Clinical features associated with vaginal discharge in the study group (
Abnormal vaginal discharge in a pregnant woman causes discomfort and increases risk of complications. Management of such patient is difficult as the physician will need to distinguish leucorrhoea of pregnancy from pathological vaginal discharge and also to decide on the drugs to prescribe that are not contraindicated in pregnancy.
- Vaginal discharge
- Antibiotic treatment
Most pregnant women have vaginal discharges that are either physiologic or pathologic. The challenge to the clinician is to separate the vaginal infections with potentially serious input for pregnancy from annoying but not serious secretions, irritation and pruritus . Infectious vaginitis is usually caused by yeast, such as
Vaginal pH, glycogen content and amount of secretion influence the quantity and type of organisms present in the vagina. Lactobacilli restrict the growth of other organisms by producing lactic acid, thus maintaining a low pH. These organisms also produce hydrogen peroxide, which is toxic to anaerobes. The normal vaginal bacterial population assists in inhibiting the growth of pathologic vaginal organisms. If the normal vaginal ecosystem is altered, there is a greater chance of proliferation of pathogenic organisms. The challenge of treating vaginitis in pregnancy is the necessity of making accurate diagnosis and treating correctly . True infections (some of which can have dangerous effect on gestation) must be separated and distinguished from the exaggeration of physiologic discharge by pregnancy. Infection with bacterial vaginosis,
2. Management of common causes of abnormal vaginal discharge in pregnancy
2.1. Vulvovaginal candidiasis
Vulvovaginal candidiasis (VVC) is a common cause of vaginal discharge worldwide [5, 6]. It is estimated that approximately 75% of women will experience an episode of VVC . Candidiasis is caused by the fungus,
Most patients with VVC will complain of vaginal discharge . Dyspareunia, vulval pruritus and burning are the main symptoms . Patients commonly complain of pruritus and burning after intercourse or upon urination. Erythema and oedema of the labia majora and minora and rashes on the perineum and thighs may be seen on physical examination, and a whitish, thick and curd-like vaginal discharge is usually present . Recurrence requiring repeated treatment during pregnancy is likely .
The diagnosis is made on both clinical examination and laboratory identification of
Various drug formulations are effective in treating both uncomplicated and complicated infections . Both intravaginal and oral agents are available [10, 19]. Uncomplicated VVC includes sporadic or infrequent VVC, mild-to-moderate VVC, VVC with likely infecting agent being
Prolonged local intravaginal therapy regimens and addition of oral fluconazole may be required to treat non-albicans VVC . Fluconazole, 100–200 mg weekly for 6 months, is also the drug for prevention of recurrent VVC, whereas 600 mg boric acid gelatine capsule intravaginally daily for 2 weeks is useful in the management of non-albicans recurrent VVC .
2.2. Anaerobic bacterial infection and bacterial vaginosis
Vaginal flora of a normal asymptomatic reproductive-aged woman includes multiple aerobic or facultative species as well as obligate anaerobic species . Of these, anaerobes are predominant and outnumber aerobic species approximately 10–1 . These anaerobes include gram-negative organisms such as
Bacterial vaginosis is characterised by a shift from normal vaginal population of lactobacilli to anaerobes such as
Bacterial vaginosis has been strongly associated with poor pregnancy outcomes such as preterm delivery and low birth weight infants, and several studies have now established the associations between bacterial vaginosis, human immunodeficiency virus and puerperal sepsis [20, 22].
Bacterial vaginosis appears to be particularly common in Sub-Saharan Africa where several studies have reported high prevalence rates, ranging from 20–49% among women presenting to STD clinics with vaginal discharge to 21–52% among pregnant women attending antenatal clinic . These are very much higher than the rates reported from industrialised countries with 13% in the United Kingdom , 11% in London  and 15–30% in the United States .
Bacterial vaginosis usually occurs in sexually active patients. Some of the other risk factors include multiple sexual partners, low socioeconomic status, lesbians, presence of intrauterine device and prior STD . It is still debatable whether it is sexually transmitted; however, supporting this is the recovery of
Bacterial vaginosis is characterised by a malodorous, profuse, thin, homogenous yellow, white or grey discharge that is adherent to the anterior and lateral vaginal walls. Typically, the patient may complain of a fishy odour during or shortly after coitus and also during menses. The alkaline nature of blood or semen (pH > 7) brings about a transient increase in the vaginal pH, and this causes the release of amines, which the patient perceives as fishy odour. This typical discharge may be found on examination in some patients who in fact have not complained of a vaginal discharge . The fishy smell of the discharge is the main problem and is often responsible for sexual disharmony between partners. Vulvitis and pruritus are very minimal or totally absent. Nearly half of patients with BV have no symptoms. Obstetric complications include premature rupture of foetal membranes, late miscarriage and postpartum endometritis, whereas pelvic inflammatory disease, post-hysterectomy cuff infection and postabortal sepsis are some of the gynaecological complications .
Diagnosis of BV can be based on the Amsel’s clinical criteria or the microbiological Nugent’s scoring technique [26, 27]. In Amsel’s criteria, three of the following are required to diagnose BV: (1) homogenous vaginal discharge; (2) vaginal pH greater than 4.5; (3) positive Whiff test and (4) presence of clue cells on microscopy. The Nugent’s method relies on the identification of categories of vaginal microflora based on quantitative assessment of a vaginal gram-stained smear. The Nugent’s method has been extensively validated in industrialised countries where assessment of vaginal microflora is an important step in understanding the pattern of flora association with BV. Culture is the least accurate in making a diagnosis of BV as there is overgrowth of many vaginal organisms in this condition . Though virtually, all patients with BV have
In pregnancy, BV should be treated with metronidazole 250 mg three times a day (alternatives; metronidazole 2 g single dose, clindamycin 300 mg twice a day; or metronidazole gel) . The standard treatment of BV in non-pregnant women is oral metronidazole 500 mg twice daily for 7 days; clindamycin cream 2% on applicator ful (5 g) intravaginally at bedtime for 7 days or metronidazole gel one applicator ful (5 g) intravaginally once or twice a day for 5 days [5, 10, 28].
Trichomoniasis is the commonest sexually transmitted disease worldwide . It was originally thought to be innocuous but has now been found to be associated with preterm labour, premature rupture of membranes, increased perinatal loss and pelvic inflammatory disease (PID) [5, 29].
The vaginal discharge of trichomoniasis is malodorous, frothy and profuse, thin creamy or slightly greenish and may cause itching. The classic yellow–green discharge is found in 20–50% of patients ; more often, the discharge is grey or white. The patient may also complain of dyspareunia, postcoital bleeding, pruritus vulvae, frequency of micturition and dysuria. Characteristically, vulvitis is minimal or absent compared with candidiasis. On speculum exam, apart from the discharge, a cervical erosion may be seen, and in severe cases, multiple, small punctuate haemorrhages and swollen papillae may be found on the cervix (“straw berry” cervix) and vagina .
The vaginal pH is usually 5–5.5 in trichomonas infection . Applying litmus to the unlubricated speculum after it has been withdrawn from the vagina easily tests the pH. A saline wet mount of the swab taken from the vagina or cervix will show motile flagellated protozoa and leucocytes. Wet mount alone detects 64% infection in asymptomatic women, 75% of those with clinical vaginitis and 80% of those with characteristic symptoms . The use of culture (Feinberg-Whittington or Diamond culture) gives a sensitivity of 86–97% . Pap smear has a detection rate of about 50–86% . Monoclonal antibody staining is also used. It is sensitive and is reported to detect 77% of those missed on wet mount .
Metronidazole is effective in eradicating
2.4. Gonorrhoea and chlamydial infection
The prevalence of
Most women with gonorrhoea are asymptomatic . When symptoms occur, they are localised to the lower genitourinary tract and include vaginal discharge, urinary frequency or dysuria and rectal discomfort. The incubation period is only 3–5 days . The vulva, vagina, cervix and urethra may be inflamed and may itch or burn. Specimens of discharge from the cervix, urethra and anus should be taken for culture from the symptomatic patients. A stain of purulent urethra exudates may demonstrate gram-negative diplococci in leucocytes. Similar findings in a purulent cervical discharge are less conclusively diagnostic of
3. Outcome of study on abnormal vaginal discharge among pregnant women conducted in Maiduguri, Borno State in North-eastern Nigeria
3.1. Goal and objectives
The general objective of the study is to detect the clinical features associated with abnormal vaginal discharge and antibiotic sensitivity pattern of the causative microorganisms in pregnant women to improve the early diagnosis and prompt treatment. The specific objectives were as follows:
To determine the prevalence of abnormal vaginal discharge as a presenting complaint in pregnancy
To determine the frequency of bacterial causes of abnormal vaginal discharge in pregnancy and symptoms associated with it
To evaluate the sensitivity of microbial isolates from the vaginal discharge to antibiotics
Borno State lies between latitude 10° and 14° north and longitude 14° and 45° east. It is located in the north-eastern part of Nigeria. Maiduguri is the capital city. The University of Maiduguri Teaching Hospital (UMTH) is a tertiary health institution and is the only functional teaching hospital in the north-eastern zone of Nigeria. The 2006 Nigerian provisional census puts the population of Borno State at 4,151,193 with 1,990,036 females .
It was a cross-sectional analytical study. The study population consisted of pregnant women presenting to the antenatal clinic with complaint of abnormal vaginal discharge while pregnant women without complaints of abnormal vaginal discharge attending the antenatal clinic of the hospital served as controls. A sample size of 800, consisting of 400 cases and 400 controls, was obtained using Taylor’s and Kish’s formulas . Information on sexual and reproductive risk factors and symptoms was obtained. Vaginal examination was performed, and discharge was assessed. Endocervical and high vaginal swabs were collected and immediately processed in accordance with microbiological standard. Infection with
The computer program SPSS V 20.0 (2010) Inc., Illinois, United States was used to analyse the results; the association between organisms and studied variables was compared using chi-square (
During the period of study, 1280 pregnant women were seen at the antenatal booking clinic among which 800 satisfied the inclusion criteria. Four hundred of the pregnant women complained of abnormal vaginal discharge (cases), whereas 400 had no complaint of vaginal discharge, giving a prevalence of abnormal vaginal discharge in pregnancy of 31.5%.
Table 1 shows the clinical features associated with vaginal discharge in the study group. Vulval pruritus was present in 266 patients, and 200 (75%) of them complained of vaginal discharge, whereas 66 (25%) were in the control group. There was a significant association between pruritus and vaginal discharge (
|1. Vulval itching||Yes||200 (75 %)||66 (25 %)||266|
|No||200 (37 %)||334 (63 %)||534|
|2. Dysuria||Yes||74 (83 %)||15 (17 %)||89|
|No||326 (46 %)||385 (54 %)||711|
|3. Dyspareunia||Yes||25 (61 %)||16 (39 %)||41|
|No||375 (49 %)||384 (51 %)||759|
|4. LATa||Yes||24 (60 %)||16 (40 %)||40|
|No||376(49 %)||384 (51 %)||760|
|5. Vulval warts||Yes||1 (100 %)||0 (0 %)||1|
|No||399 (49.9 %)||400 (50.1 %)||799|
Table 2 shows the association between the bacterial isolates and their antibiotic sensitivity patterns.
Vaginal discharge in pregnancy is common, but distinguishing abnormal vaginal discharge from normal leucorrhoea of pregnancy is challenging. Since findings have showed that the trio of vaginal candidiasis, trichomoniasis and bacterial vaginosis are common causes of abnormal vaginal discharge in pregnancy; efforts must be made to exclude these conditions in pregnant patients presenting with vaginal discharge so that appropriate treatment can be instituted timely. Finally, gonococcal infection must also be excluded since though it is less prevalent than others, it is a major cause of morbidity in women in developing countries.