Asymptomatic Trichomonas vagina/is, candidiasis and Haemophi/us vagina/is were found to affect approximately 20% of women attending an antenatal clinic for the first time. Eight patients (1,4%) had asymptomatic gonorrhoea. Clinical features, such as pruritus and the appearance of a discharge, were frequently misleading, whereas examination of routine Papanicolaou smears enabled the correct diagnosis to be made in most cases. The need for the early recognition and treatment of asymptomatic vaginal disease in pregnancy is commented upon.S. Afr. Med. J., 48, 803 (1974)

Jones, W

Massel, P

Notelovitz, M

English

Asymptomatic Trichomonas vagina/is, candidiasis and Haemophi/us vagina/is were found to affect approximately 20% of women attending an antenatal clinic for the first time. Eight patients (1,4%) had asymptomatic gonorrhoea. Clinical features, such as pruritus and the appearance of a discharge, were frequently misleading, whereas examination of routine Papanicolaou smears enabled the correct diagnosis to be made in most cases. The need for the early recognition and treatment of asymptomatic vaginal disease in pregnancy is commented upon.S. Afr. Med. J., 48, 803 (1974)

Notelovitz, M.

Massel, P.

Jones, W.

AJOL - African Journals Online

17 April 1974 S.-A. MEDIESE TYDSKRIF(Byvoegsel-Suid-Afrikaanse Tydskrif vir Obstetrie en Ginekologie)803o & G 41Asymptomatic Vaginal Disease •In PregnancyM. NOTELOVITZ, P. MASSEL, W. lONESSUMMARYAsymptomatic Trichomonas vagina/is, candidiasis andHaemophi/us vagina/is were found to affect approximately20% of women attending an antenatal clinic for the firsttime. Eight patients (1,4%) had asymptomatic gonorrhoea.Clinical features, such as pruritus and the appearance ofa discharge, were frequently misleading, whereas examina-tion of routine Papanicolaou smears enabled the correctdiagnosis to be made in most cases. The need for theearly recognition and treatment of asymptomatic vaginaldisease in pregnancy is commented upon.S. Afr. Med. J., 48, 803 (1974).Pregnancy is one of the few physiological conditions duringwhich most women seek medical advice. An excellent op-portunity is thus provided to screen a large sector of thenormal population for asymptomatic disease.' Clinicalvaginitis is one condition which may easily be missed andso predispose to neonatal complications, such as oral thrushand ophthalmia neonatorum. A prospective study wastherefore undertaken to determine the incidence of asymp-tomatic vaginal disease in pregnancy, and to compare theclinical presentation of this condition with the variouslaboratory methods of diagnosis. The investigation wasconducted under field conditions, to assess the accuracyof clinical personnel working under normal consultingcircumstances.PATIENTS AND METHODSPatient~ attending the Antenatal Clinic at Addington Hos-pital for the first time were studied. A total of 720patients were examined, of whom 186 were White and534 non-White. After the taking of relevant histories, thepatients were examined vaginally, and the clinical featuresnoted. Cervical and vaginal secretions were obtained fordirect inoculation onto various culture media; for micro-scopical examination of the fresh specimen, and for pre-paration as a routine Papanicolaou smear. The clinicalexamination and taking of specimens were performed by3 registrars working in the Department of Obstetrics; themicrobacteriology by a trained medical technologist (W.J.);AddingtaD Hospital, DurbanM. NOTELOVITZ, M.B. B.CH., M.D., M.R.C.O.G., Obstetricianand Gynaecologist (Present address: Chelmsford MedicalCentre, Chelmsford Road, Durban)P. MASSEL, M.B. B.CH., M.R.C.O.G., Senior Obstetrician andGynaecologistW. JONES, Part-time BacteriologistPaper presented at the 49th South African Medical Congress (MASA),held in Cape Town on 23 - 27 July 1973.while Papanicolaou smears were processed in the routinefashion. The clinical findings were not made known to themicrobiologist or to the cytologist.The media used for culture were: blood agar (for identi-fication and isolation of staphylococci and streptococci)'MacConkey's agar (for identification of Escherichia coli,Proteus and other non-lactose fermentors); chocolate agar(for identification of gonococcus and Haemophilus j'agina-lis); Mueller-Hinton media (for Neisseria gonorrhoeae andHaemophil/ls vagina/is); tomato agar (for identificationand isolation of lactobacilli and candida); Sabouraud'smedia (for isolation of Candida); and cornmeal agar (forspecific identification of Candida albicans). Wet prepara-tions were examined microscopically for evidence ofTrichomonas vaginalis. Pus cells on microscopical examina-tion of the vaginal smear denoted active infection.Four organisms commonly associated with vaginitis werelooked for, namely: Trichomonas I'aginalis, Candidaalbicans, Haemophil/ls vaginalis and Neisseria gonorrhoeae.Their incidence was compared with Doderlein's bacillus,a known vaginal commensal organism.Subjects who presented without symptoms or clinicalsigns, and in whom pus cells were not observed on micro-scopy of the vaginal secretion, were classed as normal.There were 258 subjects in this category (71 Whites and187 non-Whites).Patients who presented with no symptoms but who hadclinical signs of disease were classified as having asymp-tomatic vaginal disease. Four hundred and fifty-twopatients qualified for this category (115 Whites and 337non-Whites).RESULTSNormal FloraTable I reflects the incidence of the various organismsin the so-called 'normal' group. Whereas Doderlein's bacil-lus was distributed equally between the 2 racial groups, amarked difference was noted for all the other organisms.Trichomonas and N. gonorrhoeae are known pathogensand their presence indicates an abnormal state. There imore difficulty when interpreting the significance of H.vaginalis and Candida, since some species are thought tobe part of the normal flora of the vagina. When assessingthe degree (albeit empirical) of candidiasis in our studyoroup it was noted that values of I + or less were equallydistributed among the two racial groups. When yeast cellswere found in greater quantities, i.e. + + or more. a mark-ed difference in the incidence of involvement was noted(Whites 7%, non-Whites 18,6%). This suggests that valuesof + + or more are representative of a pathological state,while lower values are indicative of normal commensals(Table II). The same was noted for H. mgina/is.8040& G 42S.A. MEDICAL JOURNAL<;5upplement-South African Journal of Obstetrics and Gynaecology)17 April 1974TABLE I. DISTRIBUTION OF VAGINAL FLORA IN NORMALPREGNANCY'" Cl><tl Cl) .~a en 'r;; <I>0 Q; cE"'= .!:! ~ c 'a;o <tl "0 0 '0, ~ .-.<:: .S "0 <tl <1>=U Cl C c :> -a .--i:: co Cl> 0 :r: '0 ;;;f-. :> U 0 O.n(%) ('10) (%) (%) (%)Whites ... 71 5,6 36,5 0 8,3 60Non-Whites 187 13,3 SO,O 0,5 16,0 62Total 258 11,2 46,2 0,4 14,0 61Pruritus as a SymptomThe significance of pruritus was examined, since it is oneof the characteristic features which differentiates a patho-logical discharge from leucorrhoea.A total of 147 patients presented with this symptom(63 Whites, 84 non-WhiteS). Surprisingly only 38% of theWhites complaining of pruritus had evidence of some formof infection (Trichomonas, Candida, H. vagina/is, pus cellsor a combination of these). The respective figure of 80%in the non-White group was much closer to our anticipatedestimation.TABLE It. DIFFERENTIATION OF PATHOLOGICAL FROMCOMMENSAL VAGINAL CANDIDIASIS ACCORDING TO THE Clinical AccuracyNUMBER OF ORGANISMS PRESENTThe accuracy of the clinical diagnosis was assessed bycomparing the appearance of the vaginal secretion withthe laboratory result. Only 47,5% of all discharges thoughtto be Trichomonas vaginalis were confirmed (12'% provedto be Candida). The results were better when Candida wasdiagnosed, since 73% were correctly identified. Of 'monilia-like' discharges 5,5'% were misdiagnosed and were foundto be due to Trichomonas. In the 'non-specific group', 50%of subjects were found to have no specific organisms; 29'30were shown to have candidiasis, while 21,5% of so-callednon-specific discharges were due to Trichomonas vaginalis.60627,018,6Degree4,8 11,7 2,1++(%)2,829,131,4Control------------- Doderleln+++ ++++bacillus(%) (%) (%)2,8 1,422,9 8,5Scanty +(%) ('10)15,3 13,8Non-Whites(187)*Whites (71)* ...". Number of patients in brackets.Patients were therefore considered to have 'vaginaldisease' if examination of the secretions revealed the pre-sence of N. gonorrhoeae; Trichomonas; Candida ++ ormore, and H. vagina/is ++ or more.On this basis, no fewer than 11,2% of all 'normal' sub-jects (i.e. without symptoms or signs of vaginal disease),had evidence of Trichomonas vagina/is; 14% had H.vaginalis; and 0,5 % gonorrhoea. 'Pathological' candidiasisoccurred in 12,8% of the normal group.Asymptomatic DiseaseValue of the Papanicolaou SmearTo ascertain the value of the Papanicolaou smear inthe diagnosis of vaginal disease in pregnancy, the incidenceof Trichomonas vaginalis diagnosed by this method wascompared with the laboratory result. Although there weresome instances of disagreement, Le. laboratory result posi-tive and Papanicolaou smear negative, and vice versa, theover-all correlation between these two diagnostic methodswas higWy similar. Thus the pick-up rate of Trichomonasvagina/is among Whites with the laboratory technique was8,4% v. 9,0% with the Papanicolaou smear (Table IV).TABLE IV. VALUE OF THE PAPANICOLAOU SMEAR IN THEDIAGNOSIS OF TRICHOMONAS VAGINITIS AND CAN-DIDIASIS USING LABORATORY CULTURE AS A CONTROLPatients who had clinical evidence of vaginitis but whodid not present to the clinic with symptoms, were regardedas having asymptomatic disease. The incidence is set outin Table Ill. Trichomonas CandidaTABLE Ill. INCIDENCE OF ASYMPTOMATIC VAGINALDISEASE IN PREGNANCY• Number of patients in brackets.The same correlation was not obtained when screeningfor' Candida. Almost twice as many positive results werenoted among Papanicolaou smears taken from Whites. Thegreater incidence probably relates to isolated yeast cellsbeing detected on the smear, while positive laboratorydiagnosis referred to patients in whom ++ or more were* Number of patients in brackets.Pap. +(%)11,516,35,425,0Lab. +(%)Pap. +(%)9,020,7Lab. +(%)8,418,6Whites (224)* ...Non-Whites (531)*Cl><I>otocoo(%)o1,71,4.~Q;c0,~:r:(%)13,920,920,0'"Cl).!:!-a'6cCl>u('10)6,220,917,3'"<tlCoEo~.;::f-.(%)7,820,717,5Whites (115)* ...Non-Whites (337)*Total (452)*17 April 1974 S.-A. MEDIESE TYDSKRIF(Byvoegsel-SlIid-Afrikaanse Tydskrif vir Obslelrie en Ginekologie)8050& G 43TABLE V. ACCURACY OF DIAGNOSING ASYMPTOMATICVAGINAL DISEASE IN PREGNANCY: A COMPARISON OF3 DIAGNOSTIC METHODS USING LABORATORY CULTURECONTROLhoea"·13 the genital tract may harbour the gonococcus in2,2 - 30~0 of women." Data regarding the incidence ofgonorrhoea vary tremendously. depending upon the popu-lation studied and the technique used. For example, in arecent screening survey of 13725 women attending aPlanned Parenthood Clinic, 1,2°10 had confirmed positivecultures, while in a private practice situated in the samecity, a pilot study of 320 consecutive patients failed todemonstrate a single case of gonorrhoea." In yet anotherstudy involving 231 unselected private patients, 2,6% pro-duced positive gonococcal cultures." The need for im-proved diagnostic media is also obvious. Thayer-Martinselective medium is much more sensitive than, for instance,Gram·stain. This medium was not available for our studyand it is therefore possible that our figure of 1,4% is anunderestimate of the true situation. Antenatal tests forsyphilis have been accepted medical practice for manyyears. Although reliable serological screening for gonorr-hoea is not yet available, practitioners can and shouldscreen pregnant patients for gonorrhoea.Apart from an obvious discharge, pruritus or a vulvalirritation is the most likely symptom that will bring apatient to a doctor. The significance of this symptom,however, depends in large measure on the fastidiousnessof the patient concerned. Although other causes of pruritus,such as the use of vaginal deodorants, were not inquiredinto, it would appear that the significance of this symptomis often exaggerated. Oriel et al.' found pruritus in only50% of their patients with yeast infections.Another interesting observation was the error in theclinical diagnosis of vaginal discharges, as judged by theirappearance. Although the examiners were relatively in-experienced, the 'typical' appearance of vaginal dischargesis frequently misleading. The 'thrush plaque' is said to bepathognomonic of candidiasis.' This was confirmed inthe present study since 73 % of monilial discharges werecorrectly diagnosed - a figure closely approximating the77,6% quoted by Peeters et al.' The clinical presentation oftrichomonas vaginitis however is much more variable,only 47,5% of our patients having the characteristic yellowgreen frothy discharge and injected vagina.When we compared the reliability and accuracy of thevarious diagnostic methods, using the laboratory as ourcontrol, the Papanicolaou smear was found to be the mostaccurate means of diagnosing trichomonas vaginitis (seeTable V). Clinical signs were much more reliable in thediagnosis of candidiasis.28,5'1032,0'10tU.~ (J)c cClU Ul47,5%73,0'1088,0%81,5'10Q)c '-; a. ~o tU ED:Cl..Ul82,5%96,0'10TrichomonasCandidiasisDISCUSSIONfound. Conversely, culture yielded more positive results inthe non-Whites.The presence of vaginal organisms such as N. gonorrhoeaeand Trichomonas vaginalis is indicative of a diseasedstate. The diagnosis of vaginitis - especially if unasso-ciated with obvious clinical signs - is much more dif-ficult when the organism isolated may be a normal com-mensal of the vagina. Occasional yeast spores found in avaginal smear serve as an example. Reference to the litera-ture is conflicting. Hurley' refers to C. albicans as a 'nor-mal' commensal of the vagina, occurring in some 36% ofpregnant females.' More recently, in a well-documentedprospective study of 303 pregnant women, Carroll et al.'detected C. albicans in 16,5% of patients, only once froma healthy vagina. They concluded that the presence ofgenital yeasts was indicative of a diseased state and con-tradicted the long-held belief that C. albicans is often acommensal of the healthy vagina! The same conclusionswere reached by Oriel et al.' when studying a group ofwomen attending a venereology clinic.Of the many species of yeasts found in the vagina, onlyC. albicans and Torulopsis glabrata are thought to be ofpathogenic significance: although the latter rarely pro-duces symptoms.' The yeasts in our study were not dif-ferentiated, but since C. albicans is found in some 75 - 95%of patients with significant monilial vaginitis, we cansafely assume that the predominant yeast in our serieswas C. albicans.'" We arbitrarily divided our study materialinto patients with + + or more, and regarded them ashaving candidiasis of pathogenic significance. Of ourpatients 12,8% were affected. As the majority of ourpatients (77,2%) did not yield positive cultures, we agreewith Carroll et aP that the isolation of C. albicans in thevagina of pregnant patients is associated with morbidityand is indicative of disease of the lower genital tract.Although H. vaginalis (Corynebacterium vaginale) hasbeen isolated from women who have had no gynaecologi-cal complaints: this organism is now known to be patho-genic and is responsible for so-called 'non-specific' vagini-tis." H. vaginalis may be readily diagnosed by Gram-stain-ing, culture and immunofluorescent techniques. Lewis andO'Brein'o demonstrated that Papanicolaou smears couldalso be used for the cytological diagnosis of H. vaginalis,and this technique was used in the present study. With thisdiagnostic medium, 8,3% of 'normal' Whites and 16,0% of'normal' non-Whites were found to have H. vaginalis onassessment of routine Papanicolaou smears.Patients who may have had clinical evidence of vaginaldisease but who did not present to the clinic with symptomswere classified as having had asymptomatic vaginal diseasein pregnancy (Table Ill). Of the 337 non-Whites in thiscategory, no fewer than lout of every 5 had evidence ofsignificant vaginal disease. The incidence was lower forWhites. The over-all incidence of candidiasis is similar tothat of other series."N. gonorrhoeae was isolated from the vaginal secretionsin 8 of our patients (1,4%), all of whom were asymptomatic.Because of the frequently asymptomatic nature of gonorr-8060& G 44S.A. MEDICAL JOURNAL(Supplemem-Sourh African Journal of Obstetrics and Gynaecology)17 April 1974It may therefore be concluded that both trichomonasvaginitis and significant moniliasis are often asymptomatic,but that evidence of their presence can frequently be de-tected by routine Papanicolaou smears. H. vaginalis wasnot included in this part of the study.SHOULD ONE TREAT ASYMPTOMATICVAGINITIS?The decision is easy when organisms such as N. gonorr-hoeae and Trichomonas vaginalis are found. With candi-diasis and H. vaginalis the position is less clear since com-paratively little is known about the biological circumstanceswhich cause asymptomatic vaginal discharges to becomesymptomatic. Alteration in the vaginal pH may be animportant factor. CohenH has shown that patients withthe severest symptoms have the lowest pH. He maintainsthat the pH of the vagina is dependent upon fermentationof the glycogen of the shed epithelial cells and the cervicalmucus. Excessive shedding of the epithelium and invasionof the deeper layers by normally benign saprophyticorganisms occur, and this results in their becoming patho-genic. The shedding of the epithelium may be regulated bythe amount of circulating oestrogen. Cohen has also shownthat patients with low vaginal pH are relatively resistantto treatment, while patients with a high pH may harbouryeasts and Trichomonas and yet remain symptomless.Further, there is no way of predicting which women withasymptomatic yeast infections may later develop a clinicalmycosis. Carroll et al.' and others' therefore believe thatthe isolation of C. albicans from the vagina indicates theneed for specific antifungal therapy, irrespective of whethersymptoms or signs of vaginal mycoses are present. Weare of the same opinion, especially when one appreciates,for example, that the incidence of oral thrush is 35 timesmore common in children born to women with vaginalcandidiasis than in those who are free from disease.'Fortunately patients with asymtomatic vaginal 'diseaseduring pregnancy can be safely treated without adverselyaffecting mother or child.We wish to thank Messrs Pfizer Laboratories for financialsupport given to this project.REFERENCESI. Notelovitz, M. (1974): S. Air. Med. J., 48, 178.2. Hurley, R. in Philips, E. E., Burns, J. and Newton, M., eds (1970):Sciefllific Foundations of Obstetrics and Gynaecology, p. 597. London:William Heinemann.3. Careoll, C. J., Hurley, R. and Stanley, V. C. (1973): J. Obstet.Gynaec. Brit. CWlth, 80, 258.4. Penza, J. and Rankin, J. S. (1970): Clin. Obstet. Gynec., 13, 233.5. Oriel, J. D., Partridge, B. M., Denny, M. J. and Coleman, J. C.(1972): Brit. Med. J., 2, 761.6. Hurley, R., Leask, B. G. S., Faktor, J. A. and De Fonseka, C. P.(1973): J. Obstet. Gynaec. Brit. Cwlth, 80, 252.7. Peeters, F., Snauwaert, R., Segers, J., van Cutsem, J. and Amery, W.(1972): Amer. J. Obstet. Gynec., 112, 80.8. Dunkelberg, W. E., Hefner, J. D., Patow, W. E., Wyman, F. J. andOmp, H. J. (1962): Obstet. and Gynec.. 20,629.9. Lewis, J. F., O'Brein, S. M., Vral, W. M. and Burke, T. (1972):Amer. J. Obstet. Gynec., 112, 87.10. Lewis, J. F. and O'Brein, S. M. (1969): Amer. J. Clin. Path., 51, 412.11. Brown, W. J. (1971): J. Infect. Dis., 123, 681.12. Clark, D. O. in Mattingly, R. F. (1973): Clinical Obstetrics and Gyne-cology, vo!. 16. No. 2, p.3. New York: Harper & Row.13. Hart, M. (1971): J. Amer. Med. Assoc., 216, 1609.14. Cohen, 1. R. (1968/1969): Brit. J. Ven. Dis., 44/45, 241.

Asymptomatic vaginal disease in pregnancy

Asymptomatic Vaginal Disease in Pregnancy

https://www.ajol.info/index.php/samj/article/download/188697/177947

Asymptomatic Vaginal Disease in Pregnancy

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online

AJOL - African Journals Online