A 25-year-old healthy female presents with a 1 week history of a thin, mildly odorous vaginal discharge accompanied by mild vaginal itching. Physical examination is normal except for a thin, homogeneous discharge, with no significant cervical or vaginal inflammation. A wet-mount preparation of the discharge reveals numerous epithelial cells coated with small non-motile organisms. A KOH preparation is negative but has a “fishy” odor.
Which one of the following is correct regarding this patient’s condition?
Correct Answer D: The patient described has a classic case of bacterial vaginosis. The role of sexual transmission is unclear and there is no documented benefit to treating the male partner(s). Treatment is fairly easily accomplished with oral or vaginal clindamycin or metronidazole.
A 28-year-old female presents for evaluation of a persistent thin discharge, with a “fishy” odor particularly noticeable after intercourse. She has no dyspareunia or dysuria, is in a monogamous relationship, and has used oral contraceptives for many years. Physical examination reveals no vulvar, vaginal, or cervical erythema. There is a homogeneous white discharge that coats the vaginal walls. The vaginal pH is 7.0 and on microscopy you note stippled epithelial cells but no hyphae or trichomonads. She insists on treating this infection.
Which one of the following is true regarding this patient?
Correct Answer A: The patient has the typical symptoms and signs of bacterial vaginosis. There is no need for confirmatory testing. The treatment of choice is oral metronidazole, which may cause a disulfiram-like interaction with alcohol. Treatment of the partner has not been shown to improve the outcome. Gram's stain of vaginal discharge is the gold standard for diagnosis of bacterial vaginosis but is mostly performed in research studies because it requires more time, resources, and expertise.
A 30-year-old black female presents with a vaginal discharge. On examination the discharge is homogeneous with a pH of 5.5, a positive whiff test, and many clue cells.
Which one of the following findings in this patient is most specific for the diagnosis of bacterial vaginosis?
Correct Answer B: Patients must have 3 of 4 Amsel criteria to be diagnosed with bacterial vaginosis. These include a pH > 4.5 (most sensitive), clue cells > 20% (most specific), a homogeneous discharge, and a positive whiff test (amine odor with addition of KOH).
A G3P2 at 23 weeks gestation develops pain in her flank, fever and chills. A positive urinalysis (presence of nitrites and white blood cells) confirms the diagnosis of which one of the following?
Correct Answer A: Acute pyelonephritis is a leading cause of admission for pregnant women. It is an ascending infection involving the kidney causing symptoms of fever, nausea, vomiting, and chills. Physical exam will show flank pain. Initial labs should include urinalysis and urine culture. Most women with acute pyelonephritis have marked pyuria or a positive leukocyte esterase test, which often is accompanied by microscopic hematuria or a positive heme dipstick test. In contrast, gross hematuria is rare in patients with acute pyelonephritis and is more common in patients with acute uncomplicated cystitis. The presence of white blood cell casts indicates renal-origin pyuria, supporting the diagnosis of acute pyelonephritis, but casts are not often seen.
IV antibiotics are the mainstay of treatment.
A 39-year-old black multigravida at 36 weeks gestation presents with a temperature of 40.0°C (104.0°F), chills, backache and vomiting. On physical examination, the uterus is noted to be nontender. There is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in clumps, as well as numerous bacteria.
Of the following, the most appropriate therapy at this time would be:
Correct Answer E: Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital, at least until the patient is stabilized and cultures are available. Ampicillin is widely used as an agent of first choice, but because of variable drug resistance some studies suggest adding an aminoglycoside for a woman who is seriously ill. Alternatively, an extended-spectrum penicillin or a third-generation cephalosporin may be used.
Sulfonamides are contraindicated late in pregnancy because they may increase the incidence of kernicterus. Tetracyclines are contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth. Nitrofurantion may induce hemolysis in women who are deficient in G-6-PD, which includes approximately 2% of black women. The safety of levofloxacin in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.
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