Local Inflammations.Vulvitis

Owing to edema and congestion of the vulva and to the pronounced projection of the pelvic floor which exposes the organ to injury, vulvitis is not rare in gestation. Lack of cleanliness, obesity, difficulty in keeping the vulva clear of mucus and smegma and purulent discharges, together with the exposure of the introitus, invite infection and eczema. Mycotic infections, resembling thrush of the mouth, which may cover the whole of the hyperemic and moist vulva, and purulent infections, including gonorrhea, occur. Vegetations or condylomas may be seen on the labia minora or in the raphe and occasionally they may attain enormous size. The pudendal region is the habitat of Escherichia coli, staphylococcus and streptococcus, with hosts of others.

Bartholinitis. This is often but not always due to the gonococcus. Because of danger of puerperal infection an abscess should be cured before labor, preferably by the electric cautery. Cysts of the labia, if not infected, are best left alone until after the puerperium. If they obstruct delivery, puncture and aspiration of their contents will remove the obstacle, or the cysts may be opened and their lining destroyed by means of electric cautery.

Vaginitis. It is not rare to find a reddened granular, thickened mucosa in the fornices, vaginitis granulosa, but occasionally colpitis emphysematosa is present. In this condition the vaginal wall is full of large and small cysts and the epithelium is congested. This abnormality disappears spontaneously after delivery. All discharges must be studied by fresh hanging drops and stained smears to detect the causative organism which may be Trichomonas vaginalis, monilia or gonococcus. The trichomonas is readily observed in a hanging drop because of its motility. The treatment we recommend is washing the vagina with tincture of green soap, drying and instilling an acid-glucose powder. In cases of trichomonas and gonorrhea, after the organisms have disappeared, vaginal douches containing approximately 60 g of white vinegar to a full douche bag 1.4-1.5 l or lactic acid douches are helpful.

Gonorrhea. Acute gonorrhea is more common in primiparas, being conveyed at the time of impregnation. Unlike ordinary cases of acute gonorrhea, in which the inflammation is limited to or most pronounced in the urethra, the vulvar glands and the cervix, in the pregnant patient the gonococcus, favored by the succulency of the tissues, attacks the vaginal and vulvar epithelium in addition to the areas just mentioned. Profuse secretion of greenish-yellow pus results; the vulva is red and sometimes covered with grayish exudate, sometimes ulcerated or covered with pointed condylomas; the vagina is thick and granular, like a nutmeg grater, and bleeds even on light touch; the cervix is swollen, vascular, eroded, easily vulnerable and emits a foul mucopus in which the gonococci are readily found.

Chronic infection is the form usually encountered and it has left the surfaces, covered by squamous epithelium, to localize in the urethra, Skene's tubules, the crypts around the hymen, the bartholin ducts and glands and the cervix, in which it is recognizable by the usual signs. Acute as well as chronic gonorrhea may affect the uterine decidua and cause abortion but as a rule the gonorrheal infection remains latent until after delivery. Many women having a slight mucopurulent leukorrhea are delivered without the physician being aware of the existence of infection until the baby's eyes show gonorrheal ophthalmia.

Through the traumatism of labor the gonococci are pressed out of the deep cervical glands and by virtue of the open cervix and the puerperal processes unlimited opportunities are afforded to them for further virulent development. As a result gonorrheal endometritis, salpingitis, ovaritis and pelvic peritonitis ensue. Acute infections are likely to show the exacerbation in the first days of the puerperium, because of the associated streptococci and staphylococci. Chronic gonorrhea causes the "late fevers" of the tenth to the thirteenth day; that is, an ascending inflammation which results in pus tubes or adhesive obliterating peritonitis, often leaving permanent sterility and gynecologic invalidism. Acute gonorrhea in gestation can cause rheumatism with disorganization of the joints (wrist, knee and hip) or even endocarditis and general septicemia.

Diagnosis. Repeated bacteriologic examination of secretions is often required for the detection of gonococcus. In the acute cases smears are dependable but in chronic cases smears alone are of little value. The diagnosis must usually be made following cultures and fixation tests. However, a combination of smears and cultures may be used to great advantage. One negative smear and culture do not rule out gonorrhea. The history is valuable. An obstinately inflamed single joint is strongly suggestive. Ophthalmia in the infant does not prove the existence of gonorrhea in the mother unless the gonococcus is found in the pus and other sources of infection of the child's eyes are eliminated.

Treatment. Gonorrheal infections appear more persistent and resistant to treatment during pregnancy. In acute cases rest in bed is important. The diet should be bland and alcohol and spices avoided. Sexual intercourse must be forbidden. At present cures are readily obtained by administering sulfonamide derivatives and penicillin. Some authors recommend local therapy to the vulva, vagina and cervix in addition to the antibiotics by mouth. For example, applying an ointment containing 2 per cent of allantoin, 15 per cent of sulfanilamide and 5 per cent of lactose in a special greaseless base buffered to a pH of 4.5 with lactic acid. Sodium penicillin produces dramatic results in gonorrheal infections. Smears and cultures should be taken at intervals of twenty-eight days to be certain that a cure persists. If gonococci return the treatment must be repeated. Should abortion occur curettage is not to be undertaken if it is at all avoidable.

During labor in cases of known gonorrhea a 1:1000 solution of metaphen should be instilled into the vagina every six hours. Vaginal explorations and operations are limited to an irreducible minimum, the bag of waters is saved, if possible, until the child's head is fully delivered and every precaution is taken to prevent the entrance of vaginal mucus into the conjunctival sacs. Immediately after the baby is born silver nitrate or silver acetate must be instilled into its eyes. This should be repeated on the second and third days. During the puerperium the patient should be kept in bed fully ten days to prevent the ascension of the infection through the uterus to the tubes.

Erosions and Hypertrophy of the Cervix. Erosions and hypertrpohy of the cervix are frequent and since the softened vascular structure bleeds readily the flow may suggest abortion. Erosions need not be treated during pregnancy unless they bleed. If they are friable the electric cautery may be applied safely to correct the condition, but care must be exercised not to place the cautery needle too near the internal os nor too deeply into the cervical tissue. Often applications of silver nitrate will suffice.