Vaginal Secretions & Pregnancy Testing PDF

VAGINAL SECRETIONS AND PREGNANCY TESTING Lovely Camille S. Sayson, RMT OUTLINE What are vaginal secretions? Specimen Collection and Handling Laboratory Examinations Vaginal Disorders Human Chorionic Gonadotropin (hCG) hCG in Pregnancy Testing References WHAT ARE VAGINAL SECRETIONS? Vaginal secre...

VAGINAL SECRETIONS AND PREGNANCY TESTING Lovely Camille S. Sayson, RMT OUTLINE What are vaginal secretions? Specimen Collection and Handling Laboratory Examinations Vaginal Disorders Human Chorionic Gonadotropin (hCG) hCG in Pregnancy Testing References WHAT ARE VAGINAL SECRETIONS? Vaginal secretions are normally produced by the glands in the cervix Continuously released Contains water, nutrients, electrolytes, & proteins 1 Estrogen ) Altered by hormonal and dietary factors Amounts vary throughout the menstrual cycle collected by obgyn * 0.5 - 1mL sterile physiologic saline 1 Nss ) = container Spx should within 2hm 0 Why : SPECIMEN COLLECTION AND HANDLING immediately should be processed transported to see vaginalis motility trick identi it . Collected by a healthcare provider during pelvic examination Method of collection and containers specific for the testing Materials: Warmed speculum - to visualize the the vaginal fornices 1 wid den the vagina ) One / more Swabs - specific for the test to 1. 2. mention status Exposure to STI g. Vaginal lubricants , Creams , douches / Infection ) SPECIMEN COLLECTION AND HANDLING AVOID : Speculum Lubricants - antibacterial agents Collected by swabbing the vaginal walls (posterior vaginal fornix) and vaginal pool Storage: to observe the motility Room temp - T. vaginalis (motility), N. gonorrhoeae Refrigerator temp - C. trachomatis, HSV patient ng (prevent overgrowth of normal flora) Specimens should be tested with pH paper prior placing in the container neisseria is < temp sensitive if the Hamed ia LI Li trans ph 1. 2. / Commercial ph Paper Swab lateral wall ☐ for 1 minute SPECIMEN COLLECTION candidiasis - trichomoniasis White spots - can see a * strawberry lentil commonly Dalton R Rayon well ] avoid to pill damage / organisms ( Bawa 1) ↳ 9in , prone to drying + Fatty acid is • good * ↳ tip / dulong swab in viruses z LABORATORY EXAMINATIONS (PHYSICAL CHARACTERISTICS) 1. 2. Macroscopic pH - lateral wall + swab Pano i check yung pH Normal Appearance and pH = Fluid appears white and may have a flocculent discharge containing few WBCs because OF normal Flora part pH 3.8-4.5 (Lactobacillus species) Reddish discharge - encountered when patient is menstruating " g of sticky and white Watch ' C ☐ ( odor ) " Md / odor sa the video - 7 Add KOH to d. trimethylamine D would breakdown trim to amine discharge → 50-90010 to produce " odor + Fishy LABORATORY EXAMINATIONS (PHYSICAL CHARACTERISTICS) Abnormal Appearance and pH Thin, white/gray, or gray - Bacterial vaginosis “Cottage cheese” appearance - Candida infections Yellow-green frothy - Trichomonas Yellow opaque - Chlamydia infections Rise in vaginal pH - decreased Lactobacillus spp. ↳ imparts acidic pH curd like LABORATORY EXAMINATIONS (MICROSCOPY) Usually initial screening test / Lpf HPF Lpo / - HPO to Chuk tht distribution - identity at cells ( identification uses of microscope : 1. 2. area of Bright Field - Phase contrast WET MOUNT [ i. 2 wet mount performed KOH . Golden -3 standard 4 - . . Gram staining paps smear D For his to path Saline wet mount Initial screening test Presence of : “clue cells”, microorganisms, WBCs, epithelial cells, RBCs, hyphae/pseudohyphae LABORATORY EXAMINATIONS (MICROSCOPY) WHITE BLOOD CELLS (WBCs) 14-16 μm in diameter Granular cytoplasm Rare to scanty Increased during ovulation and menses LABORATORY EXAMINATIONS (MICROSCOPY) RED BLOOD CELLS (RBCs) Smooth, nonnucleated, biconcave disks 7-8 μm in diameter Distorted in vaginal specimens Not usually seen, except during: Menstruation Desquamative Inflammatory Process Confused with yeast cells Distinguished through KOH LABORATORY EXAMINATIONS (MICROSCOPY) SQUAMOUS EPITHELIAL CELLS 30-60 mm Thin, flat, polygonal, “flagstone” appearance Prominent nucleus - centrally located, same size with that of the RBC Large amount of irregular cytoplasm, lacking granularity with distinct cell margins INTRACELLULAR KERATOHYALIN GRANULATION Fine granulation as the cell ages Must not be confused with the shaggy appearance of clue cells 2 microscopic characteristics Keratohyalin granules vary in size Usually larger and more refractile than bacteria LABORATORY EXAMINATIONS (MICROSCOPY) CLUE CELLS Diagnostic indicator of Bacterial vaginosis - 1 clue cell per 10 fields Abnormal variation of the squamous epithelial cell Coccobacillus bacteria attached in clusters on the cell surface, spreading past the edges of the cell, and making the border appear indistinct or stippled granular, irregular appearance - “shaggy” “bacteria-laden cells with shaggy-appearing edges” sometimes described as “bearded” CLUE CELLS LABORATORY EXAMINATIONS (MICROSCOPY) PARABASAL CELLS Round to oval-shaped, distinct cytoplasmic borders 16-40 μm in diameter N:C ratio 1:1 to 1:2 Marked basophilic granulation / amorphic basophilic structures - “blue blobs” Rare, except: Menstruating patient Postmenopausal patient Increased - Atrophic vaginitis & Desquamative inflammatory vaginitis LABORATORY EXAMINATIONS (MICROSCOPY) BASAL CELLS Round 10-16 μm in diameter N:C ratio 1:2 Distinguished from WBCs - round nucleus Not normally seen - abnormal if present If present - accompanied by large number of WBCs & altered vaginal flora Desquamative inflammatory vaginitis LABORATORY EXAMINATIONS (MICROSCOPY) BACTERIA Lactobacillus species - comprise the largest portion (50%-90%) of vaginal bacteria Large, gram-positive, non-motile rods, produce lactic acid (pH 3.8-4.5) Hydrogen peroxide production - suppress the overgrowth of other organisms Other bacteria commonly present: Anaerobic streptococci Diphtheroids CONS Alpha-hemolytic streptococci BACTERIA LABORATORY EXAMINATIONS (MICROSCOPY) Trichomonas vaginalis Atrial flagellated protozoan 5-18 μm in diameter Pear- or turnip-shaped Has 4 anterior flagella and an undulating membrane (half the length of the body) Axostyle bisects the trophozoite longitudinally “Flitting” or “Jerky” motion Not to confuse - sperm, WBCs * pH 6 * environment : anaerobic Trichomonas vaginalis LABORATORY EXAMINATIONS (MICROSCOPY) YEAST CELLS most common Candida albicans and non-Candida cspecies Occasionally seen - normal flora Budding yeast cells (blastospores) Hyphae / Pseudohyphae - multiple buds that do not detach & form chains Difficult to distinguish with RBCs YEAST CELLS LABORATORY EXAMINATIONS (MICROSCOPY) won to at microscope KOH MOUNTS Initial screening test 10% KOH Prepared slides - stand for 5 mins to dissolve epithelial cells and blood cells Heat may be applied to speed up the process (i.e., slide warmer) : preserve1 drop of 10% glycerin can be added to prevent deterioration inaamoy AMINE / WHIFF TEST Initial screening test 10% KOH “Fishy” amine odor trimethylamine (POSITIVE) Volatile amines are not present in normal vaginal secretion Pungent and foul-smelling odor memorize ! ! memorize ! ! Gram Positive LABORATORY EXAMINATIONS (MICROSCOPY) Large Rods GRAM STAIN Confirmatory test (Gold standard) - Bacterial Vaginosis Yeast infection color yeast : ¥5,7m : 0 Buddy yeast cells , check the variations in normal flora , NUGENT SCORE 0-3 : Normal vaginal flora 4-6 : Intermediate 7 or more : Bacterial vaginosis LABORATORY EXAMINATIONS (CULTURE) usually plant µ Gold standard - yeast and Trichomonas Time consuming G. vaginalis culture - not diagnostic (part of the normal flora) Diamond medium - T. vaginalis Commercial transport and culture pouch system (T. vaginalis) Inoculated within 30 mins of collection and incubated for 5 days at 37 degrees celsius in a carbon dioxide atmosphere rarely done : DIAMOND’S MEDIUM, MODIFIED FOR TRICHOMONAS InPouch® TV, Biomed diagnostics LABORATORY EXAMINATIONS (MOLECULAR TESTING) DNA TESTING DNA hybridization probe Results - 1 hour DNA probes amplified by PCR Most accurate diagnostic method Detection of nonviable organisms LABORATORY EXAMINATIONS (POINT-OF-CARE TESTS) ANTIGEN TESTING OSOM Trichomonas Rapid Test Immunochromatographic strip - 10 mins T. vaginalis antigen LABORATORY EXAMINATIONS (POINT-OF-CARE TESTS) ANTIGEN TESTING OSOM BVBLUE test Vaginal fluid sialidase bacterial pathogens Gardnerella, Bacteroides, Prevotella, Mobilincus 1 min LABORATORY EXAMINATIONS (POINT-OF-CARE TESTS) LABORATORY EXAMINATIONS (POINT-OF-CARE TESTS) pH AND AMINE TESTING VS-Sense Pro Swab FemExam pH Amines TestCard LABORATORY EXAMINATIONS (POINT-OF-CARE TESTS) LABORATORY EXAMINATIONS (ASSOCIATED WITH PREGNANCY) FETAL FIBRONECTIN ENZYME TEST Isoform of fibronectin Adhesive glycoprotein produced by the fetal cells Found in the space between the chorion (fetal sac) and the decidua (uterine lining) Binds the fetal sac to the uterine lining and begins to break down toward the end of pregnancy Clinical application - Preterm delivery Presence of fFN in vaginal secretions between 24 & 34 weeks gestation Must not be contaminated - lubricants, creams, soaps, or disinfectants FETAL FIBRONECTIN ENZYME TEST Methods: Solid-phase ELISA Lateral flow, solid-phase immunochromatographic assay FDC-6 monoclonal antibody 550 nm Symptomatic and (+) fFN test : increased risk for delivery in less than or equal to 714 days from specimen collection Asymptomatic : less than or equal to 34 weeks - 6 days of gestation LABORATORY EXAMINATIONS (ASSOCIATED WITH PREGNANCY) PLACENTAL ALPHA MACROGLOBULIN-1 (PAMG-1) Protein expressed by the cells of the decidual part of placenta Secreted into the amniotic fluid (throughout all trimesters) Present at very low levels - cervicovaginal secretions (when fetal membranes are intact) Appears in the vaginal secretions after the ROM Amnisure Test Done immediately ; delays - closed sample vial and refrigerated for 6 hours False positives - large amounts of blood LABORATORY EXAMINATIONS (ASSOCIATED WITH PREGNANCY) INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN-1 (IGFBP-1) Secreted by the decidual cells of placenta High concentration - amniotic fluid Actim PROM Lateral flow immunochromatography Blood, urine, semen, bath, and odor products, common vaginal infections, medications -will not interfere Heavy bleeding - higher concentration of IGFBP-1 LABORATORY EXAMINATIONS (ASSOCIATED WITH PREGNANCY) ROM PLUS Detection of amniotic fluid in vaginal secretions Detects both AFP & IFGBP-1 protein / PP12 Lateral flow device Monoclonal & polyclonal antibodies VAGINAL DISORDERS BACTERIAL VAGINOSIS Most common cause of vaginal infection Occurs when there is imbalance in the ratio of normal vaginal bacterial flora Lactobacilli is replaced by overgrowth of G. vaginalis, Mobilincus spp., Prevotella spp., Porphyromonas, Peptostreptococcus, M. hominis, and Ureaplasma spp. Malodor and increased abnormal vaginal discharge - “gray / off-white, thin, and homogenous” Associated with new or multiple sex partners, frequent douching, use of intrauterine devices, pregnancy, and lack of the protective lactobacilli Amsel’s Diagnostic Criteria VAGINAL DISORDERS BACTERIAL VAGINOSIS Complications: Increased risk - premature labor and delivery, low-birth-weight infants Untreated - progression to endometritis and PID Notable feature: WBCs - rare Do not invade the subepithelial tissue Treatment Oral - Metronidazole Treatment and recolonization - Lactobacillus-containing vaginal suppositories Concurrent treatment of sexual partners is NOT RECOMMENDED VAGINAL DISORDERS TRICHOMONIASIS Acquired : Sexual intercourse (classified as an STI) Frequently occurs with infections of gonorrhea / Chlamydia Enhanced transmission rates of HIV Pregnant women Low birth weight Premature rupture of membranes Preterm delivery Characterized - “green-yellow frothy vaginal discharge”, malodor, pruritus, irritation, dysuria, dyspareunia, and vaginal mucosa erythema “Strawbery cervix” - punctate hemorrhages Numerous WBCs (often clumped), mixed bacterial flora with reduced lactobacilli VAGINAL DISORDERS TRICHOMONIASIS Treatment Oral therapy - ensures all potential sites are treated Metronidazole Allergic to metronidazole Tinidazole “All sexual partners of patients, even if asymptomatic, should be treated to avoid reinfection” VAGINAL DISORDERS CANDIDIASIS Most common cause of vaginitis - women of childbearing age Most infections - C. albicans Nonalbican species - C. glabrata, C. parapsilosis, C. tropicalis, C. krusei Change in the vaginal environment - permits overgrowth Use of broad-spectrum antibiotics Oral contraceptives Estrogen replacement therapy Hormonal changes - pregnancy, ovulation, menopause Immunocompromised patients Characterized - genital itching / burning, dyspareunia, dysuria, abnormal thick, white, curd-like vaginal discharge Increased number of yeast cells and pseudohyphae with concomitant increase in WBCs Amine test (-) Treatment OTC Azole antifungal agents Intravaginal, suppository, or oral agents VAGINAL DISORDERS DESQUAMATIVE INFLAMMATORY VAGINITIS Characterized - profuse purulent vaginal discharge, vaginal erythema, dyspareunia Large numbers of WBCs, RBCs, occasional parabasal, and basal cells, squamous epithelial cells, reduced or absent lactobacilli Heterogenous group of causes Beta-hemolytic gram positive streptococci (most patients) Secondary to atrophic vaginitis (postmenopausal women = decreased estrogen) Treatment 2% clindamycin Hormone replacement therapy VAGINAL DISORDERS ATROPHIC VAGINITIS Found in postmenopausal women Thinning of the vaginal mucosa - reduced production of estrogen and glycogen Vaginal environment changes Altered normal flora Characterized - vaginal dryness, soreness, dyspareunia, inflamed vaginal mucosa, purulent discharge Large numbers of WBCs, presence of RBCs, ocassional parabasal and basal cells, squamous epithelial cells, decrease lactobacilli Recurring UTI Treatment Initially - topical vaginal ointments Estrogen replacement Frequent, recurrent episodes - oral / transcutaneous (patch) modes WHAT IS HUMAN CHORIONIC GONADOTROPIN A glycoprotein containing a protein core with branched carbohydrate sidechains that usually terminate with sialic acid Heterodimer - alpha and beta Synthesized in the syncytiotrophoblast cells of the placenta Minute amounts - pituitary glands of older men & women Chromosome 6 Stimulates the corpus luteum (ovary) to synthesize progesterone during the first weeks of pregnancy No specific receptor Binds and activates the LH receptor (corpus luteum) WHAT IS HUMAN CHORIONIC GONADOTROPIN Measurement of hCG is utilized for: Diagnosing and dating pregnancy Identifying ectopic pregnancies and other abnormalities Managing certain neoplasms Predicting the risk of Down syndrome and Trisomy 18 hCG IN PREGNANCY TESTING May be performed on urine or on blood Detection of beta-human chorionic gonadotropin (beta-hCG) Best specimen : First morning urine Most concentrated Urine SG should be 1.015 or higher False results : Large amounts of blood, protein, or bacterial contamination Enzyme immunoassays - most popular type REFERENCES Burtis, Carl A, et al. Tietz Fundamentals of Clinical Chemistry and Molecular Diagnostics. 7th ed., St. Louis, Elsevier/Saunders, 2015. Brunzel, Nancy A. Fundamentals of Urine and Body Fluid Analysis. 5th ed., S.L., Elsevier - Health Science, 2021. Mundt, Lillian, and Kristy Shanahan. Graff’s Textbook of Urinalysis and Body Fluids. 3rd ed., Jones & Bartlett Learning, 15 June 2020. Strasinger, Susan King, and Marjorie Schaub Di Lorenzo. Urinalysis and Body Fluids. 7th ed., Philadelphia, F.A. Davis Company, 2021.