Presenting for a scheduled prenatal visit at 16 weeks gestation, a 28-year-old gravida 1, … — USMLE Step 2 CK

Presenting for a scheduled prenatal visit at 16 weeks gestation, a 28-year-old gravida 1, para 0 describes a newly developed, malodorous vaginal discharge. She notes the odor is particularly strong after intercourse. She denies any dysuria, pelvic pain, or vulvar pruritus. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $112/70\text{ mmHg}$ , and pulse is $78/\text{min}$ . Speculum examination demonstrates a thin, homogeneous, grayish-white fluid smoothly coating the vaginal walls without associated vulvovaginal erythema or friability. Vaginal pH is 5.5. A sample of the discharge is placed on a slide with normal saline; microscopic evaluation reveals numerous squamous epithelial cells whose borders are completely obscured by adherent coccobacilli. Which of the following is the most appropriate management for this patient?

Prescribe oral metronidazoleAnswer
B
Prescribe oral fluconazole
C
Administer intramuscular ceftriaxone and oral azithromycin
D
Reassure the patient and observe without treatment
E
Prescribe oral metronidazole for the patient and her sexual partner

Answer

Prescribe oral metronidazole

This patient presents with a classic case of bacterial vaginosis (BV). The diagnosis is established using Amsel criteria, which require three of the following four signs: a thin, homogeneous vaginal discharge; a vaginal pH greater than 4.5; a positive whiff test (fishy odor, often exacerbated after intercourse); and the presence of clue cells (epithelial cells with margins obscured by adherent bacteria) on saline wet mount. This patient meets the criteria with her thin grayish-white discharge, pH of 5.5, and clue cells. The standard of care for symptomatic BV in both pregnant and nonpregnant patients is treatment with oral metronidazole (or topical metronidazole/clindamycin). Treatment effectively resolves the bothersome symptoms and is considered safe throughout all trimesters of pregnancy.

Step-by-Step Solution

Evaluate the clinical presentation and physical exam findings.

The patient has a thin, grayish-white, malodorous discharge, an elevated vaginal pH (5.5), and clue cells on wet mount microscopy.

These findings fulfill Amsel criteria, confirming a diagnosis of bacterial vaginosis (BV).

Determine the indication for treatment.

The patient is symptomatic and specifically complains of a bothersome odor.

Symptomatic BV requires treatment to relieve discomfort, regardless of the patient's pregnancy status.

Select the appropriate pharmacotherapy.

Oral metronidazole is chosen as the first-line therapy.

Metronidazole (oral or topical) or topical clindamycin are the standard, safe, and effective treatments for BV in pregnant patients.

Key Concept

Diagnosis and first-line pharmacotherapy for bacterial vaginosis in pregnancy.

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