A 23-year-old woman, gravida 1 para 0, at 12 weeks gestation comes to the emergency department for vaginal bleeding after intercourse. The patient had intercourse 12 hours ago and has since noticed blood in the toilet after urination and bright red blood on the toilet paper. She has no medical history and takes no medications. The patient reports occasional alcohol use prior to pregnancy but no history of tobacco or illicit drug use. Blood pressure is 120/70 mm Hg and pulse is 65/min. Fetal heart rate is normal by Doppler ultrasound. Pelvic examination shows normal external genitalia and a thick, yellow malodorous discharge in the vagina that is tinged with blood. The cervix is closed and bleeds after being touched with a cotton applicator; no masses are noted. Bimanual examination shows an enlarged uterus but no cervical motion tenderness, adnexal masses, or tenderness. Which of the following is the most likely diagnosis in this patient?

Question

A 23-year-old woman, gravida 1 para 0, at 12 weeks gestation comes to the emergency department for vaginal bleeding after intercourse.  The patient had intercourse 12 hours ago and has since noticed blood in the toilet after urination and bright red blood on the toilet paper.  She has no medical history and takes no medications.  The patient reports occasional alcohol use prior to pregnancy but no history of tobacco or illicit drug use.  Blood pressure is 120/70 mm Hg and pulse is 65/min.  Fetal heart rate is normal by Doppler ultrasound.  Pelvic examination shows normal external genitalia and a thick, yellow malodorous discharge in the vagina that is tinged with blood.  The cervix is closed and bleeds after being touched with a cotton applicator; no masses are noted.  Bimanual examination shows an enlarged uterus but no cervical motion tenderness, adnexal masses, or tenderness.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d1e3_3d92_bc81_4378dd7877ca_MD0003_00 This pregnant patient with postcoital bleeding and thick, mucopurulent discharge most likely has acute cervicitis caused by Chlamydia trachomatis or Neisseria gonorrhoeae, the 2 most prevalent sexually transmitted bacteria in women age <25. Other less common symptoms of cervicitis include dysuria, dyspareunia, and vulvovaginal pruritus. Pregnant patients with cervicitis often have no cervical motion tenderness (a sign of ascending upper reproductive tract infection) because the gravid uterus is sealed from the lower reproductive tract to maintain uterine sterility via the mucus plug. Acute cervicitis is diagnosed clinically by a pelvic examination that shows a malodorous, mucopurulent discharge and a friable cervix (eg, bleeds easily on contact). Nucleic acid amplification testing should be performed for confirmation. However, empiric treatment is recommended because a delay increases the risk for obstetric complications (eg, spontaneous abortion, preterm prelabor rupture of membranes). Pregnant patients are empirically treated with ceftriaxone and azithromycin; doxycycline is avoided due to potential teratogenic effects. (Choice B) Bacterial vaginosis, caused by overgrowth of Gardnerella vaginalis, is an uncommon cause of acute cervicitis. Patients typically have thin, gray discharge with a fishy odor rather than mucopurulent discharge and cervical bleeding. (Choice C) A cervical polyp can cause intermenstrual spotting or postcoital bleeding. However, cervical polyps are typically visible on pelvic examination, appearing as red, lobular structures originating from the cervix. cervical polyp (Choice D) An inevitable abortion presents with vaginal bleeding, cramping, and a dilated cervix, often with products of conception visualized at the os. This patient has a closed cervix and no pain, making this diagnosis unlikely. (Choice E) In contrast to this patient with bleeding from the cervix due to acute cervicitis, patients with a threatened abortion typically have bleeding originating from the uterus (eg, bleeding from the endocervical canal on examination). (Choice F) Pregnant patients with von Willebrand disease (vWD) are at increased risk for postpartum hemorrhage. However, vWD does not typically cause postcoital bleeding and is not associated with mucopurulent discharge. Educational objective: Acute cervicitis can cause postcoital bleeding, mucopurulent discharge, and a friable cervix. In pregnancy, empiric treatment is with ceftriaxone and azithromycin to cover the most common pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae. References: Postcoital bleeding: a review on etiology, diagnosis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/25045355) Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296)

A 23-Year-Old Woman, Gravida 1 Para 0, at 12 Weeks