Original Paper Gynecol Obstet Invest 1992;34:73-75
Department of Obstetrics and Gynecology, Central Hospital. Maputo, Mozambique: Department of Obstetrics and Gynecology, University Hospital, Uppsala, Sweden
Key Words Vulvar oedema Pregnancy
Vulvar Oedema among Pregnant Mozambican Women
Abstract
During a 3-year period, a total of 22 pregnant women with vulvar oedema were observed in a high-risk antenatal clinic (ANC) in Maputo. They were compared with 22 unselectcd normal ANC attenders, matched for age, parity, gestational length and area of living. Reported and observed genital ulcers were more prevalent in the oedema group than in the referent group. Reported and observed vaginal discharge was also significantly more common in the oedema group. Syphilis screening by VDRL was positive in 61.9% of oedema cases while positivity reached 5.0% in referents (p < 0.005). Cases found sero positive on screening were confirmed using Wassermann reaction (WR) in a reference laboratory, in which WR-positive cases underwent FTA-ABS analy sis and IgM assay with solid-phase haemadsorption. IgM-positive individuals were significantly more prevalent among WR-positive oedema cases than among WR-positive referents (p < 0.05). It is concluded that among antenatal attenders in Maputo presenting with vulvar oedema, a significant proportion is associated with recent syphilis. Vulvar oedema should be considered as an important marker for seropositive syphilis during pregnancy.
Introduction
Oedema of the vulva is a common entity in Africa. It is occasionally encountered among women suffering from adverse socio-economical circumstances involving poor hygiene, malnutrition, genital traumata and ulcers. Its aetiology has, however, remained unclear. The prevalence of vulvar oedema has never been stated, but its frequent appearance in outpatient obstetrics and gynaecology in tropical countries seems to escape geographical limits [ 1]. As a discorder affecting sexual life and reproduction, it tends to bring affected women to hospital ear
Received: October 24,1991 Accepted after revision: January 31. 1992
ly. Even if, as a rule, early recognition of vulvar oedema by the patient is probable, it also appears likely that a sig nificant number of affected women never seek medical help, or do so very late, because of cultural factors, shame or prejudice. The purpose of the present study was to investigate pregnant women appearing in a high-risk antenatal clinic (ANC) with vulvar oedema. It was hoped this would give a clue to the aetiology of this phenomenon in an African urban setting with reference to sexually transmitted dis ease in general and to syphilis in particular.
Dr. Stafian Bergstrom Department of Obstetrics and Gynaecology University Hospital S-75185 Uppsala (Sweden)
© 1992 S. Kargcr AG. Basel 0378-7346/92/0342-0073 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 4:51:04 AM
Stajfan Bergstrom
Tables 1-3. Fourfold tables on the relationships of oedema cases and their referents, concerning genital ulcers (reported/observed), vaginal discharge (reported/observed), VDRL seropositivity and the presence of IgM/SPHA in WR-positive patients with vulvar oedema and their WR-positive referents 1
Vulvar oedema
yes no
Total 2
Vulvar oedema
yes no
Total 3
Vulvar oedema Total
yes no
Reported genital ulcers
Reported vaginal discharge
yes
total
yes
22 22 44
19 3 10 12 1________ 1 p < 0.05
no
15 7 4 18 1________1 p < 0.05
no
total 22 22 44
Observed genital ulcers
Observed vaginal discharge
yes
total
yes
22 22 44
20 2 7 15 1 1 p < 0.005
no
14 8 1 21 1________1 p < 0.005
no
total 22 22 44
VDRL reactivity
IgM SPHA
positive negative total
positive negative total
13 8 1 19 1 1 p < 0.005
21 20 41
12 I 0 3 1________ 1 p < 0.05
13 3 16'
1 Note that only WR-positive individuals were IgM tested.
A total of 22 pregnant patients with vulvar oedema were seen by the author in an outpatient referral ANC for high-risk cases in Mapu to, capital of Mozambique. The patients were found among a total of 2,200 high-risk cases referred to this ANC, for various risk factors or for emergency reasons, during a 3-year period. The same number of referents were picked from unselected normal ANC attenders, matched with the oedema cases for age, parity, gestational length and area of living (bairro). The referents were randomly selected within ± 2 years of age, within parity category (0 para, 1-3 para or > 4 para), within ± 2 weeks of gestational length as calculated from the last menstrual period and within bairro. All 44 women were regis tered, using the current ANC card. At the time of the study (19831986), about 95 % of the pregnant population in Maputo city were covered by ANC. The obstetric history items and the clinical param eters analysed were those of the national ANC card. The laboratory analyses comprised haemoglobin, VDRL, stool parasitology and thick drop for malaria plasmodia. A wet smear was prepared from the cervial canal for the detection of clue cells, Candida albicans and Trichomonas vaginalis and after staining intracellular diplococci. Filaria blood films were not prepared, since filariasis does not occur in the region. All cases were serologically checked blindly in a reference labora tory (National Bacteriological Laboratory, Stockholm, Sweden) us
74
Bergström
ing the Wassermann reaction (WR). In order to differentiate between active and inactive syphilis, confirmed WR-positive sera were fur ther analysed with FTA-ABS and with solid-phase haemadsorption assay (SPHA) for the presence of IgM. The technique used was per formed according to the description given by Schmidt [2]. Rabbit anti-human IgM chain-specific serum (Dako, Denmark) was used for coating the solid-phase microtitre plates. Treponema pallidum-sensi tized sheep blood cells (Fujizoki, Japan) were used for haemadsorp tion. A titre of 4 was regarded as positive. The statistical analyses were carried out using the y} test or, when appropriate, Fisher’s exact test.
Results
The comparison of cases and referents is presented in tables 1-3. The majority of the cases presented a history of other genital affections during the current pregnancy. Genital ulcers were reported in 15/22 (68%) oedema cases and in 4/22 (18%) referent cases (p < 0.05). A similar association (p < 0.05) was found concerning vaginal dis charge, being reported in 19/22 (86%) and 10/22 (45%) oedema and referent cases, respectively. Other anamnes
Vulvar Oedema in Pregnancy
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 4:51:04 AM
Materials and Methods
tic parameters did not show any significant differences when comparing cases and referents. Observed clinical signs agreed with reported symp toms. In 14/22 (63.6%) oedema patients, there were geni tal ulcers, some of which were reported to be recent. In the referent group, genital ulcers were observed in 1/22 (5%). This difference is significant (p < 0.005). In 20/22 (91 %) oedema patients, there was an abnormal discharge from the vagina; in the referent group 7/22 (32%) had abnormal discharge (p < 0.005). Unilateral inguinal adenitis was palpated in 4/22 oedema patients and in 1/21 referents. Among laboratory analyses, wet vaginal smears were studied from all 44 individuals, showing a similar pattern in both groups. In oedema cases and referents, Candida was encountered in 10/22 and 8/22, T. vaginalis in 6/22 and 7/22, and clue cells in 4/22 and 6/22, respectively. Intracellular diplococci were seen in 3/22 and 2/22, respectively. Urine and stool microscopy did not show any significant differenes. Serum analyses showed that VDRL distinguished oe dema patients from referents. A total of 13/21 (62%) oedema patients had a positive VDRL. while only 1/20 (5.0%) referents had a negative test (p < 0.005). All 41 sera were checked with WR and the positivity was con firmed in all of the 14 individuals previously found posi tive. Two more WR-positive individuals were found, both in the referent group. All the remaining sera were negative. When WR-positive sera were checked by FTAABS, 12/13 were positive among the oedema cases and 1/3 among the referents. The ensuing SPHA comprised all the 16 WR-positive sera, showing that 12/13 WR-positive oedema cases, all positive in FTA-ABS, and 0/3 WR-positive referents were IgM positive in the SPHA (p < 0.05).
ious local lymphatic obstructive diseases [3]. The present finding of a significantly increased prevalence of VDRL positives among oedema cases in relation to referents indicates that secondary syphilis probably plays a signifi cant role in the aetiology of oedema of the vulva in the population under study. The significant difference in the presence of IgM in oedema patients and referents, con firms that the difference in seropositivity was due to recent infection. Reported history of genital ulcer and the overrepresentation of vaginal discharge in cases in rela tion to referents seem to indicate that the oedema patients are more prone to show evidence of sexually transmitted diseases. However, the gonorrhoea prevalence was not different in the two groups. There are a number of other infectious diseases poten tially leading to vulvar oedema. Filariasis was not encoun tered in the region and could be excluded as a cause. Tuberculosis has been described as a potential aetiology in cases of vulvar oedema as has streptococcal infection. Other nonbacterial inflammations like Crohn’s disease of the vulva have also been included in the list of potential aetio logies [3]. Neither of these inflammatory changes seems to have played any role in the population under study. Urticaria [4] has been found rarely in cases of vulvar oedema and then, presumably more as an expression of a generalized oedema tendency. A similar systemic aetiol ogy may be encountered in cases with hereditary angiooedema resulting from an inhibition of the Ci component of the complement [5], It is concluded that in the pregnant population investi gated, secondary syphilis and recent genital ulcers might play an unrecognized role in the aetiology of vulvar oede ma.
Acknowledgements Discussion
References
i
Lawson JB. Stewart DB: Obstetrics and Gyne cology in the Tropics and Developing Coun tries. London, Arnold, 1974, pp 466-480. 2 Schmidt BL: Solid phase haemadsorption. A method for the rapid detection of Treponema pallidum specific IgM. Sex Transm Dis 1980;7: 53-56.
3 4 5
Ridley CN: The Vulva. London, WB Saunders, 1988, p 198. Rainford DJ: Southey’s tubes and vulval oede ma. Br Med J 1970;iv:538. Warin R, Champion RH: Urticaria, chapter 7, London, WB Saunders. 1974, p 114.
75
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 4:51:04 AM
The aetiology of vulvar oedema is multifaceted and covers a wide range of pathological entities. The predomi nant aetiologies reported in the literature comprise var
This study was supported by a grant from the Swedish Agency for Research Cooperation with Developing countries (SAREC). The expert laboratory testing carried out by Associate Prof. Bengt Hederstedt, Swedish National Bacteriological Laboratory (SBL) is grate fully acknowledged.
Department of Obstetrics and Gynecology, Central Hospital. Maputo, Mozambique: Department of Obstetrics and Gynecology, University Hospital, Uppsala, Sweden
Key Words Vulvar oedema Pregnancy
Vulvar Oedema among Pregnant Mozambican Women
Abstract
During a 3-year period, a total of 22 pregnant women with vulvar oedema were observed in a high-risk antenatal clinic (ANC) in Maputo. They were compared with 22 unselectcd normal ANC attenders, matched for age, parity, gestational length and area of living. Reported and observed genital ulcers were more prevalent in the oedema group than in the referent group. Reported and observed vaginal discharge was also significantly more common in the oedema group. Syphilis screening by VDRL was positive in 61.9% of oedema cases while positivity reached 5.0% in referents (p < 0.005). Cases found sero positive on screening were confirmed using Wassermann reaction (WR) in a reference laboratory, in which WR-positive cases underwent FTA-ABS analy sis and IgM assay with solid-phase haemadsorption. IgM-positive individuals were significantly more prevalent among WR-positive oedema cases than among WR-positive referents (p < 0.05). It is concluded that among antenatal attenders in Maputo presenting with vulvar oedema, a significant proportion is associated with recent syphilis. Vulvar oedema should be considered as an important marker for seropositive syphilis during pregnancy.
Introduction
Oedema of the vulva is a common entity in Africa. It is occasionally encountered among women suffering from adverse socio-economical circumstances involving poor hygiene, malnutrition, genital traumata and ulcers. Its aetiology has, however, remained unclear. The prevalence of vulvar oedema has never been stated, but its frequent appearance in outpatient obstetrics and gynaecology in tropical countries seems to escape geographical limits [ 1]. As a discorder affecting sexual life and reproduction, it tends to bring affected women to hospital ear
Received: October 24,1991 Accepted after revision: January 31. 1992
ly. Even if, as a rule, early recognition of vulvar oedema by the patient is probable, it also appears likely that a sig nificant number of affected women never seek medical help, or do so very late, because of cultural factors, shame or prejudice. The purpose of the present study was to investigate pregnant women appearing in a high-risk antenatal clinic (ANC) with vulvar oedema. It was hoped this would give a clue to the aetiology of this phenomenon in an African urban setting with reference to sexually transmitted dis ease in general and to syphilis in particular.
Dr. Stafian Bergstrom Department of Obstetrics and Gynaecology University Hospital S-75185 Uppsala (Sweden)
© 1992 S. Kargcr AG. Basel 0378-7346/92/0342-0073 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 4:51:04 AM
Stajfan Bergstrom
Tables 1-3. Fourfold tables on the relationships of oedema cases and their referents, concerning genital ulcers (reported/observed), vaginal discharge (reported/observed), VDRL seropositivity and the presence of IgM/SPHA in WR-positive patients with vulvar oedema and their WR-positive referents 1
Vulvar oedema
yes no
Total 2
Vulvar oedema
yes no
Total 3
Vulvar oedema Total
yes no
Reported genital ulcers
Reported vaginal discharge
yes
total
yes
22 22 44
19 3 10 12 1________ 1 p < 0.05
no
15 7 4 18 1________1 p < 0.05
no
total 22 22 44
Observed genital ulcers
Observed vaginal discharge
yes
total
yes
22 22 44
20 2 7 15 1 1 p < 0.005
no
14 8 1 21 1________1 p < 0.005
no
total 22 22 44
VDRL reactivity
IgM SPHA
positive negative total
positive negative total
13 8 1 19 1 1 p < 0.005
21 20 41
12 I 0 3 1________ 1 p < 0.05
13 3 16'
1 Note that only WR-positive individuals were IgM tested.
A total of 22 pregnant patients with vulvar oedema were seen by the author in an outpatient referral ANC for high-risk cases in Mapu to, capital of Mozambique. The patients were found among a total of 2,200 high-risk cases referred to this ANC, for various risk factors or for emergency reasons, during a 3-year period. The same number of referents were picked from unselected normal ANC attenders, matched with the oedema cases for age, parity, gestational length and area of living (bairro). The referents were randomly selected within ± 2 years of age, within parity category (0 para, 1-3 para or > 4 para), within ± 2 weeks of gestational length as calculated from the last menstrual period and within bairro. All 44 women were regis tered, using the current ANC card. At the time of the study (19831986), about 95 % of the pregnant population in Maputo city were covered by ANC. The obstetric history items and the clinical param eters analysed were those of the national ANC card. The laboratory analyses comprised haemoglobin, VDRL, stool parasitology and thick drop for malaria plasmodia. A wet smear was prepared from the cervial canal for the detection of clue cells, Candida albicans and Trichomonas vaginalis and after staining intracellular diplococci. Filaria blood films were not prepared, since filariasis does not occur in the region. All cases were serologically checked blindly in a reference labora tory (National Bacteriological Laboratory, Stockholm, Sweden) us
74
Bergström
ing the Wassermann reaction (WR). In order to differentiate between active and inactive syphilis, confirmed WR-positive sera were fur ther analysed with FTA-ABS and with solid-phase haemadsorption assay (SPHA) for the presence of IgM. The technique used was per formed according to the description given by Schmidt [2]. Rabbit anti-human IgM chain-specific serum (Dako, Denmark) was used for coating the solid-phase microtitre plates. Treponema pallidum-sensi tized sheep blood cells (Fujizoki, Japan) were used for haemadsorp tion. A titre of 4 was regarded as positive. The statistical analyses were carried out using the y} test or, when appropriate, Fisher’s exact test.
Results
The comparison of cases and referents is presented in tables 1-3. The majority of the cases presented a history of other genital affections during the current pregnancy. Genital ulcers were reported in 15/22 (68%) oedema cases and in 4/22 (18%) referent cases (p < 0.05). A similar association (p < 0.05) was found concerning vaginal dis charge, being reported in 19/22 (86%) and 10/22 (45%) oedema and referent cases, respectively. Other anamnes
Vulvar Oedema in Pregnancy
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 4:51:04 AM
Materials and Methods
tic parameters did not show any significant differences when comparing cases and referents. Observed clinical signs agreed with reported symp toms. In 14/22 (63.6%) oedema patients, there were geni tal ulcers, some of which were reported to be recent. In the referent group, genital ulcers were observed in 1/22 (5%). This difference is significant (p < 0.005). In 20/22 (91 %) oedema patients, there was an abnormal discharge from the vagina; in the referent group 7/22 (32%) had abnormal discharge (p < 0.005). Unilateral inguinal adenitis was palpated in 4/22 oedema patients and in 1/21 referents. Among laboratory analyses, wet vaginal smears were studied from all 44 individuals, showing a similar pattern in both groups. In oedema cases and referents, Candida was encountered in 10/22 and 8/22, T. vaginalis in 6/22 and 7/22, and clue cells in 4/22 and 6/22, respectively. Intracellular diplococci were seen in 3/22 and 2/22, respectively. Urine and stool microscopy did not show any significant differenes. Serum analyses showed that VDRL distinguished oe dema patients from referents. A total of 13/21 (62%) oedema patients had a positive VDRL. while only 1/20 (5.0%) referents had a negative test (p < 0.005). All 41 sera were checked with WR and the positivity was con firmed in all of the 14 individuals previously found posi tive. Two more WR-positive individuals were found, both in the referent group. All the remaining sera were negative. When WR-positive sera were checked by FTAABS, 12/13 were positive among the oedema cases and 1/3 among the referents. The ensuing SPHA comprised all the 16 WR-positive sera, showing that 12/13 WR-positive oedema cases, all positive in FTA-ABS, and 0/3 WR-positive referents were IgM positive in the SPHA (p < 0.05).
ious local lymphatic obstructive diseases [3]. The present finding of a significantly increased prevalence of VDRL positives among oedema cases in relation to referents indicates that secondary syphilis probably plays a signifi cant role in the aetiology of oedema of the vulva in the population under study. The significant difference in the presence of IgM in oedema patients and referents, con firms that the difference in seropositivity was due to recent infection. Reported history of genital ulcer and the overrepresentation of vaginal discharge in cases in rela tion to referents seem to indicate that the oedema patients are more prone to show evidence of sexually transmitted diseases. However, the gonorrhoea prevalence was not different in the two groups. There are a number of other infectious diseases poten tially leading to vulvar oedema. Filariasis was not encoun tered in the region and could be excluded as a cause. Tuberculosis has been described as a potential aetiology in cases of vulvar oedema as has streptococcal infection. Other nonbacterial inflammations like Crohn’s disease of the vulva have also been included in the list of potential aetio logies [3]. Neither of these inflammatory changes seems to have played any role in the population under study. Urticaria [4] has been found rarely in cases of vulvar oedema and then, presumably more as an expression of a generalized oedema tendency. A similar systemic aetiol ogy may be encountered in cases with hereditary angiooedema resulting from an inhibition of the Ci component of the complement [5], It is concluded that in the pregnant population investi gated, secondary syphilis and recent genital ulcers might play an unrecognized role in the aetiology of vulvar oede ma.
Acknowledgements Discussion
References
i
Lawson JB. Stewart DB: Obstetrics and Gyne cology in the Tropics and Developing Coun tries. London, Arnold, 1974, pp 466-480. 2 Schmidt BL: Solid phase haemadsorption. A method for the rapid detection of Treponema pallidum specific IgM. Sex Transm Dis 1980;7: 53-56.
3 4 5
Ridley CN: The Vulva. London, WB Saunders, 1988, p 198. Rainford DJ: Southey’s tubes and vulval oede ma. Br Med J 1970;iv:538. Warin R, Champion RH: Urticaria, chapter 7, London, WB Saunders. 1974, p 114.
75
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 4:51:04 AM
The aetiology of vulvar oedema is multifaceted and covers a wide range of pathological entities. The predomi nant aetiologies reported in the literature comprise var
This study was supported by a grant from the Swedish Agency for Research Cooperation with Developing countries (SAREC). The expert laboratory testing carried out by Associate Prof. Bengt Hederstedt, Swedish National Bacteriological Laboratory (SBL) is grate fully acknowledged.
