In pregnancy, bacterial and viral lower genital tract infections are common and generally managed medically. Sexually transmitted diseases (STDs) such as gonorrhea, trichomoniasis, and chlamydial infection are treated with antibiotic regimens according to guidelines outlined by the Centers for Disease Control and Prevention (CDC) (Workowski, 2015). Vulvovaginal candidiasis and bacterial vaginosis can also cause symptomatic vaginal discharge during pregnancy. Treatment recommendations for all these are briefly reviewed and interwoven within the specific topics of this chapter.
In contrast, surgical treatment is generally reserved for vulvovaginal abscesses or for condylomata causing marked obstruction. Otherwise, surgery has little role in treating chronic viral or bacterial infections during pregnancy.
The clinical presentation of vulvovaginal infections is probably minimally affected by pregnancy. Host factors such as diabetes mellitus or human immunodeficiency virus (HIV) are evaluated prior to management decisions. Importantly, immunosuppression from HIV and acquired immunodeficiency syndrome (AIDS) may mask clinical and laboratory signs of local infection and bacteremia due to impaired inflammatory response (Berger, 1994).
These usually involve the labia majora, and vulvar abscesses occasionally complicate pregnancy. Acute infections can stem from pyogenic folliculitis, and common risks include local trauma from shaving, obesity, or diabetes mellitus. Chronic or recurrent vulvar abscesses may develop in women with furunculosis, carbuncles, hidradenitis suppurativa, methicillin-resistant Staphylococcus aureus (MRSA) colonization, or less often, with Crohn disease.
Small abscesses may be painful but can often be initially managed conservatively with hot compresses and sitz baths. Most superficial infections will become fluctuant, expand, and then drain spontaneously. After spontaneous emptying, persistent erythema or pain may reflect a surrounding cellulitis. Also, a deeper-seated abscess with a thick wall may not reach the skin surface to drain. Thus, differentiation between cellulitis with marked induration and abscess can be difficult. If the clinical picture is unclear, needle aspiration of the affected area can help distinguish between the two. Additionally, in rare cases with unconventional findings, sonography, if readily available, of the swelling can be considered (Blaivas, 2011).
The involved pathogenic bacteria generally are usual skin flora (staphylococcal and streptococcal species) but may also be composed of a mixed aerobic and anaerobic flora. In complicated infections, culture collection prior to antibiotic initiation may be helpful for later antibiotic regimen adjustment.
Mature, superficial vulvar abscesses are best treated with simple incision and drainage (I & D) (Fig. 12-1). Surgical consent is obtained from the patient, and specific risks include bleeding, recurrent abscess, worsening infection, and scar formation or chronic pain at the incision site.
Right vulvar abscess. A. Before drainage. B. Iodoform gauze packing in place.
To begin, the skin overlying the planned I & D site is cleaned with a chlorhexidine or betadine ...