Evaluation of causes of vaginal discharge in relation to pregnancy status

Introduction

The female genital tract has a complex microbial flora which varies with site, age of the patient and hormonal background. Likewise, the quality and quantity of cervical and vagina secretions vary with many factors including age, phase of menstrual cycle, and use of oral contraceptive device.[1]

The normal flora of the vagina change according to circulating oestrogen levels. When oestrogen is present, the vaginal epithelium contains glycogen which favours colonisation b) lactobacilli and other acid tolerant bacteria which metabolise glycogen to lactic acid. This results it a pH of 4.5 or less. Other bacteria commonly present in large numbers include anaerobic streptococci, diphtheroids, coagulase negative staphylococci and a-haemolytic streptococci. Other common commensale which can act as pathogens include candida spp, staphylococci and b-haemolytic streptococci including streptococcus agalactiae and actinomyces spp. In bacterial vaginosis the concentration of Gardnerella vaginalis, mobiluncus spp, anaerobic Gram negative rods (for example, bacterioides spp, prevotella spp, and porphyromonas spp) and Mycoplasma hominis increases compared with the lactobacilli. The vaginal secretions of prepubertal children and post menopausal women are more alkaline and contain a varied bacterial flora dominated by coagulase negative staphylococci, diptheroids, a-haemolytic steptococci, anaerobic Gram negative rods and Escherichia coli.[1]

Vaginal discharge is common condition which affects many women during their reproductive years. Because of its relatively trivial nature vaginal discharge is often not investigated fully and empirical treatment may be initiated based on clinical finding alone. However the common aetiological agents of vaginal discharge respond to specific therapies and their symptoms are sufficiently similar to render clinical diagnosis difficult. Therefore, laboratory investigations are appropriate. The incidence of vaginal discharge rises during pregnancy and this increase is often assumed to result from overgrowth of yeasts, present in small numbers in the vaginal flora, associated with the normal changes during pregnancy. Another common condition is bacterial vaginosis, a synergistic interaction between obligate anaerobes and Gardnerella vaginalis. Trichomonas vaginalis is a less frequent cause of vaginal discharge but remains important because it is transmitted by sexual contact.[2]

The purpose of this study was to determine incidence of these pathogens in pregnant and non-pregnant sexually active females of age group 20-40 years presenting with the chief complaint of vaginal discharge.

Materials and Methods

One hundred sexually active females in the age group of 20-40 years, with complaint of vaginal discharge attending Obstetrics and Gynecology clinic of Government Medical College and Hospital, Faridkot, were selected for this study at random. A detailed clinical history and a thorough examination of all the cases were done. After making the clinical diagnosis, appropriate tests for diagnosing candidiasis, trichomoniasis, gonorrhoea and bacterial vaginosis were done.

Observation and Results

It was observed that out of 100 cases, 13 (13%) patients were pregnant and 87 (87%) were non pregnant.

4 (30.76%) of pregnant cases had bacterial vaginosis, 8 (61.61 %) had vulvovaginal condidiasis and 1(7.69%) belonged to other causes.

41 (47.12%) of non-pregnant cases had bacterial vaginosis, 23 (26.43%) had vulvovaginal candidiasis, 2(2.26%) had trichomoniasis, 3(3.44%) had gonorrhoea, 5(5.75%) had non-specific urogenital infection and 13(14.94%) belonged to other causes of vaginal discharge (Table-I). There was an insignificant relation between pregnancy status and type of discharge (p>0.05) and non-pregnant females

Discussion

Bacterial vaginosis was more common in non-pregnant women (30.76% Vs 47.12%) whereas C. albicans was more common in pregnant women (61.53% Vs 26.43%). Similar results were also revealed by Levett[2] who also found that bacterial vaginosis was more common in non-pregnant women (33% Vs 23%%, c2=2.816 with one degree of freedom, Yates correction applied) and C. albicans was more common among pregnant women (49% Vs 39%, c2=1.488with one degree of freedom, Yates correction is applied) although neither difference reached statistical significance.

During pregnancy, the vagina shows an increased susceptibility to infection by candida species resulting in both a higher rate of vaginal colonization and a higher rate of symptomatic vaginitis. It is generally thought that high levels of hormones, by providing a higher glycogen content in the vaginal tissue, provide an excellent carbon source for candida organisms. It is also said that oestrogen enhances adherence of yeast cells to the vaginal mucosa[3].