A 28 year old primigravid female at 20 weeks gestation presents for 2 days of vaginal irritation and discharge. Her pregnancy has been uncomplicated, and her only medication is prenatal vitamins. She denies any fever, vomiting, abdominal pain, vaginal bleeding, or dysuria. Vital signs are: HR 92, BP 110/70, T 37.3 C, RR 20, SpO2 98%. Pelvic exam reveals vulvar erythema and white vaginal discharge. Cervical os is closed. Wet mount is shown below. Which of the following is the appropriate treatment?

A: clindamycin vaginal cream

B: clotrimazole vaginal cream

C: PO metronidazole

D: PO fluconazole

Answer: clotrimazole vaginal cream

This patient is presenting with candida vulvovaginitis proven by her wet prep demonstrating budding yeasts and pseudohyphae. Candidal vaginitis infections in pregnant women should be treated with topical azoles. Oral fluconazole is the typical treatment of candida vaginitis in non-pregnant patients but should be avoided in pregnancy due to increased risk for congenital malformations and spontaneous abortion. Clindamycin vaginal cream is an alternative treatment option for bacterial vaginitis. Oral metronidazole is the treatment for either trichomonas or bacterial vaginitis.

Treatment of Vaginitis in Pregnancy
Bacterial	PO metronidazole or vaginal gel Clindamycin vaginal cream
Candida	Topical intravaginal azoles oral azoles contraindicated (category C)
Trichomonas	Metronidazole

References:

Barclay-Buchanan C.J., & Barton M.A. (2020). Vulvovaginitis. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Mølgaard-Nielsen D, Svanström H, Melbye M, Hviid A, Pasternak B. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58–67. doi:10.1001/jama.2015.17844

A 25 year old female with an unknown past medical history arrives via EMS for altered mental status. The only history obtained from roommates was that she was found unresponsive on the floor and she was normal yesterday. She was intubated in the field for poor mental status and inability to protect airway. Physical exam shows no evidence of trauma. GCS is E1 V1T M4. Vitals are within normal limits. Head CT shows no evidence of acute intracranial abnormality. Basic metabolic panel results a sodium level of 116. Urine drug screen and urine electrolyte studies are in process. Which of the following is the recommended initial management of her electrolyte derangement at this time?

A: 0.9% normal saline at maintenance rate

B: 1 liter of 0.9% normal saline bolus

C: 150 mL of 3% hypertonic saline over 20 minutes

D: 2 mcg of IV desmopressin

Answer: C. 150 mL of 3% hypertonic saline over 20 minutes

This patient is presenting with acute hyponatremia. The etiology is broad, but in the acute setting, it is most commonly due to excessive water intoxication, psychiatric illness, or substance use. The recommended initial treatment for adult hyponatremic patients with severe neurologic symptoms such as seizures or coma is 100-150 mL of 3% hypertonic saline IV over 15-20 minutes. This may be repeated up to 3 times for an improvement in neurologic status or increase in sodium concentration up to 5 mEq/L. In general, hyponatremic patients should be fluid restricted until differentiating the underlying cause. Thus, 1 liter of normal saline bolus or at maintenance rate is incorrect. A bolus of 1 liter of normal saline may also correct the sodium too quickly, resulting in osmotic demyelination syndrome. Desmopressin is frequently used when hyponatremia is corrected too rapidly in addition to its use in the treatment of diabetes insipidus.

References:
Petrino R, & Marino R (2020). Fluids and electrolytes. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.