A 38-year-old woman, gravida 7 para 6, at 37 weeks gestation comes to the office for a routine prenatal visit. For the past week, the patient has had leakage of clear fluid whenever she stands from a sitting position, forcing her to change her underwear twice daily. She has had no vaginal bleeding or contractions. The patient did not experience similar leakage during her other pregnancies, all of which ended in uncomplicated term vaginal deliveries. During this pregnancy, she was treated for chlamydia at 10 weeks gestation. Blood pressure is 110/70 mm Hg and weight is 105 kg (231.5 lb). Fetal heart rate is 150/min. Speculum examination shows a slightly open cervix and a scant amount of clear fluid in the posterior vagina, but no fluid emerges from the cervix when the patient coughs. The vaginal fluid does not turn nitrazine paper blue; a dried smear shows no ferning on microscopy. Which of the following is the most likely cause of this patient's symptoms?

Question

A 38-year-old woman, gravida 7 para 6, at 37 weeks gestation comes to the office for a routine prenatal visit.  For the past week, the patient has had leakage of clear fluid whenever she stands from a sitting position, forcing her to change her underwear twice daily.  She has had no vaginal bleeding or contractions.  The patient did not experience similar leakage during her other pregnancies, all of which ended in uncomplicated term vaginal deliveries.  During this pregnancy, she was treated for chlamydia at 10 weeks gestation.  Blood pressure is 110/70 mm Hg and weight is 105 kg (231.5 lb).  Fetal heart rate is 150/min.  Speculum examination shows a slightly open cervix and a scant amount of clear fluid in the posterior vagina, but no fluid emerges from the cervix when the patient coughs.  The vaginal fluid does not turn nitrazine paper blue; a dried smear shows no ferning on microscopy.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_da8e_a157_bc81_6d23daa40dd5_MD0003_00 Vaginal wetness or leakage of fluid in pregnancy may be due to a variety of causes. The most concerning is loss of amniotic fluid (eg, labor, intraamniotic infection); therefore, all pregnant patients with leakage of fluid require evaluation for prelabor rupture of membranes (PROM). PROM typically causes a large gush of fluid but may also cause vaginal wetness or intermittent leakage of small volumes. Confirmation is usually with visualization of amniotic fluid emerging from the cervix with Valsalva (eg, cough), nitrazine-positive testing (ie, turns blue), and/or ferning on microscopy. However, none of these signs are seen in this patient, making PROM unlikely (Choice C). A more likely cause of leakage of fluid in this patient is stress urinary incontinence (SUI), the involuntary leakage of urine with increased intraabdominal pressure (eg, standing from a sitting position, laughing). SUI is the most common type of urinary incontinence during pregnancy, due to decreased pelvic floor muscle and urethral sphincter strength as well as increased bladder pressure from the fetal presenting part and the weight of the gravid uterus. A small pool of urine in the posterior vagina may be seen on speculum examination because urine can become trapped in the vagina (ie, retrograde vaginal voiding) during pregnancy due to effects of the growing uterus and positional changes while voiding. (Choices A, B, and D) Patients with bacterial vaginosis and trichomoniasis can have intermittent leakage of fluid from vaginal discharge; however, speculum examination typically shows a discharge that is gray and malodorous (bacterial vaginosis) or green/yellow and frothy (trichomoniasis). Speculum examination of symptomatic patients with chlamydia typically shows mucopurulent cervical discharge. (Choice F) Vesicovaginal fistula is a pathological communication between the bladder and vagina that is usually a sequela of gynecologic surgery or prolonged labor. Vesicovaginal fistulas typically present with continuous, rather than intermittent, urinary leakage. Vesicovaginal fistula Educational objective: Intermittent vaginal leakage or wetness may be present in patients with either prelabor rupture of membranes or stress urinary incontinence. Patients with these symptoms are likely experiencing stress urinary incontinence if no fluid emerges from the cervix on Valsalva maneuver and nitrazine and fern testing are negative. References: Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/23436035) A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques. (http://www.ncbi.nlm.nih.gov/pubmed/29332252) Urinary incontinence during pregnancy. Is there a difference between first and third trimester? (http://www.ncbi.nlm.nih.gov/pubmed/25262291)

A 38-Year-Old Woman, Gravida 7 Para 6, at 37 Weeks