 years compared with younger
women. Risks include black race, douching, and greater number of lifetime sexual partners (Sutton, 2007). Among
women, frequent sites of infection include the urethra, endocervix, and vagina. Those with symptomatic vaginitis
often have a purulent discharge, pruritus, vulvovaginal erythema, and colpitis macularis. The last is often termed a
“strawberry cervix” and displays a patchy, maculoerythematous ectocervix.
• Trichomonads are flagellated, pear-shaped, motile organisms that are somewhat larger than leukocytes. These
parasites can readily be seen microscopically moving briskly in wet preparation. Prompt inspection of vaginal
secretions is advantageous because trichomonads slow with cooling. At times, T vaginalis may be found incidentally
on a Pap test slide. Both of these microscopic approaches have low diagnostic sensitivity that approximates 60
percent (Krieger, 1988; Wiese, 2000). Pap tests can also yield false-positive results. Thus, Pap test trichomonad
findings warrant confirmation with either a wet prep or NAAT.
• Of other direct detection methods, culture is expensive, lengthy, and only 75 to 95 percent sensitive (Association of
Public Health Laboratories, 2016; Huppert, 2007). Laboratory NAAT-based evaluation of a vaginal, endocervical, or
urine sample is available, is completed in minutes to hours, and offers superior sensitivity of 95 to 100 percent (Van
Der Pol, 2016). Although more costly than wet-preparation microscopy, a NAAT may be a useful, second-line
diagnostic test for microscopy-negative samples. An optimal approach in pregnancy has not been established. Rapid
POC testing is also available but may sacrifice sensitivity for speed. The OSOM Trichomonas Rapid Test provides
results in 10 minutes, is suitable for office use, and has sensitivities of 88 to 98 percent (Herbst de Cortina, 2016).
TREATMENT
• Treatment is reserved for symptomatic women (Table 68-8). Previously, a one-time, 2-g dose of oral metronidazole was used to
eradicate T vaginalis. In nonpregnant women, a large randomized trial compared this traditional therapy against metronidazole, 500
mg orally twice daily for 7 days. The longer course provided improved efficacy (Kissinger, 2018). New guidelines from the
American College of Obstetricians and Gynecologists (2020g) now recommend this change in nonpregnant women. The CDC
recognizes this regimen for pregnancy.
• Reinfection rates among women treated for trichomoniasis are high (Kim, 2020). Thus, retesting for T vaginalis is recommended for
all sexually active women within 3 months following initial therapy (Workowski, 2021). Some authors recommend retesting 3
weeks after treatment in pregnancy (Lazenby, 2019).
• Metronidazole is not teratogenic or fetotoxic, and it may be used in all pregnancy stages (Briggs, 2022; Czeizel, 1998; Workowski,
2021). The manufacturer recommends against its use during the first trimester (Pfizer, 2021). Fewer data are available for tinidazole,
and thus metronidazole is preferred. For allergic patients, metronidazole desensitization is effective (Helms, 2008). With
breastfeeding, the longer, lower-dose metronidazole regimen is not associated with adverse infant outcomes (LactMed, 2021).
• Perinatal transmission of trichomoniasis by direct contact in the birth canal is rare but may lead to neonatal respiratory or genital
infection (Bruins, 2013; Trintis, 2010). Some studies have linked trichomonal infection with preterm birth (Van Gerwen, 2021). A
few other studies implicate this infection with PPROM and small-for-gestational age newborns (Silver, 2014). However, treatment
in two randomized studies did not lower preterm birth rates (Klebanoff, 2001; Stringer, 2010).
• In sum, treating symptomatic women is reasonable. For most asymptomatic women during pregnancy, screening is not done.
However, screening at the first prenatal visit and prompt treatment are encouraged for gravidas with comorbid HIV infection. In this
group, T vaginalis infection may be a risk factor for vertical HIV transmission (Gumbo, 2010).
• Preferred : metronidazil 500mg oraly BD for 7 d
 CANDIDIASIS

• Candida albicans or other candidal species can be identified by culture from the vagina during pregnancy in approximately
20 percent of women. A link between candidiasis and preterm birth is not robust (Cotch, 1998; Roberts, 2015). Thus,
asymptomatic colonization requires no treatment. The organism, however, can create a profuse, irritating discharge. For
symptoms, effective treatment is listed in Table 68-9. In pregnancy, the CDC recommends 7-day regimens and suggests
topical rather than oral azoles (Workowski, 2021). In some women, infection is likely to recur and require repeat treatment.
In these cases, symptomatic infection usually subsides after pregnancy (Sobel, 2007). Although not preferred treatment, a
single, 150-mg oral fluconazole dose is generally not considered teratogenic. Data showing a small association with cardiac
anomalies are conflicting, but more recent evidence is reassuring (Mølgaard-Nielsen, 2013; Zhu, 2020). In 2019, the FDA
noted that reviewed data do not provide conclusive evidence for an increased miscarriage or stillbirth risk.
• Daily intravaginal agents for 7 daies
• 1- Clotrimazol 1% cream 1 applicator
• 2- Miconazol 100mg 1 supp or 2% cream 1 applicator
• 3- Terconazol 0.4% 1 applicator