Gestational bleeding, bacterial vaginosis, and common reproductive tract infections: risk for preterm birth and benefit of treatment

Management of a pregnant woman with a large cervical polyp and moderate genital bleeding in the first trimester

Polypectomy during pregnancy is known to be a risk for spontaneous late miscarriage or preterm delivery. We managed a pregnant woman in her 30s with a large cervical polyp without polypectomy, and we administered probiotics including Clostridium butyricum and 17-alpha-hydroxyprogesterone caproate. As a result, she delivered a healthy baby at 38 weeks.

Vaginal bleeding and nausea in early pregnancy as predictors of clinical pregnancy loss

BACKGROUND

Although nausea and vaginal bleeding are commonly experienced in early pregnancy, their prognostic value in predicting clinical pregnancy loss is not well understood.

OBJECTIVE

This study aimed to understand whether timing of bleeding and nausea symptoms can be used to predict risk of pregnancy loss among women with ultrasound-confirmed pregnancies.

STUDY DESIGN

A cohort of 701 women with clinically confirmed pregnancies and 1 to 2 previous pregnancy losses were preconceptionally enrolled in the Effects of Aspirin in Gestation and Reproduction trial (2006-2012). Participants completed daily symptom diaries from 2 to 8 weeks' gestation and were prospectively monitored for detection of pregnancy loss. The risk of pregnancy loss was estimated for each observed bleeding and nausea pattern, and positive and negative predictive values for each pattern were calculated.

RESULTS

Among 701 women, 211 (30.1%) reported any vaginal bleeding, and 639 (91.2%) reported any nausea. Most bleeding experienced by women was spotting and contained within a single episode. Within 2 to <4, 4 to <6, and 6 to 8 weeks' gestation, vaginal bleeding occurred in 5.9% (41) (5.7% live birth, 7.1% clinical pregnancy loss), 14.6% (102) (13.9% live birth, 18.6% clinical pregnancy loss), and 20.8% (146) (18.4% live birth, 32.4% clinical pregnancy loss) of women, respectively. Within the same gestational periods, nausea was reported in 22.7% (159) (23.2% live birth, 20.4% clinical pregnancy loss), 65.9% (462) (67.5% live birth, 58.4% clinical pregnancy loss), and 87.0% (610) (90.6% live birth, 69.0% clinical pregnancy loss) of women. Women who had bleeding without nausea between 6 and 8 weeks' gestation (3.6% prevalance) had the greatest risk of clinical pregnancy loss (risk difference=56.1%; 95% confidence interval, 37.6-74.7), a positive predictive value of 68.0% (49.7%, 86.3%), negative predictive value of 85.8% (83.2%, 88.4%), positive likelihood ratio of 11.1 (2.04, 20.1), and negative likelihood ratio of 0.86 (0.79, 0.93). Nausea and bleeding are clinical factors that predicted clinical pregnancy loss (area under the curve, 0.87; 95% confidence interval, 0.81-0.88) similar to age, body mass index, blood pressure, and waist-to-hip ratio (area under the curve, 0.81; 95% confidence interval, 0.78-0.88) measured preconceptionally.

CONCLUSION

Women experiencing bleeding without nausea between 6 and 8 weeks' gestation had an increased risk of clinical pregnancy loss. Bleeding and nausea were not predictive risk factors of clinical pregnancy loss prior to 6 weeks' gestation.

A Bayesian Stepwise Discriminant Model for Predicting Risk Factors of Preterm Premature Rupture of Membranes: A Case-control Study

BACKGROUND

Preterm premature rupture of membrane (PPROM) can lead to serious consequences such as intrauterine infection, prolapse of the umbilical cord, and neonatal respiratory distress syndrome. Genital infection is a very important risk which closely related with PPROM. The preliminary study only made qualitative research on genital infection, but there was no deep and clear judgment about the effects of pathogenic bacteria. This study was to analyze the association of infections with PPROM in pregnant women in Shaanxi, China, and to establish Bayesian stepwise discriminant analysis to predict the incidence of PPROM.

METHODS

In training group, the 112 pregnant women with PPROM were enrolled in the case subgroup, and 108 normal pregnant women in the control subgroup using an unmatched case-control method. The sociodemographic characteristics of these participants were collected by face-to-face interviews. Vaginal excretions from each participant were sampled at 28-36+6 weeks of pregnancy using a sterile swab. DNA corresponding to Chlamydia trachomatis (CT), Ureaplasma urealyticum (UU), Candida albicans, group B streptococci (GBS), herpes simplex virus-1 (HSV-1), and HSV-2 were detected in each participant by real-time polymerase chain reaction. A model of Bayesian discriminant analysis was established and then verified by a multicenter validation group that included 500 participants in the case subgroup and 500 participants in the control subgroup from five different hospitals in the Shaanxi province, respectively.

RESULTS

The sociological characteristics were not significantly different between the case and control subgroups in both training and validation groups (all P > 0.05). In training group, the infection rates of UU (11.6% vs. 3.7%), CT (17.0% vs. 5.6%), and GBS (22.3% vs. 6.5%) showed statistically different between the case and control subgroups (all P < 0.05), log-transformed quantification of UU, CT, GBS, and HSV-2 showed statistically different between the case and control subgroups (P < 0.05). All etiological agents were introduced into the Bayesian stepwise discriminant model showed that UU, CT, and GBS infections were the main contributors to PPROM, with coefficients of 0.441, 3.347, and 4.126, respectively. The accuracy rates of the Bayesian stepwise discriminant analysis between the case and control subgroup were 84.1% and 86.8% in the training and validation groups, respectively.

CONCLUSIONS

This study established a Bayesian stepwise discriminant model to predict the incidence of PPROM. The UU, CT, and GBS infections were discriminant factors for PPROM according to a Bayesian stepwise discriminant analysis. This model could provide a new method for the early predicting of PPROM in pregnant women.

Genital infections and risk of premature rupture of membranes in Mulago Hospital, Uganda: a case control study

Background

Inflammatory mediators that weaken and cause membrane rupture are released during the course of genital infections among pregnant women. We set out to determine the association of common genital infections (Trichomonas vaginalis, syphilis, Neisseria gonorrhea, Chlamydia trachomatis, Group B Streptococcus, Bacterial vaginosis, Herpes Simplex Virus Type 2 and candidiasis) and premature rupture of membranes in Mulago hospital, Uganda.

Methods

We conducted an unmatched case–control study among women who were in the third trimester of pregnancy at New Mulago hospital, Uganda. The cases had PROM and the controls had intact membranes during latent phase of labour in the labour ward. We used interviewer-administered questionnaires to collect data on socio-demographic characteristics, obstetric and medical history. Laboratory tests were conducted to identify T. vaginalis, syphilis, N. gonorrhea, C. trachomatis, Group B Streptococcus, Bacterial vaginosis, Herpes Simplex Virus Type 2 (HSV-2) and candidiasis. Logistic regression models were used to estimate the odds ratios (OR) and 95 % CI of the association between genital infections and PROM.

Results

There was an association between PROM and abnormal vaginal discharge (OR = 2.02, 95 % CI 1.10–3.70 and AOR = 2.30, 95 % CI 1.18–4.47), presence of candidiasis (OR = 0.27, 95 % CI 0.14–0.52 and AOR = 0.22, 95 % CI 0.10–0.46) and T. vaginalis (OR = 2.98, 95 % CI 1.18–7.56 and AOR = 4.22, 95 % CI 1.51–11.80). However, there was no association between PROM and presence of C. trachomatis (OR = 2.05, 95 % CI 0.37–11.49) and HSV-2 serostatus (OR = 1.15, 95 % CI 0.63–2.09). Few or no patients with Bacterial vaginosis, Neisseria gonorrhoea, Group B streptococcus or syphilis were identified among the cases and controls. Co-infection of Trichomoniasis and candidiasis was not associated with PROM (AOR = 1.34, 95 % CI 0.16–11.10). Co infection with T. vaginalis and C. trachomatis was associated with PROM (OR = 3.09, 95 % CI 1.21–7.84 and AOR = 4.22, 95 % CI 1.51–11.83).

Conclusion

Trichomonas vaginalis alone, T. vaginalis with C. trachomatis co-infection and abnormal per vaginal discharge were found as risk factors for PROM. There was no association of HSV-2 serostatus, syphilis, N. gonorrhea, C. trachomatis, Group B Streptococcus and Bacterial vaginosis with PROM. Candidiasis seemed to have a protective effect on PROM.

'Anteroposterior placenta': a novel, simple sonographic feature indicating benign vaginal bleeding in early pregnancy

This study proposes a sonographic feature of the placenta in association with benign vaginal bleeding. A total of 286 normal singleton pregnancies were examined for 'anteroposterior, AP, placenta', which was reported when the placenta was attached to both anterior and posterior walls of the uterus in sagittal transabdominal ultrasound scans. Pregnancies were followed up by week 20. AP placenta, vaginal bleeding and spontaneous abortion were documented in 61 (21.3%), 44 (15.4%) and 2 (0.7%) pregnant women, respectively. AP placenta was significantly more common in the group with vaginal bleeding (54.5% vs 1.3%, p < 0.001, odds ratio = 6.65 with a 0.95 confidence interval of 3.34-13.24). Abortions occurred only in patients with vaginal bleeding and no AP placenta (10% vs 0%; p = 0.20). In a normal clinical pregnancy with no known risk of miscarriage, the presence of an AP placenta usually forecasts a benign vaginal bleeding/spotting in first 20 weeks of gestation.

The composition and stability of the vaginal microbiota of normal pregnant women is different from that of non-pregnant women

BACKGROUND

This study was undertaken to characterize the vaginal microbiota throughout normal human pregnancy using sequence-based techniques. We compared the vaginal microbial composition of non-pregnant patients with a group of pregnant women who delivered at term.

RESULTS

A retrospective case-control longitudinal study was designed and included non-pregnant women (n = 32) and pregnant women who delivered at term (38 to 42 weeks) without complications (n = 22). Serial samples of vaginal fluid were collected from both non-pregnant and pregnant patients. A 16S rRNA gene sequence-based survey was conducted using pyrosequencing to characterize the structure and stability of the vaginal microbiota. Linear mixed effects models and generalized estimating equations were used to identify the phylotypes whose relative abundance was different between the two study groups. The vaginal microbiota of normal pregnant women was different from that of non-pregnant women (higher abundance of Lactobacillus vaginalis, L. crispatus, L. gasseri and L. jensenii and lower abundance of 22 other phylotypes in pregnant women). Bacterial community state type (CST) IV-B or CST IV-A characterized by high relative abundance of species of genus Atopobium as well as the presence of Prevotella, Sneathia, Gardnerella, Ruminococcaceae, Parvimonas, Mobiluncus and other taxa previously shown to be associated with bacterial vaginosis were less frequent in normal pregnancy. The stability of the vaginal microbiota of pregnant women was higher than that of non-pregnant women; however, during normal pregnancy, bacterial communities shift almost exclusively from one CST dominated by Lactobacillus spp. to another CST dominated by Lactobacillus spp.

CONCLUSION

We report the first longitudinal study of the vaginal microbiota in normal pregnancy. Differences in the composition and stability of the microbial community between pregnant and non-pregnant women were observed. Lactobacillus spp. were the predominant members of the microbial community in normal pregnancy. These results can serve as the basis to study the relationship between the vaginal microbiome and adverse pregnancy outcomes.

First-trimester bleeding characteristics associate with increased risk of preterm birth: data from a prospective pregnancy cohort

BACKGROUND

Prior evidence linking first-trimester bleeding with preterm birth (PTB, <37 weeks gestation) risk has been inconsistent and may be biased by subject selection and/or incomplete documentation of bleeding episodes for all participants. Prior studies have not carefully examined the role of bleeding characteristics in PTB risk. In the present study, we estimate the association between first-trimester bleeding and PTB in a non-clinical prospective cohort and test whether bleeding characteristics better predict risk.

METHODS

Women were enrolled in Right from the Start (2000-2009), a prospective pregnancy cohort. Data about bleeding and bleeding characteristics were examined with logistic regression to assess association with PTB.

RESULTS

Among 3978 pregnancies 344 were PTB and 3634 term. Bleeding was reported by 986 (26%) participants. After screening candidate confounders, only multiple gestations remained in the model. Bleeding associated with PTB [odds ratio (OR)(adjusted) = 1.40, 95% confidence interval (CI) 1.09-1.80]. Risk did not vary by race/ethnicity. Compared with non-bleeders, PTB risk was higher for bleeding with red color (OR(adjusted) = 1.92, 95% CI, 1.32-2.82), for heavy episodes (OR(adjusted) = 2.40, 95% CI 1.18-4.88) and long duration (OR(adjusted) = 1.67, 95% CI 1.17-2.38).

CONCLUSIONS

Bleeding associated with PTB was not confounded by common risk factors for bleeding or PTB. PTB risk was greatest for women with heavy bleeding episodes with long duration and red color and would suggest that combining women with different bleeding characteristics may affect the accuracy of risk assessment. These data suggest a candidate etiologic pathway for PTB and warrant further investigation of the biologic mechanisms.

Vaginal bleeding in early pregnancy and preterm birth: systemic review and analysis of heterogeneity

OBJECTIVE

To systemically review published studies of vaginal bleeding and the risk of preterm birth (PTB) and explore sources of heterogeneity between them.

METHODS

The literature was searched for peer-reviewed articles from 1980 to 2009 in which the primary analysis was the risk of PTB among low-risk subjects with and without bleeding. Heterogeneity was assessed through I(2) statistics, and sources of heterogeneity were explored through subgroup analyses and meta-regression.

RESULTS

218 studies were initially identified, 64 reviewed and 23 included. The pooled Odds Ratio for PTB was 1.74, though significant heterogeneity was present (I(2)  =  49.7%). Meta-regression demonstrated a significant association between a study's incidence of bleeding and quality assessment and subsequent odds ratio, such that studies with a lower quality assessment or lower incidence of bleeding demonstrated an increased odds of PTB.

CONCLUSIONS

Bleeding in early pregnancy is associated with an increased risk of PTB; however, excessive heterogeneity exists among published studies. The heterogeneity arises in part from differences in the reported incidence of bleeding within study populations. Presumably studies that identify bleeding in a larger percentage of subjects consequently dilute the magnitude of the risk.

Interventions for trichomoniasis in pregnancy

BACKGROUND

Vaginitis due to Trichomonas vaginalis is one of the most common of sexually transmitted diseases. Trichomoniasis affects women during pregnancy as well but it is not clearly established whether it causes preterm birth and other pregnancy complications.

OBJECTIVES

The objective of this review was to assess the effects of various treatments for trichomoniasis during pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 January 2011).

SELECTION CRITERIA

Randomized trials comparing anti-trichomonas agents during pregnancy. Trials including symptomatic or asymptomatic women with trichomoniasis were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality.

MAIN RESULTS

We included two trials with 842 pregnant women. In both trials around 90% of women were cleared of trichomonas in the vagina after treatment. In the US trial, women with asymptomatic trichomoniasis between 16 and 23 weeks were treated with metronidazole on two occasions at least two weeks apart. The trial was stopped before reaching its target recruitment because metronidazole was not effective in reducing preterm birth and there was a likelihood of harm (risk ratio 1.78; 95% confidence interval 1.19 to 2.66). The South African trial recruited women later in pregnancy and did not have the design and power to address adverse clinical outcomes. We excluded two recent studies, identified for the current update, because they did not address the primary question.

AUTHORS' CONCLUSIONS

Metronidazole, given as a single dose, is likely to provide parasitological cure for trichomoniasis, but it is not known whether this treatment will have any effect on pregnancy outcomes. The cure rate could probably be higher if more partners used the treatment.

Patterns and predictors of vaginal bleeding in the first trimester of pregnancy

PURPOSE

Although first-trimester vaginal bleeding is an alarming symptom, few studies have investigated the prevalence and predictors of early bleeding. This study characterizes first trimester bleeding, setting aside bleeding that occurs at time of miscarriage.

METHODS

Participants (n = 4539) were women ages 18 to 45 enrolled in Right From the Start, a community-based pregnancy study (2000-2008). Bleeding information included timing, heaviness, duration, color, and associated pain. Life table analyses were used to describe gestational timing of bleeding. Factors associated with bleeding were investigated by the use of multiple logistic regression with multiple imputation for missing data.

RESULTS

Approximately one fourth of participants (n = 1207) reported bleeding (n = 1656 episodes), but only 8% of women with bleeding reported heavy bleeding. Of the spotting and light bleeding episodes (n = 1555), 28% were associated with pain. Among heavy episodes (n = 100), 54% were associated with pain. Most episodes lasted less than 3 days, and most occurred between gestational weeks 5 to 8. Twelve percent of women with bleeding and 13% of those without experienced miscarriage. Maternal characteristics associated with bleeding included fibroids and prior miscarriage.

CONCLUSIONS

Consistent with the hypothesis that bleeding is a marker for placental dysfunction, bleeding is most likely to be observed around the time of the luteal-placental shift.

Vaginal and oral microbes, host genotype and preterm birth

Preterm birth (PTB) is a leading cause of infant mortality and morbidity in the US and across the globe. Infection and associated inflammation are important initiators for PTB pathways; an estimated 40% of PTBs are attributed to amniochorionic-decidual or systemic inflammation. Historically, intrauterine infections have been implicated in PTB; recent evidence suggests that infections remote from the fetal site may also be causative. There is strong epidemiological evidence that bacterial vaginosis and periodontitis--two syndromes characterized by perturbations in the normal vaginal and oral bacterial microflora, respectively--are linked to infection-associated PTB. Oral and vaginal environments are similar in their bacterial microbiology; identical bacterial species have been independently isolated in periodontitis and bacterial vaginosis. Periodontitis and bacterial vaginosis also share many behavioral and sociodemographic risk factors suggesting a possible common pathophysiology. Genetic polymorphisms in host inflammatory responses to infection are shared between bacterial vaginosis, periodontitis and PTB, suggesting common mechanisms through which host genotype modify the effect of abnormal bacterial colonization on preterm birth. We review the state of knowledge regarding the risk of PTB attributable to perturbations in bacterial flora in oral and vaginal sites and the role of host genetics in modifying the risk of infection-related PTB. We posit that bacterial species that are common in perturbed vaginal and oral sites are associated with PTB through their interaction with the host immune system.

Autoprélèvement vaginal à la recherche d'une vaginose bactérienne pendant la grossesse : étude pilote

OBJECTIVE

To study the feasibility of a screening for bacterial vaginosis by a self-collected vaginal swab during pregnancy. To measure bacterial vaginosis prevalence in a non-representative sample of women.

PATIENTS AND METHODS

A self-collected swab was suggested to 398 women who consulted between 15 and 33 weeks of gestation in three different centres. Gram stain evaluation using Nugent criteria was used for the diagnosis of bacterial vaginosis.

RESULTS

Three hundred and forty-one women agreed to take part in the study (86%). The quality of the swabs was satisfactory in 93% of the cases. Concerning the 15 non-interpretable slides, the cellular and bacterial density was too poor, owing to a poor quality or a low vaginal flora. Thirty-one women (9%) had a bacterial vaginosis--Nugent score included between 7 and 10--and this frequency did not vary according to the centre. Thirty-five women (10%) had an intermediate flora--score between 4 and 6--and this result varied from 2 to 12% depending on the centre, but the difference was not significant.

DISCUSSION AND CONCLUSION

Self-collected swabs to detect bacterial vaginosis are well accepted by most of pregnant women, and the quality of the swabs seems to be satisfactory. In case vaginal flora is intermediate--between 4 and 6--the interpretation of the slides could be difficult.

Antibiotics for Bacterial Vaginosis or Trichomonas vaginalis in Pregnancy: A Systematic Review

OBJECTIVE

To determine whether antibiotic treatment for bacterial vaginosis or Trichomonas vaginalis during pregnancy decreases the risk of preterm birth and associated adverse outcomes.

DATA SOURCES

Pre-MEDLINE and MEDLINE (1966-2003), EMBASE (1980-2003), and the Cochrane Library were searched using the keywords "bacterial vaginosis", "Trichomonas", "Trichomonas vaginalis", "Trichomonas vaginitis", "Trichomonas infections", "pregnancy", "pregnant", "antibiotics", and "antibiotic prophylaxis".

METHODS OF STUDY SELECTION

The search produced 1,888 titles, of which 1,256 abstracts were reviewed further. Of these, 1,217 were ineligible. Inclusion criteria were the following: randomized controlled trials in which antibiotics were compared with no antibiotic or placebo, for women in the second or third trimester of pregnancy with symptomatic or asymptomatic bacterial vaginosis or Trichomonas vaginalis, intact membranes, and not in labor. Exclusion criteria were as follows: published in a language other than English, dropout rate of more than 20% of women in either group, and lack of usable outcomes. Of the 39 papers reviewed in detail, 14 studies were included in the meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

One of the authors reviewed titles obtained from the searches, and 2 reviewers independently reviewed the abstracts, excluded those that were ineligible, identified eligible papers, and abstracted the data. For women with bacterial vaginosis, antibiotics reduced the risk of persistent infection but did not reduce the risk of preterm birth or the incidence of associated adverse outcomes for the general population or for any subgroup analyzed. For women with Trichomonas vaginalis, metronidazole reduced the risk of persistent infection but increased the incidence of preterm birth.

CONCLUSION

Contrary to the conclusions of 3 recent systematic reviews, we found no evidence to support the use of antibiotic treatment for bacterial vaginosis or Trichomonas vaginalis in pregnancy to reduce the risk of preterm birth or its associated morbidities in low- or high-risk women.

Vaginal bleeding during pregnancy and preterm birth

This study investigated the relation between self-reported vaginal bleeding during pregnancy and preterm birth in a prospective cohort of 2,829 pregnant women enrolled from prenatal clinics between 1995 and 2000 in central North Carolina. The overall association between vaginal bleeding and preterm birth was modest (risk ratio (RR) = 1.3, 95% confidence interval (CI): 1.1, 1.6). Bleeding in the first trimester only was associated with earlier preterm birth (< or =34 weeks' gestation) (RR = 1.6, 95% CI: 1.1, 2.4) and preterm birth due to preterm premature rupture of the membranes (PPROM) (RR = 1.9, 95% CI: 1.1, 3.3). Bleeding in both trimesters was associated with preterm birth due to preterm labor (RR = 3.6, 95% CI: 1.9, 6.8). Bleeding of multiple episodes, on multiple days, and with more total blood loss was associated with an approximate twofold increased risk of earlier preterm birth, PPROM, and preterm labor. In contrast, bleeding in the second trimester only, of a single episode, on a single day, and with less total blood loss was not associated with any category of preterm birth. Vaginal bleeding was not associated with preterm birth among African Amercians (RR = 1.2, 95% CI: 0.9, 1.7). This study indicates that more intense but not less intense bleeding is associated with earlier preterm birth and spontaneous preterm birth presenting as PPROM or preterm labor, and it suggests that bleeding is less predictive of preterm birth among African-American compared with White women.

The effect of treating bacterial vaginosis on preterm labor

Objective: Multiple studies suggest that bacterial vaginosis (BV) causes preterm labor; yet its routine treatment remains controversial. In order to help to elucidate this controversy, we performed a thorough review of studies with levels of evidence ranging from I to II–II.

Methods: We searched for all of the studies from the years 1994 to 2001 via Medline’s database, including MD Consult and Ovid Mednet.

Results: Several trials discovered a decrease in the incidence of preterm labor when BV was treated, but most of those trials were performed on women with a history of preterm labor. However, the majority of trials reviewed advise against treatment of a general low-risk obstetric population, as there was no significant decrease in preterm labor.

Conclusions: Therefore, based on the above studies and the current guidelines of the Centers for Disease Control and Prevention (CDC), treating pregnant women in high-risk populations who are diagnosed with BV provides the clinician with an opportunity to possibly prevent preterm labor in this population. In nulliparous women without a history of preterm birth, treatment is recommended if other risk factors are present (e.g. gonorrhea or chlamydia). However, in the general low-risk populations, routine screening is not indicated.

Efficacy of the combination of 2 g oral tinidazole and acidic buffering vaginal gel in comparison with vaginal clindamycin alone in bacterial vaginosis: a randomized, investigator-blinded, controlled trial

OBJECTIVE

To evaluate the efficacy of tinidazole (T) (Trimonase, Mipharm, Italy) and an acidic vaginal gel (Miphil) (M) in comparison with vaginal clindamycin (CL) (Cleocin Pharmacia Upjohn) in BV.

DESIGN

A multicentre, randomised, investigator-blinded, controlled trial.

POPULATION AND METHODS

64 women with BV were enrolled. Thirty-two were allocated to receive oral T 2g, single dose, and 32 were assigned to CL 2% for 7 consecutive days. After week 1, T group were treated with an acidic vaginal gel, 2g every 3 days, for additional 3 weeks, whereas CL group did not received any additional treatment. Patients were evaluated at week 1 and 4. Vaginal pH, the BV-blue test (Gryphus Diagnostics, USA) and the whiff test were performed at baseline and at week 4.

MAIN OUTCOMES MEASURES

Clinical cure rate; normalisation of vaginal pH (pH<4.5); and laboratory cure rate (defined as a clinical cure rate and a negative results of BV-blue and whiff test).

RESULTS

At baseline, vaginal pH values were (mean+/-S.D.) 5.4+/-0.7 and 5.3+/-0.5 in T and CL groups, respectively. Six patients (2 in T group and 4 in CL group) withdrew from the study due to side effects. At week 1, the clinical cure rates were 84% in both T and CL treated group (P=N.S.). At week 4, clinical cure rates were 94% in T+M group and 77% in CL group (P=N.S.). The laboratory cure rates were 81% in T+M group and 59% in CL group (P<0.04). Vaginal pH normalisation (i.e. pH <4.5) was achieved in 78% and in 38% of T+M and CL groups, respectively (P<0.0007).

CONCLUSIONS

In the short term, 2g single oral dose tinidazole was at least as effective as 7-day of vaginal clindamycin. The sequential treatment of tinidazole and acidic vaginal gel was superior to vaginal clindamycin in lowering vaginal pH and achieving a higher laboratory tests normalization rate at 1-month follow-up.

Interventions for trichomoniasis in pregnancy

BACKGROUND

Vaginitis due to Trichomonas vaginalis is one of the most common of sexually transmitted diseases. Trichomoniasis affects women during pregnancy as well but it is not clearly established whether it causes preterm birth and other pregnancy complications.

OBJECTIVES

The objective of this review was to assess the effects of various treatments for trichomoniasis during pregnancy.

SEARCH STRATEGY

The Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: 22 December 1999.

SELECTION CRITERIA

Randomised trials comparing antitrichomonas agents during pregnancy.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality was assessed by one reviewer.

MAIN RESULTS

One study in which benzoylmetronidazole was compared to no treatment in low risk symptomatic and asymptomatic women was included. Of the treated women, 95% (97/102) and 93% (77/83) were free of infection on day seven and week four respectively. This equates to a relative risk of 0.11, and 95% confidence interval 0.05 to 0.24. About 75% of partners were reported to have taken the treatment.

REVIEWER'S CONCLUSIONS

Metronidazole, given as a single dose, is likely to provide parasitological cure for trichomonas, but it is not known whether this treatment will have any effect on pregnancy outcomes. The cure rate could probably be higher if more partners used the treatment.