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Muthiani Y, Hunter PJ, Näsänen-Gilmore PK, Koivu AM, Isojärvi J, Luoma J, Salenius M, Hadji M, Ashorn U, Ashorn P. Antenatal interventions to reduce risk of low birth weight related to maternal infections during pregnancy. Am J Clin Nutr 2023; 117 Suppl 2:S118-S133. [PMID: 37331759 DOI: 10.1016/j.ajcnut.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Maternal infections during pregnancy have been linked to increased risk of adverse birth outcomes, including low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA), and stillbirth (SB). OBJECTIVES The purpose of this article was to summarize evidence from published literature on the effect of key interventions targeting maternal infections on adverse birth outcomes. METHODS We searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL Complete between March 2020 and May 2020 with an update to cover until August 2022. We included randomized controlled trials (RCTs) and reviews of RCTs of 15 antenatal interventions for pregnant women reporting LBW, PTB, SGA, or SB as outcomes. RESULTS Of the 15 reviewed interventions, the administration of 3 or more doses of intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine [IPTp-SP; RR: 0.80 (95% CI: 0.69, 0.94)] can reduce risk of LBW compared with 2 doses. The provision of insecticide-treated bed nets, periodontal treatment, and screening and treatment of asymptomatic bacteriuria may reduce risk of LBW. Maternal viral influenza vaccination, treatment of bacterial vaginosis, intermittent preventive treatment with dihydroartemisinin-piperaquine compared with IPTp-SP, and intermittent screening and treatment of malaria during pregnancy compared with IPTp were deemed unlikely to reduce the prevalence of adverse birth outcomes. CONCLUSIONS At present, there is limited evidence from RCTs available for some potentially relevant interventions targeting maternal infections, which could be prioritized for future research.
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Affiliation(s)
- Yvonne Muthiani
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Patricia J Hunter
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Pieta K Näsänen-Gilmore
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Public Health and Welfare, Finnish Institute for Health and Welfare, FI-00271, Helsinki, Finland
| | - Annariina M Koivu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jaana Isojärvi
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juho Luoma
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Meeri Salenius
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Maryam Hadji
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Paediatrics, Tampere University Hospital, Tampere, Finland
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Klebanoff MA, Schuit E, Lamont RF, Larsson PG, Odendaal HJ, Ugwumadu A, Kiss H, Petricevic L, Andrews WW, Hoffman MK, Shennan A, Seed PT, Goldenberg RL, Emel LM, Bhandaru V, Weiner S, Larsen MD. Antibiotic treatment of bacterial vaginosis to prevent preterm delivery: Systematic review and individual participant data meta-analysis. Paediatr Perinat Epidemiol 2023; 37:239-251. [PMID: 36651636 PMCID: PMC10171232 DOI: 10.1111/ppe.12947] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bacterial vaginosis (BV) increases preterm delivery (PTD) risk, but treatment trials showed mixed results in preventing PTD. OBJECTIVES Determine, using individual participant data (IPD), whether BV treatment during pregnancy reduced PTD or prolonged time-to-delivery. DATA SOURCES Cochrane Systematic Review (2013), MEDLINE, EMBASE, journal searches, and searches (January 2013-September 2022) ("bacterial vaginosis AND pregnancy") of (i) clinicaltrials.gov; (ii) Cochrane Central Register of Controlled Trials; (iii) World Health Organization International Clinical Trials Registry Platform Portal; and (iv) Web of Science ("bacterial vaginosis"). STUDY SELECTION AND DATA EXTRACTION Studies randomising asymptomatic pregnant individuals with BV to antibiotics or control, measuring delivery gestation. Extraction was from original data files. Bias risk was assessed using the Cochrane tool. Analysis used "one-step" logistic and Cox random effect models, adjusting gestation at randomisation and PTD history; heterogeneity by I2 . Subgroup analysis tested interactions with treatment. In sensitivity analyses, studies not providing IPD were incorporated by "multiple random-donor hot-deck" imputation, using IPD studies as donors. RESULTS There were 121 references (96 studies) with 23 eligible trials (11,979 participants); 13 studies (6915 participants) provided IPD; 12 (6115) were incorporated. Results from 9 (4887 participants) not providing IPD were imputed. Odds ratios for PTD for metronidazole and clindamycin versus placebo were 1.00 (95% CI 0.84, 1.17), I2 = 62%, and 0.59 (95% CI 0.42, 0.82), I2 = 0 before; and 0.95 (95% CI 0.81, 1.11), I2 = 59%, and 0.90 (95% CI: 0.72, 1.12), I2 = 0, after imputation. Time-to-delivery did not differ from null with either treatment. Including imputed IPD, there was no evidence that either drug was more effective when administered earlier, or among those with a PTD history. CONCLUSIONS Clindamycin, but not metronidazole, was beneficial in studies providing IPD, but after imputing data from missing IPD studies, treatment of BV during pregnancy did not reduce PTD, nor prolong pregnancy, in any subgroup or when started earlier in gestation.
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Affiliation(s)
- Mark A. Klebanoff
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
- Departments of Pediatrics and Obstetrics and Gynecology, and Division of Epidemiology, The Ohio State University, Columbus, Ohio, USA
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, and Cochrane Netherlands, both at University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ronald F. Lamont
- Division of Surgery, University College London, Northwick Park Institute for Medical Research Campus, London, UK
- Odense University Hospital, Department of Gynecology and Obstetrics, University of Southern Denmark, Institute of Clinical Research, Research Unit of Gynecology and Obstetrics, Odense, Denmark
| | - Per-Göran Larsson
- Department of Obstetrics and Gynaecology, Skaraborg Hospital, Skövde, Sweden
- Department of Clinical and Experimental Medicine (IKE), Linköping University, Linköping, Sweden
| | - Hein J. Odendaal
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | - Austin Ugwumadu
- Department of Obstetrics and Gynecology, St. George’s Hospital, University of London, London, UK
| | - Herbert Kiss
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Wien, Austria
| | - Ljubomir Petricevic
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Wien, Austria
| | - William W. Andrews
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Health Services, Newark, Delaware, USA
| | - Andrew Shennan
- Department of Women and Children’s Health, School of Life Course Sciences, FoLSM, King’s College, London, UK
| | - Paul T. Seed
- Division of Women’s Health, King’s College, London, UK
| | - Robert L. Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York City, New York, USA
| | - Lynda M. Emel
- Biostatistics, Bioinformatics, and Epidemiology/VIDD, Fred Hutchinson Cancer Center Seattle, Seattle, Washington, USA
| | - Vinay Bhandaru
- The Biostatistics Center, Milken School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Steven Weiner
- The Biostatistics Center, Milken School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Michael D. Larsen
- The Biostatistics Center, Milken School of Public Health, The George Washington University, Washington, District of Columbia, USA
- Department of Mathematics and Statistics, St. Michael’s College, Colchester, Vermont, USA
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Pavlidis I, Stock SJ. Preterm Birth Therapies to Target Inflammation. J Clin Pharmacol 2022; 62 Suppl 1:S79-S93. [PMID: 36106783 PMCID: PMC9545799 DOI: 10.1002/jcph.2107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/06/2022] [Indexed: 12/04/2022]
Abstract
Preterm birth (PTB; defined as delivery before 37 weeks of pregnancy) is the leading cause of morbidity and mortality in infants and children aged <5 years, conferring potentially devastating short‐ and long‐term complications. Despite extensive research in the field, there is currently a paucity of medications available for PTB prevention and treatment. Over the past few decades, inflammation in gestational tissues has emerged at the forefront of PTB pathophysiology. Even in the absence of infection, inflammation alone can prematurely activate the main components of parturition resulting in uterine contractions, cervical ripening and dilatation, membrane rupture, and subsequent PTB. Mechanistic studies have identified critical elements of the complex inflammatory molecular pathways involved in PTB. Here, we discuss therapeutic options that target such key mediators with an aim to prevent, postpone, or treat PTB. We provide an overview of more traditional therapies that are currently used or being tested in humans, and we highlight recent advances in preclinical studies introducing novel approaches with therapeutic potential. We conclude that urgent collaborative action is required to address the unmet need of developing effective strategies to tackle the challenge of PTB and its complications.
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Affiliation(s)
- Ioannis Pavlidis
- University of Warwick Biomedical Research Unit in Reproductive Health, Coventry, UK
| | - Sarah J Stock
- University of Edinburgh Usher Institute, Edinburgh, UK
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Coler BS, Shynlova O, Boros-Rausch A, Lye S, McCartney S, Leimert KB, Xu W, Chemtob S, Olson D, Li M, Huebner E, Curtin A, Kachikis A, Savitsky L, Paul JW, Smith R, Adams Waldorf KM. Landscape of Preterm Birth Therapeutics and a Path Forward. J Clin Med 2021; 10:2912. [PMID: 34209869 PMCID: PMC8268657 DOI: 10.3390/jcm10132912] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022] Open
Abstract
Preterm birth (PTB) remains the leading cause of infant morbidity and mortality. Despite 50 years of research, therapeutic options are limited and many lack clear efficacy. Tocolytic agents are drugs that briefly delay PTB, typically to allow antenatal corticosteroid administration for accelerating fetal lung maturity or to transfer patients to high-level care facilities. Globally, there is an unmet need for better tocolytic agents, particularly in low- and middle-income countries. Although most tocolytics, such as betamimetics and indomethacin, suppress downstream mediators of the parturition pathway, newer therapeutics are being designed to selectively target inflammatory checkpoints with the goal of providing broader and more effective tocolysis. However, the relatively small market for new PTB therapeutics and formidable regulatory hurdles have led to minimal pharmaceutical interest and a stagnant drug pipeline. In this review, we present the current landscape of PTB therapeutics, assessing the history of drug development, mechanisms of action, adverse effects, and the updated literature on drug efficacy. We also review the regulatory hurdles and other obstacles impairing novel tocolytic development. Ultimately, we present possible steps to expedite drug development and meet the growing need for effective preterm birth therapeutics.
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Affiliation(s)
- Brahm Seymour Coler
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Oksana Shynlova
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Adam Boros-Rausch
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
| | - Stephen Lye
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Stephen McCartney
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Kelycia B. Leimert
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
| | - Wendy Xu
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
| | - Sylvain Chemtob
- Departments of Pediatrics, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | - David Olson
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
- Departments of Pediatrics and Physiology, University of Alberta, Edmonton, AB T6G 2S2, Canada
| | - Miranda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Department of Biological Sciencies, Columbia University, New York, NY 10027, USA
| | - Emily Huebner
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Anna Curtin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Alisa Kachikis
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Leah Savitsky
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Jonathan W. Paul
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; (J.W.P.); (R.S.)
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Roger Smith
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; (J.W.P.); (R.S.)
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Kristina M. Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Department of Global Health, University of Washington, Seattle, WA 98195, USA
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Buxton MA, Meraz-Cruz N, Sanchez BN, Foxman B, Castillo-Castrejon M, O’Neill MS, Vadillo-Ortega F. Timing of Cervico-Vaginal Cytokine Collection during Pregnancy and Preterm Birth: A Comparative Analysis in the PRINCESA Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3436. [PMID: 33810264 PMCID: PMC8036528 DOI: 10.3390/ijerph18073436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 12/02/2022]
Abstract
Preterm birth (PTB), defined as birth before 37 completed weeks of gestation, is a major cause of infant morbidity and mortality. Inflammation is an important component in the physiopathologic pathway leading to PTB but results from cross-sectional studies on associations between inflammation, as measured by cytokines, and PTB are inconsistent. Timing of cytokine measurement during pregnancy varies between studies and may contribute to inconsistent findings. We investigated the effects of timing on associations between 16 cervico-vaginal cytokines (Eotaxin, IL-10, IL-12p40, IL-17, IL-1RA, sIL-2rα, IL-1a, IL-1β, IL-2, IL-6, IP-10, MCP-1, MIP-1α, MIP-1β, TNFα, and VEGF) and PTB among 90 women throughout pregnancy. We used logistic regression to compare associations between concentrations of cervico-vaginal cytokines from periods in pregnancy and PTB. Trimester 1 cytokines had the strongest positive associations with PTB; for example, OR = 1.76 (95% confidence interval: 1.28, 2.42) for IL-6. Second and third trimester associations were weaker but largely positive. IL-1α was the only cytokine with a negative association (trimesters 2, 3 and overall pregnancy). Strong first trimester associations between cytokines and PTB suggest that measuring cytokines early in pregnancy may hold promise for early identification of PTB risk. Variations in cytokine measurement during pregnancy may contribute to inconsistencies among studies.
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Affiliation(s)
- Miatta A. Buxton
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (B.F.); (M.S.O.)
| | - Noemi Meraz-Cruz
- Unidad de Vinculación Científica de la Facultad de Medicina, Universidad Nacional Autónoma de México en el Instituto Nacional de Medicina Genómica, Mexico City 14610, Mexico; (N.M.-C.); (F.V.-O.)
| | - Brisa N. Sanchez
- Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Philadelphia, PA 19104, USA;
| | - Betsy Foxman
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (B.F.); (M.S.O.)
| | - Marisol Castillo-Castrejon
- Stephenson Cancer Center, Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Marie S. O’Neill
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (B.F.); (M.S.O.)
- Department of Environmental Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Felipe Vadillo-Ortega
- Unidad de Vinculación Científica de la Facultad de Medicina, Universidad Nacional Autónoma de México en el Instituto Nacional de Medicina Genómica, Mexico City 14610, Mexico; (N.M.-C.); (F.V.-O.)
- Department of Environmental Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
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Yudin MH, Money DM. No. 211-Screening and Management of Bacterial Vaginosis in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:e184-e191. [PMID: 28729110 DOI: 10.1016/j.jogc.2017.04.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review the evidence and provide recommendations on screening for and management of bacterial vaginosis in pregnancy. OPTIONS The clinical practice options considered in formulating the guideline. OUTCOMES Outcomes evaluated include antibiotic treatment efficacy and cure rates, and the influence of the treatment of bacterial vaginosis on the rates of adverse pregnancy outcomes such as preterm labour and delivery and preterm premature rupture of membranes. EVIDENCE Medline, EMBASE, CINAHL, and Cochrane databases were searched for articles, published in English before the end of June 2007 on the topic of bacterial vaginosis in pregnancy. VALUES The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Guideline implementation will assist the practitioner in developing an approach to the diagnosis and treatment of bacterial vaginosis in pregnant women. Patients will benefit from appropriate management of this condition. VALIDATION These guidelines have been prepared by the Infectious Diseases Committee of the SOGC, and approved by the Executive and Council of the SOGC. SPONSORS The Society of Obstetricians and Gynaecologists of Canada. RECOMMENDATIONS There is currently no consensus as to whether to screen for or treat bacterial vaginosis in the general pregnant population in order to prevent adverse outcomes, such as preterm birth.
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Rebouças KF, Jr. JE, Peixoto RC, Costa APF, Cobucci RN, Gonçalves AK. Treatment of bacterial vaginosis before 28 weeks of pregnancy to reduce the incidence of preterm labor. Int J Gynaecol Obstet 2019; 146:271-276. [DOI: 10.1002/ijgo.12829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/24/2018] [Accepted: 04/17/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Karinne F. Rebouças
- Department of Maternal and Child HealthFederal University of Ceará Fortaleza Brazil
| | - José Eleutério Jr.
- Department of Maternal and Child HealthFederal University of Ceará Fortaleza Brazil
| | - Raquel C. Peixoto
- Department of Maternal and Child HealthFederal University of Ceará Fortaleza Brazil
| | - Ana Paula F. Costa
- Postgraduate Program in Health SciencesFederal University of Rio Grande do Norte Natal Brazil
| | | | - Ana K. Gonçalves
- Postgraduate Program in Health SciencesFederal University of Rio Grande do Norte Natal Brazil
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Subtil D, Brabant G, Tilloy E, Devos P, Canis F, Fruchart A, Bissinger MC, Dugimont JC, Nolf C, Hacot C, Gautier S, Chantrel J, Jousse M, Desseauve D, Plennevaux JL, Delaeter C, Deghilage S, Personne A, Joyez E, Guinard E, Kipnis E, Faure K, Grandbastien B, Ancel PY, Goffinet F, Dessein R. Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA): a multicentre, double-blind, randomised controlled trial. Lancet 2018; 392:2171-2179. [PMID: 30322724 DOI: 10.1016/s0140-6736(18)31617-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 02/22/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Preterm delivery during pregnancy (<37 weeks' gestation) is a leading cause of perinatal mortality and morbidity. Treating bacterial vaginosis during pregnancy can reduce poor outcomes, such as preterm birth. We aimed to investigate whether treatment of bacterial vaginosis decreases late miscarriages or spontaneous very preterm birth. METHODS PREMEVA was a double-blind randomised controlled trial done in 40 French centres. Women aged 18 years or older with bacterial vaginosis and low-risk pregnancy were eligible for inclusion and were randomly assigned (2:1) to three parallel groups: single-course or triple-course 300 mg clindamycin twice-daily for 4 days, or placebo. Women with high-risk pregnancy outcomes were eligible for inclusion in a high-risk subtrial and were randomly assigned (1:1) to either single-course or triple-course clindamycin. The primary outcome was a composite of late miscarriage (16-21 weeks) or spontaneous very preterm birth (22-32 weeks), which we assessed in all patients with delivery data (modified intention to treat). Adverse events were systematically reported. This study is registered with ClinicalTrials.gov, number NCT00642980. FINDINGS Between April 1, 2006, and June 30, 2011, we screened 84 530 pregnant women before 14 weeks' gestation. 5630 had bacterial vaginosis, of whom 3105 were randomly assigned to groups in the low-risk trial (n=943 to receive single-course clindamycin, n=968 to receive triple-course clindamycin, and n=958 to receive placebo) or high-risk subtrial (n=122 to receive single-course clindamycin and n=114 to receive triple-course clindamycin). In 2869 low-risk pregnancies, the primary outcome occurred in 22 (1·2%) of 1904 participants receiving clindamycin and 10 (1·0%) of 956 participants receiving placebo (relative risk [RR] 1·10, 95% CI 0·53-2·32; p=0·82). In 236 high-risk pregnancies, the primary outcome occurred in 5 (4·4%) participants in the triple-course clindamycin group and 8 (6·0%) participants in the single-course clindamycin group (RR 0·67, 95% CI 0·23-2·00; p=0·47). In the low-risk trial, adverse events were more common in the clindamycin groups than in the placebo group (58 [3·0%] of 1904 vs 12 [1·3%] of 956; p=0·0035). The most commonly reported adverse event was diarrhoea (30 [1·6%] in the clindamycin groups vs 4 [0·4%] in the placebo group; p=0·0071); abdominal pain was also observed in the clindamycin groups (9 [0·6%] participants) versus none in the placebo group (p=0·034). No severe adverse event was reported in any group. Adverse fetal and neonatal outcomes did not differ significantly between groups in the high-risk subtrial. INTERPRETATION Systematic screening and subsequent treatment for bacterial vaginosis in women with low-risk pregnancies shows no evidence of risk reduction of late miscarriage or spontaneous very preterm birth. Use of antibiotics to prevent preterm delivery in this patient population should be reconsidered. FUNDING French Ministry of Health.
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Affiliation(s)
- Damien Subtil
- Pôle Femme Mère Nouveau-né, Centre Hospitalier Universitaire de Lille, Lille, France; Epidémiologie et Qualité des soins (EA 2694), Université de Lille, Lille, France
| | - Gilles Brabant
- Service de Gynécologie-Obstétrique, Groupement des Hôpitaux de l'Institut Catholique de Lille, Hôpital Saint Vincent, Lille, France
| | - Emma Tilloy
- Pôle Femme Mère Nouveau-né, Centre Hospitalier Universitaire de Lille, Lille, France; Epidémiologie et Qualité des soins (EA 2694), Université de Lille, Lille, France
| | - Patrick Devos
- Epidémiologie et Qualité des soins (EA 2694), Université de Lille, Lille, France
| | - Frédérique Canis
- Laboratoire de Biologie Médicale, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Annie Fruchart
- Institut de Microbiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | | | - Catherine Nolf
- Association des Biologistes des Régions Nord Picardie, Marcq-en-Baroeul, France
| | - Christophe Hacot
- Association des Biologistes des Régions Nord Picardie, Marcq-en-Baroeul, France
| | - Sophie Gautier
- Centre Regional de Pharmacovigilance, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jérôme Chantrel
- Hôpital Privé de Villeneuve d'Ascq, Villeneuve d'Ascq, France
| | - Marielle Jousse
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - David Desseauve
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | | | - Christine Delaeter
- Pôle Femme Mère Nouveau-né, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sylvie Deghilage
- Pôle Femme Mère Nouveau-né, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Personne
- Pôle Femme Mère Nouveau-né, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Emmanuelle Joyez
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Calais, Calais, France
| | - Elisabeth Guinard
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Calais, Calais, France
| | - Eric Kipnis
- Service de Réanimation Chirurgicale, Centre Hospitalier Universitaire de Lille, Lille, France; Recherche Translationelle Relation Hôte-Pathogènes, Université de Lille, Lille, France
| | - Karine Faure
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire de Lille, Lille, France; Recherche Translationelle Relation Hôte-Pathogènes, Université de Lille, Lille, France
| | - Bruno Grandbastien
- Service de Gestion de Risque Infectieux et des Vigilances, Centre Hospitalier Universitaire de Lille, Lille, France; Epidémiologie et Qualité des soins (EA 2694), Université de Lille, Lille, France
| | - Pierre-Yves Ancel
- Epidemiological Research in Perinatal Health and Women's and Children Health, INSERM UMR 1153, Paris, France
| | - François Goffinet
- Epidemiological Research in Perinatal Health and Women's and Children Health, INSERM UMR 1153, Paris, France; Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Cochin Port Royal Saint Vincent de Paul, Paris, France
| | - Rodrigue Dessein
- Institut de Microbiologie, Centre Hospitalier Universitaire de Lille, Lille, France; Recherche Translationelle Relation Hôte-Pathogènes, Université de Lille, Lille, France.
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Lannon SMR, Adams Waldorf KM, Fiedler T, Kapur RP, Agnew K, Rajagopal L, Gravett MG, Fredricks DN. Parallel detection of lactobacillus and bacterial vaginosis-associated bacterial DNA in the chorioamnion and vagina of pregnant women at term. J Matern Fetal Neonatal Med 2018; 32:2702-2710. [PMID: 29478370 DOI: 10.1080/14767058.2018.1446208] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The majority of early preterm births are associated with intrauterine infections, which are thought to occur when microbes traffic into the uterus from the lower genital tract and seed the placenta. Bacterial vaginosis (BV) is associated with heterogeneous bacterial communities in the vagina and is linked to preterm birth. The extent to which trafficking into the uterus of normal and BV-associated vaginal bacteria occurs is unknown. The study objective was to characterize in parallel the distribution and quantities of bacteria in the vagina, uterus, and placental compartments. METHODS Pregnant women at term (≥37 weeks) presenting for delivery were recruited prospectively. Swabs were collected in parallel from the vagina, chorioamnion. Choriodecidual swabs were collected if a cesarean section was performed. Samples were analyzed by culture, broad-range 16S rRNA gene PCR, and bacterial species-specific quantitative PCR (qPCR) for DNA from Lactobacillus and a panel of BV-associated bacteria. Results were correlated with placental histopathology. RESULTS Of the 23 women enrolled, 15 were delivered by cesarean section (N = 10 without labor; N = 5 in labor) and eight were delivered vaginally. BV was diagnosed in two women not in labor. Placental histopathology identified chorioamnionitis or funisitis in six cases [1/10 (10%) not in labor; 5/13 (38%) in labor]. Among non-laboring women, broad-range 16S qPCR detected bacteria in the chorioamnion and the choriodecidua (4/10; 40%). Among laboring women, Lactobacillus species were frequently detected in the chorioamnion by qPCR (4/13; 31%). In one case, mild chorioamnionitis was associated with qPCR detection of similar microbes in the chorioamnion and vagina (e.g. Leptotrichia/Sneathia, Megasphaera), along a quantitative gradient. CONCLUSIONS Microbial trafficking of lactobacilli and fastidious bacteria into the chorioamniotic membranes and choriodecidua occurs at term in normal pregnancies. In one case, we demonstrated a quantitative gradient between multiple bacterial species in the lower genital tract and placenta. Not all bacterial colonization is associated with placental inflammation and clinical sequelae. Further studies of the role of placental colonization with Lactobacillus in normal pregnancy and fastidious bacteria in chorioamnionitis may improve prevention and treatment approaches for preterm labor.
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Affiliation(s)
- Sophia M R Lannon
- a Department of Obstetrics & Gynecology , University of Washington , Seattle, Washington , DC , USA.,b Northwest Perinatal Associates , Portland , OR , USA
| | - Kristina M Adams Waldorf
- a Department of Obstetrics & Gynecology , University of Washington , Seattle, Washington , DC , USA
| | - Tina Fiedler
- c Fred Hutchinson Cancer Research Center , Seattle, Washington , DC , USA
| | - Raj P Kapur
- d Department of Pathology , University of Washington , Seattle, Washington , DC , USA.,e Department of Pathology , Seattle Children's Hospital , Seattle, Washington , DC , USA
| | - Kathy Agnew
- a Department of Obstetrics & Gynecology , University of Washington , Seattle, Washington , DC , USA
| | - Lakshmi Rajagopal
- f Department of Pediatrics , University of Washington , Seattle, Washington , DC , USA.,g Center for Global Infectious Disease Research, Seattle Children's Research Institute , Seattle , Washington , DC , USA
| | - Michael G Gravett
- a Department of Obstetrics & Gynecology , University of Washington , Seattle, Washington , DC , USA
| | - David N Fredricks
- c Fred Hutchinson Cancer Research Center , Seattle, Washington , DC , USA
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N o 211-Dépistage et prise en charge de la vaginose bactérienne pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:e175-e183. [DOI: 10.1016/j.jogc.2017.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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11
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Bookstaver PB, Bland CM, Griffin B, Stover KR, Eiland LS, McLaughlin M. A Review of Antibiotic Use in Pregnancy. Pharmacotherapy 2017; 35:1052-62. [PMID: 26598097 DOI: 10.1002/phar.1649] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
During pregnancy, untreated sexually transmitted or urinary tract infections are associated with significant morbidity, including low birth weight, preterm birth, and spontaneous abortion. Approximately one in four women will be prescribed an antibiotic during pregnancy, accounting for nearly 80% of prescription medications in pregnant women. Antibiotic exposures during pregnancy have been associated with both short-term (e.g., congenital abnormalities) and long-term effects (e.g., changes in gut microbiome, asthma, atopic dermatitis) in the newborn. However, it is estimated that only 10% of medications have sufficient data related to safe and effective use in pregnancy. Antibiotics such as beta-lactams, vancomycin, nitrofurantoin, metronidazole, clindamycin, and fosfomycin are generally considered safe and effective in pregnancy. Fluoroquinolones and tetracyclines are generally avoided in pregnancy. Physiologic changes in pregnancy lead to an increase in glomerular filtration rate, increase in total body volume, and enhanced cardiac output. These changes may lead to pharmacokinetic alterations in antibiotics that require dose adjustment or careful monitoring and assessment.
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Affiliation(s)
- P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina
| | - Christopher M Bland
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia
| | - Brooke Griffin
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi
| | - Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Meridian, Mississippi
| | - Milena McLaughlin
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
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Dennemark N, Meyer-Wilmes M, Schlüter R. Screening and treatment of bacterial vaginosis in the early second trimester of pregnancy: A sufficient measure for prevention of preterm deliveries? Int J STD AIDS 2016. [DOI: 10.1258/0956462971919435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Paramel Jayaprakash T, Wagner EC, van Schalkwyk J, Albert AYK, Hill JE, Money DM. High Diversity and Variability in the Vaginal Microbiome in Women following Preterm Premature Rupture of Membranes (PPROM): A Prospective Cohort Study. PLoS One 2016; 11:e0166794. [PMID: 27861554 PMCID: PMC5115810 DOI: 10.1371/journal.pone.0166794] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 11/03/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To characterize the vaginal microbiota of women following preterm premature rupture of membranes (PPROM), and determine if microbiome composition predicts latency duration and perinatal outcomes. Design A prospective cohort study Setting Canada Population Women with PPROM between 24+0 and 33+6 weeks gestational age (GA). Methods Microbiome profiles, based on pyrosequencing of the cpn60 universal target, were generated from vaginal samples at time of presentation with PPROM, weekly thereafter, and at delivery. Main Outcome Measures Vaginal microbiome composition, latency duration, gestational age at delivery, perinatal outcomes. Results Microbiome profiles were generated from 70 samples from 36 women. Mean GA at PPROM was 28.8 wk (mean latency 2.7 wk). Microbiome profiles were highly diverse but sequences representing Megasphaera type 1 and Prevotella spp. were detected in all vaginal samples. Only 13/70 samples were dominated by Lactobacillus spp. Microbiome profiles at the time of membrane rupture did not cluster by gestational age at PPROM, latency duration, presence of chorioamnionitis or by infant outcomes. Mycoplasma and/or Ureaplasma were detected by PCR in 81% (29/36) of women, and these women had significantly lower GA at delivery and correspondingly lower birth weight infants than Mycoplasma and/or Ureaplasma negative women. Conclusion Women with PPROM had mixed, abnormal vaginal microbiota but the microbiome profile at PPROM did not correlate with latency duration. Prevotella spp. and Megasphaera type I were ubiquitous. The presence of Mollicutes in the vaginal microbiome was associated with lower GA at delivery. The microbiome was remarkably unstable during the latency period.
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Affiliation(s)
| | - Emily C. Wagner
- Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC, Canada
| | - Julie van Schalkwyk
- Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC, Canada
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Arianne Y. K. Albert
- Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC, Canada
| | - Janet E. Hill
- Department of Veterinary Microbiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Deborah M. Money
- Women’s Health Research Institute, BC Women’s Hospital and Health Centre, Vancouver, BC, Canada
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- * E-mail:
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Brabant G. [Bacterial vaginosis and spontaneous preterm birth]. ACTA ACUST UNITED AC 2016; 45:1247-1260. [PMID: 27793493 DOI: 10.1016/j.jgyn.2016.09.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine if bacterial vaginosis is a marker for risk of spontaneous preterm delivery and if its detection and treatment can reduce this risk. METHODS Consultation of the database Pubmed/Medline, Science Direct, and international guidelines of medical societies. RESULTS Bacterial vaginosis (BV) is a dysbiosis resulting in an imbalance in the vaginal flora through the multiplication of anaerobic bacteria and jointly of a disappearance of well-known protective Lactobacilli. His diagnosis is based on clinical Amsel criteria and/or a Gram stain with establishment of the Nugent score. The prevalence of the BV extraordinarily varies according to ethnic and/or geographical origin (4-58 %), in France, it is close to 7 % in the first trimester of pregnancy (EL2). The link between BV and spontaneous premature delivery is low with an odds ratio between 1.5 and 2 in the most recent studies (EL3). Metronidazole or clindamycin is effective to treat BV (EL3). It is recommended to prescribe one of these antibiotics in the case of symptomatic BV (Professional Consensus). The testing associated with the treatment of BV in the global population showed no benefit in the prevention of the risk of spontaneous preterm delivery (EL2). Concerning low-risk asymptomatic population (defined by the absence of antecedent of premature delivery), it has been failed profit to track and treat the BV in the prevention of the risk of spontaneous preterm delivery (EL1). Concerning the high-risk population (defined by a history of preterm delivery), it has been failed profit to track and treat the VB in the prevention of the risk of spontaneous preterm delivery (EL3). However, in the sub population of patients with a history of preterm delivery occurred in a context of materno-fetal bacterial infection, there may be a benefit to detect and treat early and systematically genital infection, and in particular the BV (Professional Consensus). CONCLUSION The screening and treatment of BV during pregnancy in asymptomatic low-risk population is not recommended in the prevention of the risk of spontaneous preterm delivery (grade A). In the population at high risk with the only notion of antecedent of premature delivery, screening and treatment of the BV is not recommended (grade C).
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Affiliation(s)
- G Brabant
- Hôpital Saint-Vincent-de-Paul, GHICL, FLMM, 59000 Lille, France.
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Nelson DB. Treatment and Management of Bacterial Vaginosis in Pregnancy: Current and Future Perspectives. WOMENS HEALTH 2016; 2:267-77. [DOI: 10.2217/17455057.2.2.267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Bacterial vaginosis accounts for the majority of cases of vaginal discharge and has been consistently linked to an increased risk of preterm delivery. Bacterial vaginosis is characterized by the reduced number or absence of hydrogen peroxide-producing Lactobacillus spp., which promotes the overgrowth of anaerobic bacteria, including Gardnerella vaginalis, Mycoplasma hominis, Bacteroides spp., and Mobiluncus spp. Black race, higher-risk sexual activity, frequent vaginal douching and the substantial reduction of hydrogen peroxide-producing Lactobacillus spp. are the main predictors of bacterial vaginosis development. Clinical- and laboratory-based bacterial vaginosis diagnostic tests are widely used to screen for bacterial vaginosis but, more recently, office-based bacterial vaginosis screening tools have been developed. Although systemic treatment for bacterial vaginosis with metronidazole or clindamycin has been demonstrated to be effective in the short-term cure of bacterial vaginosis, recurrence of bacterial vaginosis within 3 months of treatment is common, and treatment for bacterial vaginosis using these strategies has not been effective in reducing the risk of preterm delivery.
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Affiliation(s)
- Deborah B Nelson
- College of Health Professions, Department of Public Health, Temple University, 1700 North Broad Street, Room 403F, Philadelphia, PA 19122, USA, Tel.: +1 215 204 9659; School of Medicine, Department of Obstetrics and Gynecology, Temple University, Philadelphia, PA, USA,
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Haahr T, Ersbøll AS, Karlsen MA, Svare J, Sneider K, Hee L, Weile LK, Ziobrowska-Bech A, Østergaard C, Jensen JS, Helmig RB, Uldbjerg N. Treatment of bacterial vaginosis in pregnancy in order to reduce the risk of spontaneous preterm delivery - a clinical recommendation. Acta Obstet Gynecol Scand 2016; 95:850-60. [PMID: 27258798 DOI: 10.1111/aogs.12933] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Bacterial vaginosis (BV) is characterized by a dysbiosis of the vaginal microbiota with a depletion of Lactobacillus spp. In pregnancy, prevalence's between 7 and 30% have been reported depending on the study population and the definition. BV may be associated with an increased risk of spontaneous preterm delivery (sPTD). However, it is controversial whether or not BV-positive pregnant women will benefit from treatment to reduce the risk of sPTD. We could not identify any good-quality guideline addressing this issue. Consequently we aimed to produce this clinical recommendation based on GRADE. MATERIAL AND METHODS Systematic literature searches were conducted in the following databases: Guidelines International Network: G-I-N, Medline, Embase, The Cochrane Database of Systematic Reviews, Web of Science and http://www.clinicaltrials.gov from 1999 to 3 October 2014. Hence, nine guidelines, 34 reviews, 18 randomized controlled trials and 12 observational studies were included. RESULTS The GRADE quality of evidence was consistently low or very low, primarily because none of the risk ratios (RR) for the risk of sPTD at <37 weeks were statistically significant. Concerning treatment with metronidazole, RR was 1.11 (95% CI 0.93-1.34) in low-risk pregnancies and 0.96 (95% CI 0.78-1.18) in high risk pregnancies. Concerning treatment with clindamycin at any gestational age, the RR was 0.87 (95% CI 0.73-1.05). CONCLUSION This systematic review gives a strong recommendation against treatment with metronidazole and a weak recommendation against treatment with clindamycin to reduce the sPTD rate in both high-risk and low-risk pregnancies with BV.
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Affiliation(s)
- Thor Haahr
- The Fertility Clinic, Skive Regional Hospital, Copenhagen, Denmark
| | - Anne S Ersbøll
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mona A Karlsen
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jens Svare
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark
| | - Kirstine Sneider
- Department of Obstetrics and Gynecology, Vendsyssel Hospital, Aalborg University, Aalborg, Denmark
| | - Lene Hee
- Department of Obstetrics and Gynecology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Louise K Weile
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | | | - Claus Østergaard
- Department of Clinical Microbiology, Vejle Hospital, Vejle, Denmark
| | | | - Rikke B Helmig
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark
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Achondou AE, Fumoloh FF, Aseneck AC, Awah AR, Utokoro AM. PREVALENCE OF BACTERIAL VAGINOSIS AMONG SEXUALLY ACTIVE WOMEN ATTENDING THE CDC CENTRAL CLINIC TIKO, SOUTH WEST REGION, CAMEROON. Afr J Infect Dis 2016; 10:96-101. [PMID: 28480443 PMCID: PMC5411994 DOI: 10.21010/ajid.v10i2.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Bacterial vaginosis (BV) is a polymicrobial, superficial vaginal infection involving a reduction in the amount of hydrogen peroxide-producing Lactobacillus and overgrowth of anaerobic bacteria. Common symptoms include increased fishy smelling vaginal discharge which is usually white or gray in color. Burning with urination may occur and itching is uncommon. Risk factors include douching, new or multiple sex partners, antibiotics, and use of intrauterine device among others. Materials and Methods: This cross-sectional study assessed the prevalence of bacterial vaginosis among sexually active women aged 15-45 years. Vaginal swabs were obtained with the use of sterile swab sticks which were later smeared on clean glass slides and then Gram stained. The stained smears were observed for bacterial morphotypes with the X100 oil immersion objective and the Nugent scoring system was used to determine BV. Data were analyzed using the Statistical Package for Social Scientists (SPSS) version 17.0 and were considered significant at p < 0.05. Results: A total of 100 women participated in the study with the overall prevalence of BV rated 38%. The prevalence of BV with respect to associated factors was also investigated and it was observed that BV was more prevalent in the age groups 20-25 (48.1%) and 25-29 (44.4%), those who had attained only primary education (60.5%), married women, (68.4%), pregnant women (71.0%), and women who practiced vaginal douching, (97.4%). However, no statistical significant difference was observed in the prevalence between these parameters (P > 0.05). Conclusions: Conclusively, the prevalence of bacterial vaginosis in our study population is 38% and highest among women aged between 25 and 34 years, pregnant women, married women, less educated women and women who practiced poor vaginal hygiene.
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Affiliation(s)
- Akomoneh Elvis Achondou
- School of Health and Human Services, Saint Monica University, Buea.,Laboratory for Emerging Infectious Diseases, University of Buea, Cameroon
| | - Foche Francis Fumoloh
- School of Health and Human Services, Saint Monica University, Buea.,Laboratory for Emerging Infectious Diseases, University of Buea, Cameroon
| | | | - Abong Ralph Awah
- School of Health and Human Services, Saint Monica University, Buea
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Lamont RF. Advances in the Prevention of Infection-Related Preterm Birth. Front Immunol 2015; 6:566. [PMID: 26635788 PMCID: PMC4644786 DOI: 10.3389/fimmu.2015.00566] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 10/23/2015] [Indexed: 11/17/2022] Open
Abstract
Infection-related preterm birth (PTB) is more common at early gestational ages and is associated with major neonatal mortality and morbidity. Abnormal genital tract microflora in early pregnancy predicts late miscarriage and early PTB. Accordingly, it is logical to consider antibiotics as an intervention. Unfortunately, the conclusions of systematic reviews and meta-analyses (SR&MAs) carried out in an attempt to explain the confusion over the heterogeneity of individual studies are flawed by the fact that undue reliance was placed on studies which: (a) had a suboptimal choice of antibiotic (mainly metronidazole) or used antibiotics not recommended for the treatment of bacterial vaginosis (BV) or BV-related organisms; (b) used antibiotics too late in pregnancy to influence outcome (23–27 weeks); and (c) included women whose risk of PTB was not due to abnormal genital tract colonization and hence unlikely to respond to antibiotics. These risks included: (a) previous PTB of indeterminate etiology; (b) low weight/body mass index; or (c) detection of fetal fibronectin, ureaplasmas, Group B streptococcus or Trichomonas vaginalis). While individual studies have found benefit of antibiotic intervention for the prevention of PTB, in meta-analyses these effects have been negated by large methodologically flawed studies with negative results. As a result, many clinicians think that any antibiotic given at any time in pregnancy to any woman at risk of PTB will cause more harm than good. Recently, a more focused SR&MA has demonstrated that antibiotics active against BV-related organisms, used in women whose risk of PTB is due to abnormal microflora, and used early in pregnancy before irreversible inflammatory damage has occurred, can reduce the rate of PTB. This review presents those data, the background and attempts to explain the confusion using new information from culture-independent molecular-based techniques. It also gives guidance on the structure of putative future antibiotic intervention studies.
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Affiliation(s)
- Ronald F Lamont
- Research Unit of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Institute of Clinical Research, Odense University Hospital, University of Southern Denmark , Odense , Denmark ; Division of Surgery, University College London , London , UK
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Hines M, Swinburn K, McIntyre S, Novak I, Badawi N. Infants at risk of cerebral palsy: a systematic review of outcomes used in Cochrane studies of pregnancy, childbirth and neonatology. J Matern Fetal Neonatal Med 2014; 28:1871-83. [PMID: 25283846 DOI: 10.3109/14767058.2014.972355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To systematically review meta-analyses (MAs) and randomised controlled trials (RCTs) of interventions for infants at risk of cerebral palsy (CP), to determine if consensus exists in study end-points. METHODS MAs within the "Neonatal" and "Pregnancy and Childbirth" Review Groups in Cochrane Database of Systematic Reviews (to June 2011) were included if they contained risk factors for CP as a study end-point, and were either published in 2010 or 2011 or cited >20 times in Sciverse Scopus. Up to 20 RCTs from each MA were included. Outcome measures, definitions and cut-points for ordinal groupings were extracted from MAs and RCTs and frequencies calculated. RESULTS Twenty-two MAs and 165 RCTs were appraised. High consistency existed in types of outcome domains listed as important in MAs. For 10/16 most frequently cited outcome domains, <50% of RCTs contributed data for meta-analyses. Low consistency in outcome definitions, measures, cut-points in RCTs and long-term follow-up prohibited data aggregation. CONCLUSIONS Variation in outcome measurement and long-term follow up has hampered the ability of RCTs to contribute data on important outcomes for CP, resulting in lost opportunities to measure the impact of maternal and neonatal interventions. There is an urgent need for and long-term follow up of these interventions and an agreed set of standardised and clinically relevant common data elements for study end-points.
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Affiliation(s)
- Monique Hines
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia
| | - Katherine Swinburn
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia
| | - Sarah McIntyre
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia
| | - Iona Novak
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia
| | - Nadia Badawi
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia .,c Discipline of Paediatrics & Child Health, Sydney Medical School, University of Sydney , Sydney , Australia , and.,d The Children's Hospital at Westmead, Grace Centre for Newborn Care , Westmead , Australia
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Joergensen JS, Kjær Weile LK, Lamont RF. The early use of appropriate prophylactic antibiotics in susceptible women for the prevention of preterm birth of infectious etiology. Expert Opin Pharmacother 2014; 15:2173-91. [DOI: 10.1517/14656566.2014.950225] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Donders GGG, Zodzika J, Rezeberga D. Treatment of bacterial vaginosis: what we have and what we miss. Expert Opin Pharmacother 2014; 15:645-57. [PMID: 24579850 DOI: 10.1517/14656566.2014.881800] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The disturbing, foul-smelling discharge of bacterial vaginosis (BV) is a nuisance to women. Treatment possibilities for BV are limited and only achieve complete cure in 65 to 85% of cases. In most women, the condition relapses within weeks to months after treatment. AREAS COVERED In search of new therapeutic actions to cure, prevent or delay recurrences of BV, PubMed and web of science were searched for papers with i) decent study layout, ii) proper statistics, iii) comparison group (placebo or standard treatment) and iv) language English, French, Dutch or German. The following keywords were used: bacterial vaginosis and treatment or management or therapy or prophylaxis or prevention. Results were grouped in treatment categories and were discussed. EXPERT OPINION Clindamycin and metronidazole are the standard drugs for BV. As other antibiotic and acidifying treatments are progressively being studied, like tinidazole, rifaximin, nitrofuran, dequalinium chloride, vitamin C and lactic acid, more options have become available for switching therapy, combining therapies and long-term prophylactic use to prevent recurrences. Further studies are needed. Also, adjuvant therapy with probiotics may have a significant role in improving efficacy and in preventing recurrences. However, it is unlikely that probiotics will replace antibiotherapy.
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Affiliation(s)
- Gilbert G G Donders
- Femicare, Clinical Research center for Women, Tienen and Departments of Obstetrics and Gynaecology , Tienen , Belgium
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Romero R, Miranda J, Chaiworapongsa T, Chaemsaithong P, Gotsch F, Dong Z, Ahmed AI, Yoon BH, Hassan SS, Kim CJ, Korzeniewski SJ, Yeo L. A novel molecular microbiologic technique for the rapid diagnosis of microbial invasion of the amniotic cavity and intra-amniotic infection in preterm labor with intact membranes. Am J Reprod Immunol 2014; 71:330-58. [PMID: 24417618 DOI: 10.1111/aji.12189] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 11/25/2013] [Indexed: 12/16/2022] Open
Abstract
PROBLEM The diagnosis of microbial invasion of the amniotic cavity (MIAC) has been traditionally performed using traditional cultivation techniques, which require growth of microorganisms in the laboratory. Shortcomings of culture methods include the time required (days) for identification of microorganisms, and that many microbes involved in the genesis of human diseases are difficult to culture. A novel technique combines broad-range real-time polymerase chain reaction with electrospray ionization time-of-flight mass spectrometry (PCR/ESI-MS) to identify and quantify genomic material from bacteria and viruses. METHOD OF STUDY AF samples obtained by transabdominal amniocentesis from 142 women with preterm labor and intact membranes (PTL) were analyzed using cultivation techniques (aerobic, anaerobic, and genital mycoplasmas) as well as PCR/ESI-MS. The prevalence and relative magnitude of intra-amniotic inflammation [AF interleukin 6 (IL-6) concentration ≥ 2.6 ng/mL], acute histologic chorioamnionitis, spontaneous preterm delivery, and perinatal mortality were examined. RESULTS (i) The prevalence of MIAC in patients with PTL was 7% using standard cultivation techniques and 12% using PCR/ESI-MS; (ii) seven of ten patients with positive AF culture also had positive PCR/ESI-MS [≥17 genome equivalents per PCR reaction well (GE/well)]; (iii) patients with positive PCR/ESI-MS (≥17 GE/well) and negative AF cultures had significantly higher rates of intra-amniotic inflammation and acute histologic chorioamnionitis, a shorter interval to delivery [median (interquartile range-IQR)], and offspring at higher risk of perinatal mortality, than women with both tests negative [90% (9/10) versus 32% (39/122) OR: 5.6; 95% CI: 1.4-22; (P < 0.001); 70% (7/10) versus 35% (39/112); (P = 0.04); 1 (IQR: <1-2) days versus 25 (IQR: 5-51) days; (P = 0.002), respectively]; (iv) there were no significant differences in these outcomes between patients with positive PCR/ESI-MS (≥17 GE/well) who had negative AF cultures and those with positive AF cultures; and (v) PCR/ESI-MS detected genomic material from viruses in two patients (1.4%). CONCLUSION (i) Rapid diagnosis of intra-amniotic infection is possible using PCR/ESI-MS; (ii) the combined use of biomarkers of inflammation and PCR/ESI-MS allows for the identification of specific bacteria and viruses in women with preterm labor and intra-amniotic infection; and (iii) this approach may allow for administration of timely and specific interventions to reduce morbidity attributed to infection-induced preterm birth.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA, and Detroit, MI, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
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Mendez-Figueroa H, Anderson B. Vaginal innate immunity: alteration during pregnancy and its impact on pregnancy outcomes. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.63] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Oliver RS, Lamont RF. Infection and antibiotics in the aetiology, prediction and prevention of preterm birth. J OBSTET GYNAECOL 2013; 33:768-75. [DOI: 10.3109/01443615.2013.842963] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
BACKGROUND Bacterial vaginosis is an imbalance of the normal vaginal flora with an overgrowth of anaerobic bacteria and a lack of the normal lactobacillary flora. Women may have symptoms of a characteristic vaginal discharge but are often asymptomatic. Bacterial vaginosis during pregnancy has been associated with poor perinatal outcomes and, in particular, preterm birth (PTB). Identification and treatment may reduce the risk of PTB and its consequences. OBJECTIVES To assess the effects of antibiotic treatment of bacterial vaginosis in pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2012), searched cited references from retrieved articles and reviewed abstracts, letters to the editor and editorials. SELECTION CRITERIA Randomised trials comparing antibiotic treatment with placebo or no treatment, or comparing two or more antibiotic regimens in pregnant women with bacterial vaginosis or intermediate vaginal flora whether symptomatic or asymptomatic and detected through screening. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS We included 21 trials of good quality, involving 7847 women diagnosed with bacterial vaginosis or intermediate vaginal flora.Antibiotic therapy was shown to be effective at eradicating bacterial vaginosis during pregnancy (average risk ratio (RR) 0.42; 95% confidence interval (CI) 0.31 to 0.56; 10 trials, 4403 women; random-effects, T² = 0.19, I² = 91%). Antibiotic treatment also reduced the risk of late miscarriage (RR 0.20; 95% CI 0.05 to 0.76; two trials, 1270 women, fixed-effect, I² = 0%).Treatment did not reduce the risk of PTB before 37 weeks (average RR 0.88; 95% CI 0.71 to 1.09; 13 trials, 6491 women; random-effects, T² = 0.06, I² = 48%), or the risk of preterm prelabour rupture of membranes (RR 0.74; 95% CI 0.30 to 1.84; two trials, 493 women). It did increase the risk of side-effects sufficient to stop or change treatment (RR 1.66; 95% CI 1.02 to 2.68; four trials, 2323 women, fixed-effect, I² = 0%).In this updated review, treatment before 20 weeks' gestation did not reduce the risk of PTB less than 37 weeks (average RR 0.85; 95% CI 0.62 to 1.17; five trials, 4088 women; random-effects, T² = 0.06, I² = 49%).In women with a previous PTB, treatment did not affect the risk of subsequent PTB (average RR 0.78; 95% CI 0.42 to 1.48; three trials, 421 women; random-effects, T² = 0.19, I² = 72%).In women with abnormal vaginal flora (intermediate flora or bacterial vaginosis), treatment may reduce the risk of PTB before 37 weeks (RR 0.53; 95% CI 0.34 to 0.84; two trials, 894 women).One small trial of 156 women compared metronidazole and clindamycin, both oral and vaginal, with no significant differences seen for any of the pre-specified primary outcomes. Statistically significant differences were seen for the outcomes of prolongation of gestational age (days) (mean difference (MD) 1.00; 95% CI 0.26 to 1.74) and birthweight (grams) (MD 75.18; 95% CI 25.37 to 124.99) however these represent relatively small differences in the clinical setting.Oral antibiotics versus vaginal antibiotics did not reduce the risk of PTB (RR 1.09; 95% CI 0.78 to 1.52; two trials, 264 women). Oral antibiotics had some advantage over vaginal antibiotics (whether metronidazole or clindamycin) with respect to admission to neonatal unit (RR 0.63; 95% CI 0.42 to 0.92, one trial, 156 women), prolongation of gestational age (days) (MD 9.00; 95% CI 8.20 to 9.80; one trial, 156 women) and birthweight (grams) (MD 342.13; 95% CI 293.04 to 391.22; one trial, 156 women).Different frequency of dosing of antibiotics was assessed in one small trial and showed no significant difference for any outcome assessed. AUTHORS' CONCLUSIONS Antibiotic treatment can eradicate bacterial vaginosis in pregnancy. The overall risk of PTB was not significantly reduced. This review provides little evidence that screening and treating all pregnant women with bacterial vaginosis will prevent PTB and its consequences. When screening criteria were broadened to include women with abnormal flora there was a 47% reduction in preterm birth, however this is limited to two included studies.
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Lamont RF, Taylor-Robinson D, Bassett P. Rescreening for abnormal vaginal flora in pregnancy and re-treating with clindamycin vaginal cream significantly increases cure and improvement rates. Int J STD AIDS 2012; 23:565-9. [PMID: 22930293 DOI: 10.1258/ijsa.2011.011229] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We investigated 199 pregnant women with bacterial vaginosis (BV) who received clindamycin vaginal cream (CVC) for three days and compared with 205 women treated with placebo. The vaginal flora was assessed at each visit. At the second visit, 71% in the CVC group were cured/improved, compared with 12% in the placebo group (P < 0.001). At visit 3 about 90% who responded to initial CVC treatment were still cured/improved. Of women who initially failed to respond to CVC and were given an additional seven-day course, 33% were cured/improved by the third visit, compared with 15% who failed to respond to placebo initially and were given a further seven-day course (P = 0.02). By visit 4, half the women in the CVC group who received additional treatment remained cured/improved, compared with 26% who had additional placebo (P = 0.004). In the CVC group, a change from abnormal to normal rose from 71% (visit 2) to 76% (visit 3) and 79% (visit 4). A similar trend was seen in women who received placebo but the proportions were significantly lower (12%, 24% and 33%, respectively). There is value in rescreening and re-treating women who remain BV-positive after initial clindamycin treatment.
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Affiliation(s)
- R F Lamont
- Department of Obstetrics and Gynaecology, University of Southern Denmark, University Hospital, Odense, Denmark.
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Abstract
OBJECTIVES To review the literature and develop evidence-based guidelines for the use of the antibiotic clindamycin. DATA SOURCES A search of the MEDLINE database for randomized clinical trials, cohort studies and review articles that examine the therapeutic use or potential adverse effects of clindamycin was undertaken for the years 1966 to 1996. In addition, relevant citations obtained from the references cited in the identified reviews, book chapters and antibiotic guidelines were included. DATA EXTRACTION Selected articles examining the indications for or adverse effects from the prophylactic or therapeutic use of clindamycin were selected. A level of evidence was assigned to the indication according to published criteria. DATA SYNTHESIS AND CONCLUSIONS Randomized clinical trials (level 1 evidence) support the use of clindamycin in a number of common conditions, including preoperative prophylaxis, intra-abdominal infections, recurrent group A streptococcal pharyngitis, Chlamydia trachomatis cervicitis and anaerobic lung infections. Cohort studies (level 2 evidence) support the use of clindamycin for bone and soft tissue infections. Expert opinion (level 3 evidence) supports the use of clindamycin for invasive group A streptococcal infection and the treatment of diabetic foot infections. Clindamycin's disadvantages are its high cost, the common occurrence of rash and the predisposition of patients taking clindamycin to Clostridium difficile-associated colitis. Based on cohort studies, the risk of severe diarrhea in out-patients is as low as one per 1000, but the risk of in-patients acquiring C difficile colonization may be as high as 30%.
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Sherrard J, Donders G, White D, Jensen JS. European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011. Int J STD AIDS 2012; 22:421-9. [PMID: 21795415 DOI: 10.1258/ijsa.2011.011012] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Three common infections are associated with vaginal discharge: bacterial vaginosis, trichomoniasis and candidiasis, of which trichomoniasis is a sexually transmitted infection (STI). This guideline covers the presentation and clinical findings of these infections and outlines the differential diagnoses. Recommendations for investigation and management based on currently available evidence are made, including the management of persistent and recurrent infections.
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Affiliation(s)
- J Sherrard
- Department of Genitourinary Medicine, Churchill Hospital, Oxford, UK.
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Lamont RF, Nhan-Chang CL, Sobel JD, Workowski K, Conde-Agudelo A, Romero R. Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol 2011; 205:177-90. [PMID: 22071048 PMCID: PMC3217181 DOI: 10.1016/j.ajog.2011.03.047] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 03/01/2011] [Accepted: 03/23/2011] [Indexed: 01/18/2023]
Abstract
The purpose of this study was to determine whether the administration of clindamycin to women with abnormal vaginal flora at <22 weeks of gestation reduces the risk of preterm birth and late miscarriage. We conducted a systematic review and metaanalysis of randomized controlled trials of the early administration of clindamycin to women with abnormal vaginal flora at <22 weeks of gestation. Five trials that comprised 2346 women were included. Clindamycin that was administered at <22 weeks of gestation was associated with a significantly reduced risk of preterm birth at <37 weeks of gestation and late miscarriage. There were no overall differences in the risk of preterm birth at <33 weeks of gestation, low birthweight, very low birthweight, admission to neonatal intensive care unit, stillbirth, peripartum infection, and adverse effects. Clindamycin in early pregnancy in women with abnormal vaginal flora reduces the risk of spontaneous preterm birth at <37 weeks of gestation and late miscarriage. There is evidence to justify further randomized controlled trials of clindamycin for the prevention of preterm birth. However, a deeper understanding of the vaginal microbiome, mucosal immunity, and the biology of BV will be needed to inform the design of such trials.
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Affiliation(s)
- Ronald F Lamont
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, MD, USA
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Anderson BL, Cu-Uvin S, Raker CA, Fitzsimmons C, Hillier SL. Subtle perturbations of genital microflora alter mucosal immunity among low-risk pregnant women. Acta Obstet Gynecol Scand 2011; 90:510-5. [PMID: 21306340 DOI: 10.1111/j.1600-0412.2011.01082.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Alteration in the vaginal flora has been associated with adverse pregnancy outcomes. The objective of this study was to examine the impact of changes in individual microflora on genital immunity among low-risk pregnant women in early pregnancy. DESIGN Cross-sectional study. SETTING Large, tertiary care, academic hospital clinic. POPULATION Low-risk women were enrolled prior to 14 weeks' gestation. METHODS Women were included if they had no medical or previous obstetrical complications, were non-smokers, had no sexually transmitted infections and no intercourse in the last 48 hours. Consenting women underwent speculum examination for collection of vaginal culture and Dacron swabs for cytokine analysis. Semi-quantitative vaginal cultures were performed in a reference laboratory. MAIN OUTCOME MEASURES Concentrations of immune mediators were compared in the presence of various organisms. Concentrations were converted to multiples of the median to standardize the values of each mediator. Regression analyses were performed to control for race. RESULTS We enrolled 47 women. The frequencies of genital microorganisms were: H(2)O(2) -producing lactobacilli (70%), Ureaplasma urealyticum (66%), Gardnerella vaginalis (45%), anaerobic non-pigmented Gram-negative rods (ANPGNR, 40%), anaerobic pigmented Gram-negative rods (APGNR, 17%). After adjusting for race and body mass index, interleukin-1β, interferon-γ, tumor necrosis factor-α and granulocyte macrophage-colony stimulating factor were increased in the presence of G. vaginalis, ANPGNR, and APGNR. There was no consistent impact on the other markers of immune activation. CONCLUSION The presence of individual species impacts genital immunity among low-risk pregnant women. Perturbations in genital immunity could partially explain heterogeneity in adverse pregnancy outcomes.
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Affiliation(s)
- Brenna L Anderson
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Sanu O, Lamont RF. Periodontal disease and bacterial vaginosis as genetic and environmental markers for the risk of spontaneous preterm labor and preterm birth. J Matern Fetal Neonatal Med 2011; 24:1476-85. [PMID: 21261445 DOI: 10.3109/14767058.2010.545930] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to review the evidence associating periodontal disease, and bacterial vaginosis with preterm birth, and the link with gene polymorphism, as well as the preventions and interventions which might reduce the risk of spontaneous preterm labor and preterm births in women with periodontal disease and/or bacterial vaginosis. BACKGROUND Preterm birth accounts for 70% of perinatal mortality, nearly 50% of long term neurological morbidity, and a significant impact on health care costs. There is evidence that spontaneous preterm labor and preterm birth are associated with intrauterine infection due to abnormal genital and/or oral colonization. Periodontal disease and bacterial vaginosis share microbiological similarities, and both conditions are associated with spontaneous preterm labor and preterm birth. In addition, periodontal disease and bacterial vaginosis have been linked through gene polymorphism. METHODS A review of the literature using widely accepted scientific search engines in English language. RESULTS Studies evaluating antibiotic administration to eradicate periodontal disease and/or bacterial vaginosis responsible organisms, and minimize the risk of preterm births have yielded conflicting results. With respect to bacterial vaginosis, the timing and the choice of antibiotic administration might partly explain the conflicting results. The use of scaling and/or root planning for women with periodontal disease appears to reduce the risk of preterm birth, but routine administration of antibiotics has not demonstrated any impact on preterm birth. CONCLUSION Prospective studies evaluating the association of gene polymorphism with preterm birth, and the contribution of periodontal disease and bacterial vaginosis are needed.
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Affiliation(s)
- Olaleye Sanu
- Department of Obstetrics & Gynaecology, St Mary's Imperial NHS Trust, London, UK
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Ryu KY, Hoh JK, Park MI. Preconception infection and genetic counseling. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2011. [DOI: 10.5124/jkma.2011.54.8.838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ki-Young Ryu
- Department of Obstetrics and Gynecology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea
| | - Jeong-Kyu Hoh
- Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Korea
| | - Moon-Il Park
- Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Korea
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Diagnosis and management of bacterial vaginosis and other types of abnormal vaginal bacterial flora: a review. Obstet Gynecol Surv 2010; 65:462-73. [PMID: 20723268 DOI: 10.1097/ogx.0b013e3181e09621] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
UNLABELLED Bacterial vaginosis (BV) is a common cause of abnormal vaginal discharge. It is characterised by an overgrowth of predominantly anaerobic organisms (Gardnerella vaginalis, Prevotella spp., Peptostreptocci, Mobiluncus spp.) in the vagina leading to a replacement of lactobacilli and an increase in vaginal pH. BV can arise and remit spontaneously, but often presents as a chronic or recurrent disease. BV is found most often in women of childbearing age, but may also be encountered in menopausal women, and is rather rare in children. The clinical and microscopic features and diagnosis of BV are herein reviewed, and antibiotic and non-antibiotic treatment approaches discussed. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this educational activity, the participant should be better able to analyze bacterial vaginosis clinically, formulate an oral antibiotic treatment regimen for bacterial vaginosis and use vaginal treatments for bacterial vaginosis.
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Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy Childbirth 2010; 10 Suppl 1:S1. [PMID: 20233382 PMCID: PMC2841772 DOI: 10.1186/1471-2393-10-s1-s1] [Citation(s) in RCA: 474] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION This is the first of seven articles from a preterm birth and stillbirth report. Presented here is an overview of the burden, an assessment of the quality of current estimates, review of trends, and recommendations to improve data. PRETERM BIRTH Few countries have reliable national preterm birth prevalence data. Globally, an estimated 13 million babies are born before 37 completed weeks of gestation annually. Rates are generally highest in low- and middle-income countries, and increasing in some middle- and high-income countries, particularly the Americas. Preterm birth is the leading direct cause of neonatal death (27%); more than one million preterm newborns die annually. Preterm birth is also the dominant risk factor for neonatal mortality, particularly for deaths due to infections. Long-term impairment is an increasing issue. STILLBIRTH Stillbirths are currently not included in Millennium Development Goal tracking and remain invisible in global policies. For international comparisons, stillbirths include late fetal deaths weighing more than 1000g or occurring after 28 weeks gestation. Only about 2% of all stillbirths are counted through vital registration and global estimates are based on household surveys or modelling. Two global estimation exercises reached a similar estimate of around three million annually; 99% occur in low- and middle-income countries. One million stillbirths occur during birth. Global stillbirth cause-of-death estimates are impeded by multiple, complex classification systems. RECOMMENDATIONS TO IMPROVE DATA (1) increase the capture and quality of pregnancy outcome data through household surveys, the main data source for countries with 75% of the global burden; (2) increase compliance with standard definitions of gestational age and stillbirth in routine data collection systems; (3) strengthen existing data collection mechanisms--especially vital registration and facility data--by instituting a standard death certificate for stillbirth and neonatal death linked to revised International Classification of Diseases coding; (4) validate a simple, standardized classification system for stillbirth cause-of-death; and (5) improve systems and tools to capture acute morbidity and long-term impairment outcomes following preterm birth. CONCLUSION Lack of adequate data hampers visibility, effective policies, and research. Immediate opportunities exist to improve data tracking and reduce the burden of preterm birth and stillbirth.
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Affiliation(s)
- Joy E Lawn
- Saving Newborn Lives/Save the Children, 11 South Way, Pinelands Cape Town, South Africa
| | - Michael G Gravett
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington USA
| | - Toni M Nunes
- Global Alliance to Prevent Prematurity and Stillbirth, an initiative of Seattle Children's, Seattle, Washington, USA
| | - Craig E Rubens
- Global Alliance to Prevent Prematurity and Stillbirth, an initiative of Seattle Children's, Seattle, Washington, USA
- Department of Pediatrics at University of Washington School of Medicine, Seattle, Washington, USA
| | - Cynthia Stanton
- Department of Population, Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Lang CT, Iams JD. Goals and strategies for prevention of preterm birth: an obstetric perspective. Pediatr Clin North Am 2009; 56:537-63, Table of Contents. [PMID: 19501691 DOI: 10.1016/j.pcl.2009.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Complications of prematurity surpass congenital malformations as the leading cause of infant mortality in the United States. Since 1990, there has been a steady rise in preterm birth, alarming health professionals from all disciplines. This review from a prenatal perspective confirms those concerns and describes the risks and opportunities that may attend efforts to improve the health of fetuses, newborns, and infants. Fetal and live-born outcomes are included.
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Affiliation(s)
- Christopher T Lang
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal medicine, The Ohio State University College of Medicine, Columbus, OH 43210, USA.
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Yudin MH, Money DM. Screening and management of bacterial vaginosis in pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008; 30:702-708. [PMID: 18786293 DOI: 10.1016/s1701-2163(16)32919-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review the evidence and provide recommendations on screening for and management of bacterial vaginosis in pregnancy. OPTIONS The clinical practice options considered in formulating the guideline. OUTCOMES Outcomes evaluated include antibiotic treatment efficacy and cure rates, and the influence of the treatment of bacterial vaginosis on the rates of adverse pregnancy outcomes such as preterm labour and delivery and preterm premature rupture of membranes. EVIDENCE Medline, EMBASE, CINAHL, and Cochrane databases were searched for articles, published in English before the end of June 2007 on the topic of bacterial vaginosis in pregnancy. VALUES The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Guideline implementation will assist the practitioner in developing an approach to the diagnosis and treatment of bacterial vaginosis in pregnant women. Patients will benefit from appropriate management of this condition. VALIDATION These guidelines have been prepared by the Infectious Diseases Committee of the SOGC, and approved by the Executive and Council of the SOGC. SPONSORS The Society of Obstetricians and Gynaecologists of Canada.
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The clinical content of preconception care: infectious diseases in preconception care. Am J Obstet Gynecol 2008; 199:S296-309. [PMID: 19081424 DOI: 10.1016/j.ajog.2008.08.062] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 08/29/2008] [Indexed: 11/20/2022]
Abstract
A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.
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Dépistage et prise en charge de la vaginose bactérienne pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008. [DOI: 10.1016/s1701-2163(16)32920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kazy Z, Puhó E, Czeizel E. [Antimicrobial therapy associated with preterm birth]. Orv Hetil 2008; 149:449-56. [PMID: 18304912 DOI: 10.1556/oh.2008.28186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED The effect of 51 antimicrobial drugs was evaluated for the reduction of preterm birth. STUDY DESIGN Newborn infants without birth defects were selected from the population-based large data set of the Hungarian Case-Control Surveillance of Congenital Abnormalities, 1980-1996, for the study. Medically recorded gestational age and the proportion of preterm birth were the primary outcomes of the study and newborn infants born to mothers with or without a given antimicrobial drug were compared. RESULTS The use of 51 antimicrobial drugs in the mothers of 38 151 newborn infants including at least ten pregnant women was evaluated. Only two: ampicillin and clotrimazole showed an obvious preterm birth preventive effect, mainly after the use during the first trimester of pregnancy. CONCLUSIONS Our findings suggest that ampicillin and particularly clotrimazole may be effective for the reduction of preterm birth associated with infectious diseases of pregnant women.
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Affiliation(s)
- Zoltán Kazy
- Semmelweis Egyetem, Altalános Orvostudományi Kar, II. Szülészeti és Nogyógyászati Klinika, Budapest.
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Simcox R, Sin WTA, Seed PT, Briley A, Shennan AH. Prophylactic antibiotics for the prevention of preterm birth in women at risk: a meta-analysis. Aust N Z J Obstet Gynaecol 2008; 47:368-77. [PMID: 17877593 DOI: 10.1111/j.1479-828x.2007.00759.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Preterm birth (PTB) is the major determinant of perinatal morbidity and mortality. Infection is implicated in a large proportion of preterm deliveries, but there is no consensus regarding the efficacy of antibiotic prophylaxis for women at risk. AIM To determine whether antibiotic treatment reduces the risk of preterm delivery in asymptomatic pregnant women at risk of PTB. METHOD Relevant publications were identified via electronic searches of MEDLINE (1966 to August 2005), The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 3, 2005) and PubMed using multiple search terms related to PTB and antibiotics. Publications were limited to randomised controlled trials comparing antibiotics with placebo given to asymptomatic non-labouring women. A random effect model was used, and combined risk ratios calculated for the various risk groups. Associations between treatment effect and the rate of PTB were analysed by meta-regression. RESULTS Seventeen trials were included, 12 identifying women at risk by abnormal vaginal flora, three on women at high risk from a previous PTB and two recruiting women based on positive fetal fibronectin status. There was no significant association between antibiotic treatment and reduction in PTB irrespective of criteria used to assess risk, the antimicrobial agent administered, or gestational age at time of treatment (overall combined random effect for delivery at less than 37 weeks RR 1.03 (95% CI 0.86-1.24)). CONCLUSIONS Treating women at risk of PTB with antibiotics does not reduce the risk of subsequent PTB.
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Affiliation(s)
- Rachael Simcox
- Maternal and Fetal Research Unit, Division of Reproduction and Endocrinology, King's College London School of Medicine at Guy's, King's College and St. Thomas' Hospitals, London, UK.
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Iams JD, Romero R, Culhane JF, Goldenberg RL. Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth. Lancet 2008; 371:164-75. [PMID: 18191687 DOI: 10.1016/s0140-6736(08)60108-7] [Citation(s) in RCA: 300] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.
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Affiliation(s)
- Jay D Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH, USA.
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Morency AM, Bujold E. The effect of second-trimester antibiotic therapy on the rate of preterm birth. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007; 29:35-44. [PMID: 17346476 DOI: 10.1016/s1701-2163(16)32350-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE As many as 50% of spontaneous preterm births are infection-related, with Mycoplasma species being the most common microbial isolates from the amniotic cavity. The goal of our study was to evaluate the effect of macrolides, a specific group of antibiotics known to be effective against Mycoplasma species, on the rate of preterm births. METHODS We performed a systematic review of the literature and a meta-analysis. We searched PubMed, Medline (1965-March 2006), Embase, and the Cochrane Library, using the key words "pregnancy," "macrolides," "erythromycin," "azithromycin," and "clarithromycin." The research was limited to randomized controlled trials and to human females. Studies included for analysis were of women in the second trimester of pregnancy who received either macrolides or placebo (or no treatment) in order to prevent preterm delivery with at least 95% of patient follow-up. We excluded studies involving women with preterm premature rupture of membranes or regular uterine contractions. Meta-analysis of the retrieved data was performed using RevMan 4.2.8 (Cochrane Collaboration) with dichotomous analyses and delivery prior to 37 weeks' gestation as the primary outcome. The analysis was subsequently repeated using the same methodology for clindamycin and metronidazole administered during the second trimester. RESULTS Of the 61 articles yielded by our search, three original papers, investigating a total of 1807 women, examined macrolide utilization and met our criteria. Women included in our analysis were all considered to be at higher risk for preterm delivery (vaginal fetal fibronectin positivity, urogenital Mycoplasma infection, prior preterm delivery, and/or pregestational maternal weight < 50 kg). Compared with placebo, macrolides were associated with a lower rate of preterm births (odds ratio [OR] 0.72; 95% confidence intervals [CI] 0.56-0.93), as was clindamycin (OR 0.68; 95% CI 0.49-0.95). On the other hand, metronidazole (OR 1.10; 95% CI 0.95-1.29) was not linked with significant changes in the rate of preterm births. A higher rate of preterm delivery was found when mid-trimester metronidazole was the only antibiotic administered (OR 1.31; 95% CI 1.08-1.58). CONCLUSION Macrolides and clindamycin, given during the second trimester of pregnancy, are associated with a lower rate of preterm delivery, whereas second-trimester metronidazole used alone is linked with a greater risk of preterm delivery in a high-risk population. Use of metronidazole, a common treatment for bacterial vaginosis and Trichomonas vaginalis, should be avoided during the second trimester of pregnancy in this population.
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Affiliation(s)
- Anne-Maude Morency
- Department of Microbiology, Université de Montréal, Montréal, Québec, Canada
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Pretorius C, Jagatt A, Lamont RF. The relationship between periodontal disease, bacterial vaginosis, and preterm birth. J Perinat Med 2007; 35:93-9. [PMID: 17343541 DOI: 10.1515/jpm.2007.039] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Spontaneous preterm labor leading to preterm birth is a major cause of perinatal mortality and morbidity worldwide. The etiology of spontaneous preterm labor is multifactoral but there is overwhelming evidence to implicate infection in up to 40% of cases. Historically, this infective link has focused on the associations between abnormal genital tract flora in pregnancy (diagnosed by the presence of bacterial vaginosis) and preterm birth. Recently, another condition related to abnormal flora (periodontal disease) has been linked with preterm birth. There are microbiological similarities between the oral cavity and the female genital tract giving rise to a possible common pathophysiology. This review records the interrelationship between periodontal disease, bacterial vaginosis, and preterm birth. We postulate on the mechanism linking the three conditions, particularly through microbiology and gene-environmental interactions. Periodontal disease and bacterial vaginosis may be risk factors in their own rights or may be interrelated. We speculate on whether periodontitisis a marker for an immune hyperresponse to abnormal flora which in the oral cavity results in periodontitis and in the case of bacterial vaginosis might result in preterm birth. We also postulate on the risk of preterm birth by periodontitis alone, bacterial vaginosis alone, or both.
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Affiliation(s)
- Christopher Pretorius
- Department of Obstetrics and Gynecology, Northwick Park and St. Marks Hospitals, Harrow, Middlesex, London, UK
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Role of antibiotic therapy for bacterial vaginosis and intermediate flora in pregnancy. Best Pract Res Clin Obstet Gynaecol 2007; 21:391-402. [PMID: 17512255 DOI: 10.1016/j.bpobgyn.2007.01.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bacterial vaginosis and intermediate flora are associated with late miscarriage and preterm delivery. The mechanisms involved are not yet fully understood. Clinical trials of antibiotic therapy to reduce these complications have yielded conflicting results. These trials, however, were conducted in mixed populations of pregnant women with variable risk profiles for preterm delivery. Furthermore, investigators used different criteria for diagnosis, treated with different antibiotics at different doses and via different routes, and initiated treatment at different gestational ages. Over 80% of pregnant women with abnormal vaginal flora have a good outcome, and in some populations the presence of bacterial vaginosis is not associated with preterm delivery, suggesting that other host factors may modify the risk. Recent studies have examined the roles of genetic regulation of host immune response, bacterial pathogenic factors, and enzymes in the vagina, and how these factors interact to drive a given outcome. These markers have the potential to better define the women at maximal risk and therefore guide future interventions. This chapter aims to appraise the current state of treatment of abnormal vaginal flora in pregnancy and suggest appropriate management based on the available evidence.
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Abstract
BACKGROUND Bacterial vaginosis is an imbalance of the normal vaginal flora with an overgrowth of anaerobic bacteria and a lack of the normal lactobacillary flora. Bacterial vaginosis during pregnancy has been associated with poor perinatal outcome and, in particular, preterm birth (PTB). Identification and treatment may reduce the risk of PTB and its consequences. OBJECTIVES To assess the effects of antibiotic treatment of bacterial vaginosis in pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2006). SELECTION CRITERIA Randomized trials comparing antibiotic treatment with placebo or no treatment, or comparing two or more antibiotic regimens in pregnant women with bacterial vaginosis or intermediate vaginal flora. DATA COLLECTION AND ANALYSIS Two review authors assessed trials and extracted data independently. We contacted study authors for additional information. MAIN RESULTS We included fifteen trials of good quality, involving 5888 women. Antibiotic therapy was effective at eradicating bacterial vaginosis during pregnancy (Peto odds ratio (OR) 0.17, 95% confidence interval (CI) 0.15 to 0.20; 10 trials, 4357 women). Treatment did not reduce the risk of PTB before 37 weeks (Peto OR 0.91, 95% CI 0.78 to 1.06; 15 trials, 5888 women), or the risk of preterm prelabour rupture of membranes (PPROM) (Peto OR 0.88, 95% CI 0.61 to 1.28; four trials, 2579 women). However, treatment before 20 weeks' gestation may reduce the risk of preterm birth less than 37 weeks (Peto OR 0.63, 95% CI 0.48 to 0.84; five trials, 2387 women). In women with a previous PTB, treatment did not affect the risk of subsequent PTB (Peto OR 0.83, 95% CI 0.59 to 1.17, five trials of 622); however, it may decrease the risk of PPROM (Peto OR 0.14, 95% CI 0.05 to 0.38) and low birthweight (Peto OR 0.31, 95% CI 0.13 to 0.75)(two trials, 114 women). In women with abnormal vaginal flora (intermediate flora or bacterial vaginosis) treatment may reduce the risk of PTB before 37 weeks (Peto OR 0.51, 95% CI 0.32 to 0.81; two trials, 894 women). Clindamycin did not reduce the risk of PTB before 37 weeks (Peto OR 0.80, 95% CI 0.60 to 1.05; six trials, 2406 women). AUTHORS' CONCLUSIONS Antibiotic treatment can eradicate bacterial vaginosis in pregnancy. This review provides little evidence that screening and treating all pregnant women with asymptomatic bacterial vaginosis will prevent PTB and its consequences. However, there is some suggestion that treatment before 20 weeks' gestation may reduce the risk of PTB. This needs to be further verified by future trials.
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Affiliation(s)
- H M McDonald
- Women's and Children's Hospital, Microbiology and Infectious Diseases, 72 King William Road, North Adelaide, South Australia, Australia, 5006.
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Abstract
Bacterial vaginosis (BV) is a common condition characterised by a polymicrobial disorder, with an overgrowth of several anaerobic or facultative bacteria and with a reduction or absence of lactobacillus colonisation. The prevalence of BV ranges from 4 to 64%, depending on the racial, geographic and clinical characteristics of the study population. In asymptomatic women, the prevalence varies from 12 to 25%, and similar percentages are observed in pregnant women. Although BV is associated with several adverse outcomes, such as upper genital tract infections, pelvic inflammatory disease, endometritis, preterm birth and low birthweight, many basic questions regarding the pathogenesis of BV remain unanswered. Mucosal immune system activation may represent a critical determinant of adverse consequences associated with BV. An unequal risk for BV acquisition and\or recurrence could derive from different mucosal immune host abilities and\or capability of invading microbes to produce factors that inactivate the local immune response. BV is associated with a two-fold increased risk of preterm birth, with the greatest risk when BV is present before 16 weeks of gestation (odds ratio = 7.55). This may indicate a critical period during early gestation when BV-related organisms can gain access to the upper genital tract and set the stage for spontaneous preterm labour later in gestation. The results of treatment trials for pregnant women with BV have been heterogeneous, with anywhere from an 80% reduction to a two-fold increase in preterm birth among women who received treatment. For this reason, in current clinical practice significant controversy surrounds determining not only who and when to screen but also who and how to treat. Recent evidence shows that individual genetic backgrounds can affect chemokine production. This is an interesting area for future research and could lead to trials of treatment only for women genetically predisposed to preterm birth.
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Affiliation(s)
- S Guaschino
- Department of Reproductive and Development Sciences, IRCCS Burlo Garofolo Hospital, University of Trieste, Trieste, Italy.
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Pararas MV, Skevaki CL, Kafetzis DA. Preterm birth due to maternal infection: causative pathogens and modes of prevention. Eur J Clin Microbiol Infect Dis 2006; 25:562-9. [PMID: 16953371 DOI: 10.1007/s10096-006-0190-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Preterm birth represents a major problem for modern obstetrics due to its increasing frequency and the accompanying socioeconomic impact. Although several maternal characteristics related to preterm birth have been identified, the etiology in most cases remains inadequately understood. Various microorganisms have been linked to the pathogenesis of preterm birth. Microbes may reach the amniotic cavity and fetus by ascending from the vagina and cervix, by hematogenous distribution through the placenta, by migration from the abdominal cavity through the fallopian tubes, or through invasive medical procedures. Organisms commonly cultured from the amniotic cavity following preterm delivery include Ureaplasma urealyticum, Mycoplasma hominis, Bacteroides spp., Gardnerella vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and group B hemolytic streptococci. Several trials have examined the effect of antibiotic administration to patients with preterm labor and intact membranes, preterm premature rupture of the membranes, genital mycoplasmal infection, asymptomatic bacteriuria, and bacterial vaginosis. The results of such studies, which were variable and often conflicting, are discussed here.
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Affiliation(s)
- M V Pararas
- Infectious Diseases Unit, P & A Kyriakou Children's Hospital, Second Department of Pediatrics, University of Athens, 115 27 Athens, Greece
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Guerra B, Ghi T, Quarta S, Morselli-Labate AM, Lazzarotto T, Pilu G, Rizzo N. Pregnancy outcome after early detection of bacterial vaginosis. Eur J Obstet Gynecol Reprod Biol 2006; 128:40-5. [PMID: 16460868 DOI: 10.1016/j.ejogrb.2005.12.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 10/11/2005] [Accepted: 12/30/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess if detecting bacterial vaginosis either in early pregnancy or at midtrimester may predict adverse pregnancy outcome in women at risk for preterm delivery. STUDY DESIGN 242 pregnant women with a previous preterm delivery were evaluated for bacterial vaginosis either in the first trimester (prior to 10+0 weeks) or in the second one (24-26 weeks). Adverse outcome was intended as miscarriage (< or =25 weeks), or premature delivery (< or =36+6). RESULTS The risk of adverse pregnancy outcome was significantly increased in women diagnosed at first trimester with bacterial vaginosis (OR: 4.56; 95% CI: 2.54-8.93); the same finding at midtrimester did not increase significantly the risk of preterm delivery. CONCLUSIONS Early screening for bacterial vaginosis in pregnant women who experienced a preterm delivery may help in predicting the risk of adverse outcome.
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Affiliation(s)
- Brunella Guerra
- Department of Obstetrics and Gynecology, Policlinico S.Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Italy
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Abstract
GOALS The goals of this research were 2-fold: (1) to determine whether a commercially available probiotic mixture (VSL-3) could survive and grow in a continuous culture system simulating the vaginal environment and (2) to determine whether the probiotic mixture was capable of suppressing the growth of a known vaginal vault pathogen, Gardnerella vaginalis. BACKGROUND An abnormal vaginal microflora, such as that associated with bacterial vaginosis (BV) is an important health issue for women. In addition, the association of this condition with preterm labor and delivery suggests that control of BV may impact the number of preterm births. Interventional trials with antibiotics have received mixed reviews and other interventional options, including the use of probiotics, are being considered. STUDY A well-documented continuous culture system has been used to determine whether VSL-3 can survive and grow in conditions simulating a vaginal environment. In addition, the ability of VSL-3 to inhibit the growth of a known vaginal vault pathogen, G. vaginalis, has been determined. RESULTS The probiotic mixture was shown to survive and maintain itself within the fermentation vessel of the continuous culture system over an extended period of time. This mixture, when challenged with a known pathogen, was also shown to suppress the growth of G. vaginalis. CONCLUSIONS It may be feasible to use probiotics as interventional therapy to suppress the growth of pathogens within the vaginal vault associated with BV.
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Affiliation(s)
- Andrew B Onderdonk
- Department of Pathology Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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