Efficacy of an acidic vaginal gel on vaginal pH and interleukin-6 levels in low-risk pregnant women: a double-blind, randomized placebo-controlled trial

Antibiotics for treating bacterial vaginosis in pregnancy

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.

First trimester bacterial vaginosis, individual microorganism levels, and risk of second trimester pregnancy loss among urban women

OBJECTIVE

To examine the role of first trimester bacterial vaginosis (BV) and level of BV-associated microorganisms, diagnosed using the Nugent gram stain criteria and the risk of second trimester pregnancy loss among urban women.

DESIGN

Prospective cohort study.

SETTING

Urban prenatal care clinics.

PATIENT(S)

Women presenting for their first prenatal care visit who had completed 12 weeks gestation or less and resided within Philadelphia, Pennsylvania.

MAIN OUTCOME MEASURE(S)

Pregnancy loss.

RESULT(S)

Of 1948 women enrolled at a mean gestational age of 10 weeks (range 7.4 to 12.6 weeks), those with the highest level of BV-related vaginal flora alteration compared with women with normal vaginal flora had over a twofold increased risk of second trimester pregnancy loss after adjustment for confounders (adjusted hazard ratio [aHR] 2.49, 95% confidence interval [CI] 1.13 to 5.48). Low Lactobacillus spp. and the absence of Lactobacillus spp. were also significantly related to the risk of second trimester pregnancy loss (aHR 1.32, 95% CI 1.10-1.64; aHR 2.30, 95% CI 1.09-4.85; respectively).

CONCLUSION(S)

Overall BV positivity was not related to second trimester pregnancy loss. Comparing the highest to lowest tertile of BV positivity in early pregnancy conferred a two-fold increased risk of second trimester pregnancy loss and low amounts or the absence of Lactobacillus spp. in the first trimester also significantly increased the risk of second trimester pregnancy loss.

Antibiotics for treating bacterial vaginosis in pregnancy

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.

The effect of polycarbophil gel (Replens™) on bacterial vaginosis: A pilot study

OBJECTIVE

To determine if use of intravaginal polycarbophil gel (Replens) for 1 month will: (1) lower vaginal pH; (2) improve signs of bacterial vaginosis (BV).

STUDY DESIGN

Seventeen women with BV self-administered polycarbophil gel every third day for 4 weeks in an open-label, prospective pilot study. Primary outcome measures included vaginal pH, presence of amines and Nugent scores.

RESULTS

At week 4, there was improvement in Nugent scores, vaginal odor and clue cell count (p<0.05). Eleven women converted from amine positive to negative (73+/-20%). There was no significant change in vaginal pH.

CONCLUSIONS

Polycarbophil gel is associated with improved signs of BV, although not vaginal pH.

Gels as vaginal drug delivery systems

The vagina has been used as a mucosal drug delivery route for a long time. Its single characteristics can be either limitative or advantageous when drug delivery is considered. Gels are semi-solid, three-dimensional, polymeric matrices comprising small amounts of solid, dispersed in relatively large amounts of liquid, yet possessing more solid-like character. These systems have been used and are receiving a great deal of interest as vaginal drug delivery systems. Gels are versatile and have been used as delivery systems for microbicides, contraceptives, labour inducers, and other substances. Although somewhat neglected in clinical studies, pharmaceutical characterization of vaginal gels is an important step in order to optimize safety, efficacy and acceptability. Indeed, the simple formulation of a gel can lead to different performances of systems containing the same amount of active substances. Therefore, this paper discusses and summarizes current use and research of vaginal drug delivery systems based in gels.

Successful treatment of bacterial vaginosis with a policarbophil-carbopol acidic vaginal gel: results from a randomised double-blind, placebo-controlled trial

OBJECTIVE

We evaluated the efficacy of a mucoadhesive vaginal gel (MVG, Miphil) with acidic-buffering properties in bacterial vaginosis (BV).

STUDY DESIGN

Double-blind, placebo-controlled, 12-week trial.

SUBJECTS

A total of 45 non-pregnant women with BV were enrolled in the trial. Patients were treated with MVG 2.5 g or the corresponding placebo (P) daily for the first week and then every 3 days for the following 5 weeks (treatment phase) in a 2:1 ratio. All patients were followed for an additional 6 weeks without treatments (follow-up phase). Clinical cure was defined as absence of vaginal discharge, vaginal pH <4.5, a negative fish odour test and a Nugent score <7.

RESULTS

At week 6, 28 out of 30 women (93%) in the MVG group were clinically cured in comparison with only 1 out of 15 (6%) in the P group (P=0.0001). At week 12, 86% of MVG treated women remained cured in comparison with 8% in P group (P=0.0001). At baseline, the vaginal pH was 6.1+/-0.7 in the MVG and 5.5+/-0.7 in the P group. Vaginal pH significantly (P=0.003) decreased to 4.3+/-0.3 in the MVG group. In P group non-significant modifications of vaginal pH were observed (5.1+/-0.5).

CONCLUSION

Our results demonstrated that this MVG is an effective treatment of BV.