KEY POINTS
• Pregnancy does not prevent or protect a woman from developing common gynecologic problems and complications.
• Untreated gynecologic problems can adversely affect obstetric care and exacerbate obstetric complications.
• Treatment of gynecologic problems is frequently the same for the pregnant and the nonpregnant patient with some notable exceptions.
EXTERNAL GENITALIA
Careful inspection of the external genitalia before pregnancy, as well as at the initial prenatal visit, is crucial to the patient’s health. Counseling about the signs and symptoms of external genital infections, as well as the risks of transmission with exposure to infectious organisms, should also be discussed.
Bartholin Abscess
Background
• Bartholin cysts are a common occurrence in the reproductive age female, and pregnancy can exacerbate their symptoms.
• Although asymptomatic cysts need not necessarily be treated, an abscess of the Bartholin gland usually requires immediate treatment.
Diagnosis
• A Bartholin gland abscess typically causes significant pain and inflammation. The diagnosis can often be made based solely on the patient’s complaints.
• Patients will complain that they feel a large tender “bump” on their labia and have severe pain with standing, walking, or sitting.
• Although the symptoms are fairly classic, a thorough examination and evaluation must be performed (1,2).
Treatment
• Drainage via an incision on the mucosal side of the gland is appropriate when the area is fluctuant. Otherwise, warm sitz baths are recommended until the abscess is ready for drainage.
• Cultures obtained at the time of initial drainage are useful, as gonococcus is often the etiologic agent, and when suspected, antibiotics are appropriate.
• Once the abscess is incised, a Word catheter is placed for 4 to 6 weeks to allow adequate epithelialization of a drainage tract. Packing the incised abscess pocket with narrow gauze is also acceptable.
• Recurrent infection or development of recurrent symptomatic cysts warrants subsequent marsupialization (surgical exteriorization of the cyst for drainage). Removal of the gland is not recommended in pregnancy and should be deferred until the puerperium is complete.
Human Papillomavirus and Condylomata Acuminata
Background
• Condylomata acuminata or genital warts are very common in both men and women.
• They are caused by the human papillomavirus (HPV) of which there are more than 100 subtypes. More than 40 of these subtypes can infect the genital area. Genital warts are usually caused by HPV types 6 and 11 (3,4).
• Reinfection and persistent infection are common.
Diagnosis
• Condyloma acuminatum has a classic “cauliflower-like” appearance and can protrude from the skin on stalks. The lesions appear fleshy and may cause some minor itching but are not painful.
• The clinician must clinically distinguish the very common condylomata acuminata (genital warts) from the rare, wart-like growths of condyloma latum, which is caused by Treponema pallidum (1,2).
• During pregnancy, genital warts may proliferate, rapidly enlarge, and become friable and can obstruct the vaginal canal.
• HPV, in rare cases, may be transmitted to the newborn, resulting in laryngeal papillomas with respiratory complications. However, delivery by cesarean section is not indicated to prevent fetal intrapartum exposure.
Treatment
• Outpatient treatment of genital warts during pregnancy can be safely achieved by
• Cryotherapy (liquid nitrogen application or nitrous oxide cryoprobe).
• Carbon dioxide laser therapy.
• Topical application of 50% to 80% trichloroacetic acid solution.
• Imiquimod cream has been used with some success but should be used with caution and only when benefits outweigh risks, as it is a category C drug in pregnancy and may be associated with fetal toxicity.
• Podophyllin, podofilox, and sinecatechins are currently not advised for use in pregnancy because of the risks of birth defects, fetal death, stillbirth, and maternal toxicity.
• Removal of condyloma via electrocautery or laser therapy is an alternative that may require general or regional anesthesia (see Chapter 3).
• Both cryotherapy and carbon dioxide laser therapy appear to be highly effective when used to treat condyloma in pregnancy, with no significant fetal, neonatal, or maternal morbidity.
• The recurrence rate of genital warts appears to be the lowest when treated in the third trimester.
• Genital warts are not considered an indication for cesarean delivery unless they are so large as to constitute physical obstruction or significant risk for vaginal/cervical lacerations.
• There are currently two U.S. Food and Drug Administration (FDA)–approved vaccines shown to be effective in preventing HPV infection in adolescents and young adults. Inadvertent administration of these vaccines during pregnancy has shown no harmful fetal effect, but women with known pregnancy should not be vaccinated (3).
Genital Herpes Simplex (See Chapter 23)
VAGINITIS (5)
Background
• Vaginal infections are among the most common reasons for urgent gynecologic office visits.
• Speculum examination and microscopic study are essential in the evaluation of pregnant women complaining of vaginal discharge. Both physiologic secretions and rupture of membranes may be misdiagnosed as vaginitis.
• Although most vaginal infections are easily treated, these infections may be associated with more serious obstetric complications such as maternal and neonatal infection, preterm premature rupture of membranes (PPROM), or preterm labor.
Candidiasis
Background
• Candida accounts for approximately 35% of vaginal infections. However, a “yeast infection” is not a sexually transmitted disease. It is a result of the overgrowth of fungal organisms that are present in the normal vaginal flora.
• The most common fungal organism is Candida albicans. Other important pathogens include Monilia, Candida tropicalis, and Candida glabrata.
• Several factors may predispose a patient to vaginal candidiasis including pregnancy, diabetes, immunosuppressive disorders, use of oral contraceptives or oral corticosteroids, or recent use of broad-spectrum antibiotics.
Diagnosis
• Typical symptoms include itching, burning, dysuria, an erythematous vulva, and curdlike (“cottage cheese”) discharge, which tends to adhere to the vaginal mucosa. The vaginal pH remains normal at less than 4.2. The vulva and groin may also exhibit “satellite lesions” or erythematous papules that often cause intense pruritus.
• Confirmation of the diagnosis is made with the microscopic observation of hyphae and budding yeast in a 10% potassium hydroxide wet preparation.
• Pregnant women, especially those previously infected, are at increased risk for candida vulvovaginitis. The signs, symptoms, and method of diagnosis are the same as for the nonpregnant patient.
Treatment
• Clotrimazole and miconazole nitrate topical (intravaginal) treatments are more effective than is nystatin and require fewer treatment days. Because small amounts of these drugs may be absorbed from the vagina, they should be used with caution in the first trimester. Topical azole treatments, applied for 7 days, are the first line for symptomatic candidiasis in pregnancy.
• Fluconazole oral medication has been used anecdotally in pregnancy, but caution should be exercised with benefits outweighing risks as it is also a category C drug in pregnancy.
Trichomoniasis
Background
• Trichomoniasis accounts for approximately 20% to 25% of vaginal infections. The causative agent is the protozoan Trichomonas vaginalis.
• Trichomoniasis is a highly contagious, sexually transmitted infection and is more often seen in young, single patients with multiple sexual partners.
• There is evidence that T. vaginalis has been associated with obstetric complications (6).
Diagnosis
• Typical signs and symptoms of this venereally transmitted protozoan include an often malodorous, frothy, yellow-green discharge accompanied by intense pruritus and dysuria.
• In 25% of cases, there may be red subepithelial abscesses and punctuate hemorrhages noted on the cervix and in the vaginal fornices giving the cervicovaginal epithelium a “strawberry” appearance.
• The diagnosis is confirmed microscopically with the observation of motile trichomonads in a wet preparation with normal saline. Vaginal pH is elevated, usually ≥4.5 (1).
Treatment
• Metronidazole is the preferred treatment for both the nonpregnant and the pregnant patient. It is administered as either
• Single 2-g oral dose or 250 mg orally three times daily for 7 to 10 days.
• Topical metronidazole is not recommended for treatment of trichomoniasis.
• The patient’s partner(s) must be referred for treatment. One must suspect, with recurrent infections, that the patient’s partner(s) has failed to receive therapy.
• Many studies have examined mother–infant pairs exposed to metronidazole throughout pregnancy with conflicting results.
• Metronidazole is known to increase the fetotoxicity and teratogenicity of alcohol in mice, which may be a confounding factor in humans as well.
• There are conflicting data regarding a potential increase in facial abnormalities in fetuses exposed to metronidazole in the first trimester. This has led to the recommendation by some experts that its use should probably be avoided early in gestation. Symptomatic treatment such as a dilute povidone–iodine douche or vaginal clotrimazole suppositories, therefore, may be helpful for the first-trimester patient. The Centers for Disease Control and Prevention (CDC), however, recommends that all symptomatic pregnant women with trichomoniasis should be considered for treatment regardless of stage of pregnancy (CDC Sexually Transmitted Treatment Guidelines, 2010; www.cdc.gov).
• There are no data to date suggesting any poor outcomes from the use of metronidazole in the second and third trimesters. The manufacturer recommends against using single-dose therapy in pregnancy (1,6); however, CDC-recommended treatment is a single 2-g oral dose in pregnancy.
Bacterial Vaginosis
Background
• Previously named for the presence of Gardnerella vaginalis, bacterial vaginosis (BV) is now understood to be a polymicrobial vaginal infection resulting from the disruption of normal vaginal flora and is comprised of anaerobes, Mobiluncus, Gardnerella, and mycoplasma organisms.
• BV in pregnant women has been associated with preterm labor and delivery, PPROM, and maternal and neonatal infections; therefore, treatment is essential to a healthy pregnancy (7).
Diagnosis
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