0071643192.pdf

OBSTETRICS AND GYNECOLOGY

■ RU-486 (mifepristone):A steroid that blocks progesterone receptors
■ A 10-mg dose is as effective as 1.5 mg of levonorgesterol in preventing
implantation (first 72 hours).
■ A dose of 600 mg may be used as an abortifacient (approved for up to
49 days gestation in the United States).
■ Side effects include cramping and vaginal bleeding.
■ When used as an abortifacient, approximately 5% of patients will require
surgical intervention for retained products.

BACTERIAL VAGINOSIS

The most common cause of abnormal vaginal discharge. BV is secondary to
high concentrations of anaerobic bacteria and Gardnerella vaginalisreplacing
the normal lactobacilli flora. It is seen in sexually active women.

SYMPTOMS/EXAM

■ “Fishy smelling” vaginal discharge
■ Itching
■ Increased discharge

DIFFERENTIAL

■ Candida vaginitis
■ Trichomoniasis
■ Pelvic inflammatory disease

DIAGNOSIS

■ Physical exam shows a malodorous gray/white discharge.
■ Wet mount shows clue cells (see Figure 12.4).
■ Addition of KOH to a smear of the discharge reveals same fish smell,
referred to as a “positive whiff test.”

TREATMENT

■ Metronidazole 500 mg PO BID ×7 days or a single 2-g dose
■ Clindamycin is a reasonable alternative.

CANDIDA VULVOVAGINITIS

CAUSES

This is caused by Candida albicans, which have filamentous forms that pene-
trate the mucosal surface, causing inflammation and lysis of tissue. Risk fac-
tors include DM, HIV, recent antibiotic use, and pregnancy (see Table 12.5).

SYMPTOMS/EXAM

■ White “cottage cheese” vaginal discharge
■ Red/swollen vaginal mucosa and labia
■ Itching is a significant complaint along with dysuria and dyspareunia.

DIFFERENTIAL

Bacterial vaginosis, trichomoniasis, pelvic inflammatory disease

FIGURE 12.4. Clue

cells in patient with bacte-

rial vaginosis.

(Reproduced, with permis-

sion, from Kasper DL et al

(eds).Harrison’s Principles

of Internal Medicine, 16th

ed. New York: McGraw-Hill,

2005:767.)

Clue cells = epithelial cells

coated by bacteria = bacterial

vaginosis = metronidazole or

clindamycin if pregnant.

When prescribing

metronidazole, warn patients

about the disulfiram-like

reaction when coingested with

alcohol.