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OG20.1-3,OG21.1-2,OG22.1-2 | Medical Termination and Contraception — PBL Case

CLINICAL SETTING

Mrs Sunanda M., a 32-year-old secondary school teacher, presents to the outpatient gynaecology clinic for the third time in eight months. Each of her two previous visits was for vaginal discharge. On both occasions she was prescribed clotrimazole pessaries, which gave temporary relief but the discharge recurred. She is accompanied by her husband, who is visibly impatient. She is parous (G2P2, two normal deliveries), her younger child is 14 months old, and she is no longer breastfeeding. Her blood pressure today is 138/88 mmHg. She does not smoke or drink alcohol. She has no known medical illnesses and takes no regular medications. She mentions, almost as an aside, that she and her husband have been using condoms inconsistently because they are 'both tired of them' and that they are certain they do not want more children. She wants 'something that works properly' for contraception. Before examining her, you note that the two previous discharge episodes were both treated empirically as candidal vaginitis without any investigations. Today's speculum examination reveals a thin, homogeneous, greyish-white discharge coating the vaginal walls. The cervix appears normal. There is no pruritus. The discharge has a faint malodour. You perform bedside tests: vaginal pH = 5.0; KOH whiff test = positive (fishy amine odour released). Wet mount preparation is pending.

Trigger 1: Diagnose the Discharge

The wet mount result returns: numerous vaginal epithelial cells with adherent coccobacilli obscuring cell borders (clue cells visible). No hyphae or pseudohyphae seen. No flagellated motile organisms seen.

DISCUSSION POINTS

  • Using Amsel criteria (homogeneous discharge, pH >4.5, positive whiff test, clue cells), how many criteria does Sunanda fulfil, and is this sufficient to diagnose bacterial vaginosis?
  • The previous two treating doctors both prescribed antifungals without investigation. What error does this represent, and why is it a high-stakes mistake in terms of patient outcomes?
  • Sunanda has had three episodes in eight months. What threshold defines recurrent bacterial vaginosis? What factors should now be investigated to explain recurrence? (Consider: sexual transmission dynamics, male partner, vaginal microbiome disruption, practices.)
Click to reveal Trigger 2: Treatment and Partner Management (discuss previous trigger first!)

Trigger 2: Treatment and Partner Management

You diagnose recurrent bacterial vaginosis. You prescribe metronidazole 400 mg orally twice daily for 7 days and provide genital hygiene counselling. Her husband asks from the corridor whether he needs to take any medication too.

DISCUSSION POINTS

  • Unlike Trichomonas vaginalis infection, routine partner treatment is NOT recommended for BV in current guidelines. Explain the pathophysiological rationale for this distinction — why does BV not mandate partner treatment while T. vaginalis does?
  • What specific vaginal hygiene and behavioural advice would you give Sunanda to reduce BV recurrence? (Consider: douching, soaps, post-coital practices, timing of antibiotic completion.)
  • If Sunanda fulfils criteria for recurrent BV (≥3 episodes/year), what maintenance therapy strategy would you consider and for how long?
Click to reveal Trigger 3: Contraceptive Need Assessment (discuss previous trigger first!)

Trigger 3: Contraceptive Need Assessment

With the discharge addressed, Sunanda wants to discuss contraception in detail. She confirms: no more pregnancies desired; BP today 138/88 mmHg (confirmed on repeat); no history of migraine; BMI 27; not breastfeeding; 32 years old. She is asking specifically about 'the copper device' after reading about it online.

DISCUSSION POINTS

  • Construct a WHO MEC eligibility assessment for the copper IUCD (CuT 380A) in Sunanda. Her blood pressure is elevated at 138/88 mmHg — what is the WHO MEC category for copper IUCD in a woman with hypertension? Compare this with the MEC category for COC in the same setting.
  • She specifically asks whether the copper IUCD will worsen her vaginal discharge or increase her risk of BV. How do you counsel her? Is active or recently treated BV a contraindication to IUCD insertion?
  • She asks about the LNG-IUS (Mirena) as an alternative. What advantage does the LNG-IUS offer over the copper IUCD in a woman with recurrent BV and possible menorrhagia concerns? What is the WHO MEC category for LNG-IUS in women with hypertension?
Click to reveal Trigger 4: IUCD Insertion Decision and Simulation Preparation (discuss previous trigger first!)

Trigger 4: IUCD Insertion Decision and Simulation Preparation

After counselling, Sunanda consents to CuT 380A insertion today. Pre-insertion pelvic examination reveals: uterus anteverted, anteflexed, normal size, non-tender; no adnexal masses; vaginal discharge treated. Uterine sounding: 8 cm. You prepare for insertion. As you are about to begin, Sunanda asks: 'How do I know if it has slipped out?'

DISCUSSION POINTS

  • Walk through the key steps of CuT 380A insertion technique in sequence (from patient positioning to thread confirmation). Identify the two most common technical errors that lead to early expulsion or failure.
  • Counsel Sunanda on: (a) signs of IUCD expulsion; (b) signs that would require urgent return (pain, fever, absent threads, missed period); (c) what she should do if she feels the device or if threads seem longer.
  • Sunanda is anxious. She asks whether the procedure will be painful. What non-pharmacological and pharmacological measures may reduce procedural discomfort during IUCD insertion?
Click to reveal Trigger 5: Four Months Later: A Complication (discuss previous trigger first!)

Trigger 5: Four Months Later: A Complication

Sunanda returns four months later with a 2-day history of lower abdominal pain, fever (38.2°C), and mucopurulent cervical discharge on speculum examination. She denies missing her period. The IUCD threads are visible and appear normal in length. She had a new partner contact 6 weeks ago while her husband was travelling.

DISCUSSION POINTS

  • What diagnosis must be excluded first? What is the most likely diagnosis given the clinical picture? Does the visibility of the IUCD threads help you rule out perforation?
  • Should the IUCD be removed immediately? Summarise current guidance (WHO/FOGSI) on IUCD management in the setting of acute pelvic inflammatory disease — when to remove and when to retain the device while treating.
  • This case highlights a gap in initial counselling. What STI screening and partner notification should have been recommended at the time of insertion? How does this case change your future counselling at IUCD insertion visits?

Group Task Assignments

  • Compile a differential diagnosis table for vaginal discharge with columns: syndrome, discharge characteristics, pH, wet mount finding, and first-line treatment. Include physiological leucorrhoea, BV, T. vaginalis, and candidal vaginitis.
  • Produce a WHO MEC comparison table for Sunanda's profile (BP 138/88, non-smoking, age 32, not breastfeeding) across four methods: COC, POP, copper IUCD (CuT 380A), and LNG-IUS. Include the MEC category and a brief rationale for each.
  • Role-play the IUCD insertion consent consultation with one student as clinician and one as patient. The 'patient' must ask at least three questions from trigger 4. The group observes and gives structured feedback.
  • Draft a post-insertion advice card (max 150 words) for Sunanda covering: when to return urgently, how to check threads, contraceptive effectiveness timeline, and who to contact.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG22.2] What are the four Amsel criteria for bacterial vaginosis, and how do they distinguish BV from Trichomonas vaginalis and candidal vaginitis?
  2. [OG22.2] Why is routine male partner treatment NOT recommended for bacterial vaginosis, while it IS mandatory for Trichomonas vaginalis infection?
  3. [OG21.1] What are the WHO MEC categories for copper IUCD and LNG-IUS in a woman with stage 1 hypertension (systolic 140–159 or diastolic 90–99)?
  4. [OG21.2] What are the steps of CuT 380A insertion, and what are the two most common errors leading to early expulsion?
  5. [OG21.2] When should an IUCD be removed in a woman diagnosed with acute pelvic inflammatory disease, and when can it be retained while treating?
  6. [OG22.1] How does vaginal pH and the KOH whiff test help distinguish physiological leucorrhoea from pathological vaginal discharge syndromes at the bedside?