A 25-year-old woman, gravida 1 para 0, at 10 weeks gestation comes to the office due to a malodorous vaginal discharge. She is sexually active, has no chronic medical conditions, and has no medication allergies. Vital signs are normal. BMI is 26 kg/m². Fetal heart tones are 160/min. Speculum examination reveals a thin, gray discharge that coats the vaginal walls, but no erythema or edema is present on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells or motile organisms are seen. Which of the following is the best management option for this patient?

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11ec25c8_da09_44c4_bc81_b54340e30cd2_MD0003_00 This patient's off-white/gray, malodorous vaginal discharge is due to bacterial vaginosis (BV), caused by an overgrowth of the anaerobic bacteria Gardnerella vaginalis and a subsequent decrease in the normal vaginal Lactobacillus flora. The change in the vaginal flora to anaerobic bacteria breaks down vaginal glycoproteins and results in the clinical manifestations of BV: a vaginal discharge with an elevated pH (>4.5) and an amine or fishy odor that is accentuated by potassium hydroxide (ie, positive whiff test). The increased vaginal pH also allows for greater adherence of the bacteria to the vaginal epithelial cells, resulting in clue cells visualized on microscopy. In contrast to other vaginal infections, BV causes no vulvovaginal inflammation (eg, erythema, pruritus). Treatment of symptomatic BV is metronidazole (500 mg twice daily for 7 days) or clindamycin, regardless of pregnancy status. There were concerns about using metronidazole during the first trimester due to possible teratogenicity, but studies have shown no increased risk of congenital anomalies. Therefore, treatment does not need to be delayed until the second trimester (Choice B). (Choice A) Boric acid vaginal suppositories are used as an adjunct to metronidazole in patients with recurrent BV; they are not used as isolated therapy. (Choice C) Azithromycin, a macrolide antibiotic, is safe for use in pregnancy to treat Chlamydia trachomatis infection. Patients with chlamydia cervicitis can have a malodorous vaginal discharge; however, they typically have multiple white blood cells on microscopy rather than coated epithelial cells. Azithromycin does not treat BV. (Choice E) Povidone-iodine vaginal douches are typically used as a general antimicrobial cleanser for preoperative preparation for vaginal surgery (eg, hysteroscopy, total vaginal hysterectomy). Povidone-iodine vaginal douches are an ineffective therapy for BV. (Choice F) Topical fluconazole is safe to use during pregnancy for the treatment of Candida vulvovaginitis. In contrast to this patient, those with Candida infection have vulvovaginal erythema and pseudohyphae on microscopy. Educational objective: Bacterial vaginosis presents with a gray, malodorous discharge; no associated vulvovaginal inflammation; and epithelial cells coated with bacteria (ie, clue cells) on microscopy. Treatment of bacterial vaginosis is with metronidazole or clindamycin, regardless of pregnancy status. References: Is metronidazole teratogenic? A meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/9278206) The use of metronidazole during pregnancy: a review of evidence. (http://www.ncbi.nlm.nih.gov/pubmed/25986038)

A 25-Year-Old Woman, Gravida 1 Para 0, at 10 Weeks