View source for WBR1118

{{WBRQuestion
|QuestionAuthor={{M.P}}
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Obstetrics & Gynecology
|Prompt=28 year old female, gravida 1 para 0 at 16 weeks of gestation presents to the office for routine prenatal screening.  She does not have any specific complaints, except for mild bloating and tiredness.  She is able to do her daily activities without any trouble.  She has been taking her iron and folic acid supplements regularly.  She is not a smoker and does not consume alcohol.  Her bowel and bladder habits are normal.  Her previous laboratory evaluations were normal.  Her past history is insignificant and her family history is unremarkable.  On examination pulse is 80/min, BP: 130/80 mmHg, temperature 37 degree Celsius.  Cardiovascular and respiratory system examinations are normal.  Abdominal examination is normal and fetal heart rate is assuring.  Pelvic examination reveals vaginal discharge and the vaginal pH is 4.6.  Microscopic examination reveals motile protozoans.  Which of the following would be the most appropriate management in this patient?
|Explanation=[[Trichomoniasis]] is caused by the single-celled protozoan parasite, [[Trichomonas vaginalis]].  The vagina is the most common site of infection in women.  Trichomoniasis, like many other sexually transmitted diseases, often occurs without any symptoms.  If symptomatic they usually present with vulvovaginal symptoms such as itching, burning, irritation, and abnormal discharge.  The other most common causes of vulvovaginal symptoms are [[bacterial vaginosis]] and vulvovaginal [[candidiasis]].  In women, a pelvic examination can reveal small red ulcerations (sores) on the vaginal wall or cervix.  Diagnosis of vaginal trichomoniasis is usually performed by microscopy of vaginal secretions, but this method has less sensitivity and requires immediate evaluation of wet preparation slide for optimal results.  Other findings that are almost invariably present with trichomonas infection, but nondiagnostic, include an elevated vaginal pH (>4.5) and an increase in [[polymorphonuclear leukocytes]] on saline microscopy.   Symptomatic patients should be treated with the either [[metronidazole]] 2 gm PO single dose or [[tinidazole]] 2 gm PO single dose.  Alternative treatment includes metronidazole 500 mg PO for 7 days.  Vaginal trichomoniasis has been associated with adverse pregnancy outcomes, particularly [[premature rupture of membranes]], preterm delivery, and [[low birth weight]].  Metronidazole is pregnancy category B that should be given appropriately for pregnant women.  In lactating women who are administered metronidazole, withholding breastfeeding during treatment and for 12–24 hours after the last dose will reduce the exposure of metronidazole to the infant.  While using tinidazole, interruption of breastfeeding is recommended during treatment and for 3 days after the last dose.
|AnswerA=Oral metronidazole


|AnswerAExp=Pregnant women should be treated with [[metronidazole]] 2 gm PO single dose or [[tinidazole]] 2 gm PO single dose or metronidazole 500 mg PO for 7 days even if asymptomatic because of the risk of [[premature rupture of membranes]], preterm delivery, and [[low birth weight]]. 
|AnswerB=Intravenous metronidazole

|AnswerBExp=Treatment for trichomoniasis are metronidazole 2 gm PO single dose or tinidazole 2 gm PO single dose or metronidazole 500 mg PO for 7 days.  IV [[metronidazole]] is not given usually.
|AnswerC=Vaginal metronidazole

|AnswerCExp=Metronidazole gel is considerably less efficacious for the treatment of trichomoniasis (<50%) than oral preparations of metronidazole.  Topically applied antimicrobials (e.g., metronidazole gel) are unlikely to achieve therapeutic levels in the [[urethra]] or perivaginal glands; therefore, use of the gel is not recommended.
|AnswerD=Treat when patient develops symptoms

|AnswerDExp=Pregnant women should be treated with oral metronidazole even if asymptomatic because of the risk of [[premature rupture of membranes]], preterm delivery, and [[low birth weight]]. 
|AnswerE=Intravenous clindamycin
|AnswerEExp=IV [[clindamycin]] is not used for treating trichomoniasis in pregnant women.
|EducationalObjectives=Pregnant women should be treated for [[Trichomoniasis]] even if asymptomatic because of the risk of [[premature rupture of membranes]], [[preterm delivery]], and [[low birth weight]]. 
|RightAnswer=A
|WBRKeyword=[[Trichomoniasis]], [[sexually transmitted disease]]
|Approved=Yes
}}