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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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Toboso Silgo L, Cruz-Melguizo S, de la Cruz Conty ML, Encinas Pardilla MB, Muñoz Algarra M, Nieto Jiménez Y, Arranz Friediger A, Martínez-Pérez Ó. Screening for Vaginal and Endocervical Infections in the First Trimester of Pregnancy? A Study That Ignites an Old Debate. Pathogens 2021; 10:pathogens10121610. [PMID: 34959565 PMCID: PMC8707201 DOI: 10.3390/pathogens10121610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/04/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: Vaginal and endocervical infections are considered a global health problem, especially after recent evidence of their association with preterm delivery and other adverse obstetric outcomes. Still, there is no consensus on the efficacy of a screening strategy for these infections in the first trimester of pregnancy. This study evaluated their prevalence and whether screening and treatment resulted as effective in reducing pregnancy and perinatal complications. Methods: A single-center prospective observational study was designed; a sample size of 400 first-trimester pregnant women was established and they were recruited between March 2016–October 2019 at the Puerta de Hierro University Hospital (Spain). They were screened for vaginal and endocervical infections and treated in case of abnormal flora. Pregnancy and delivery outcomes were compared between abnormal and normal flora groups by univariate analysis. Results: 109 patients had an abnormal flora result (27.2%). The most frequently detected infection was Ureaplasma urealyticum (12.3%), followed by Candida spp. (11.8%), bacterial vaginosis (5%), Mycoplasma hominis (1.2%) and Trichomonas vaginalis (0.8%). Patients with abnormal flora had a 5-fold increased risk of preterm premature rupture of membranes (5.3% vs. 1.1% of patients with normal flora, Odds Ratio 5.11, 95% Confidence Interval 1.20–21.71, p = 0.028). No significant differences were observed regarding preterm delivery or neonatal morbidity. Conclusions: Considering the morbimortality related to prematurity and that the results of our study suggest that the early treatment of abnormal flora could improve perinatal outcomes, the implementation of a screening program during the first trimester should be considered.
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Affiliation(s)
- Leonie Toboso Silgo
- Department of Obstetrics and Gynecology, University Hospital of Getafe, 28905 Madrid, Spain
- Correspondence:
| | - Sara Cruz-Melguizo
- Department of Obstetrics and Gynecology, Puerta de Hierro University Hospital of Majadahonda, 28222 Madrid, Spain; (S.C.-M.); (M.B.E.P.); (Y.N.J.); (A.A.F.); (Ó.M.-P.)
| | | | - María Begoña Encinas Pardilla
- Department of Obstetrics and Gynecology, Puerta de Hierro University Hospital of Majadahonda, 28222 Madrid, Spain; (S.C.-M.); (M.B.E.P.); (Y.N.J.); (A.A.F.); (Ó.M.-P.)
| | - María Muñoz Algarra
- Department of Microbiology, Puerta de Hierro University Hospital of Majadahonda, 28222 Madrid, Spain;
- Department of Obstetrics and Gynecology, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Yolanda Nieto Jiménez
- Department of Obstetrics and Gynecology, Puerta de Hierro University Hospital of Majadahonda, 28222 Madrid, Spain; (S.C.-M.); (M.B.E.P.); (Y.N.J.); (A.A.F.); (Ó.M.-P.)
| | - Alexandra Arranz Friediger
- Department of Obstetrics and Gynecology, Puerta de Hierro University Hospital of Majadahonda, 28222 Madrid, Spain; (S.C.-M.); (M.B.E.P.); (Y.N.J.); (A.A.F.); (Ó.M.-P.)
| | - Óscar Martínez-Pérez
- Department of Obstetrics and Gynecology, Puerta de Hierro University Hospital of Majadahonda, 28222 Madrid, Spain; (S.C.-M.); (M.B.E.P.); (Y.N.J.); (A.A.F.); (Ó.M.-P.)
- Department of Obstetrics and Gynecology, Universidad Autónoma de Madrid, 28029 Madrid, Spain
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Bayar E, Bennett PR, Chan D, Sykes L, MacIntyre DA. The pregnancy microbiome and preterm birth. Semin Immunopathol 2020; 42:487-499. [PMID: 32797272 PMCID: PMC7508933 DOI: 10.1007/s00281-020-00817-w] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022]
Abstract
Preterm birth is a global health concern and continues to contribute to substantial neonatal morbidity and mortality despite advances in obstetric and neonatal care. The underlying aetiology is multi-factorial and remains incompletely understood. In this review, the complex interplay between the vaginal microbiome in pregnancy and its association with preterm birth is discussed in depth. Advances in the study of bacteriology and an improved understanding of the human microbiome have seen an improved awareness of the vaginal microbiota in both health and in disease.
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Affiliation(s)
- Erna Bayar
- Imperial College Parturition Research Group, Institute for Reproductive and Developmental Biology, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Phillip R Bennett
- Imperial College Parturition Research Group, Institute for Reproductive and Developmental Biology, Imperial College London, Du Cane Road, London, W12 0HS, UK.
- March of Dimes European Preterm Birth Research Centre, Imperial College London, London, UK.
| | - Denise Chan
- Imperial College Parturition Research Group, Institute for Reproductive and Developmental Biology, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Lynne Sykes
- Imperial College Parturition Research Group, Institute for Reproductive and Developmental Biology, Imperial College London, Du Cane Road, London, W12 0HS, UK
- March of Dimes European Preterm Birth Research Centre, Imperial College London, London, UK
| | - David A MacIntyre
- Imperial College Parturition Research Group, Institute for Reproductive and Developmental Biology, Imperial College London, Du Cane Road, London, W12 0HS, UK
- March of Dimes European Preterm Birth Research Centre, Imperial College London, London, UK
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4
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Bagga R, Arora P. Genital Micro-Organisms in Pregnancy. Front Public Health 2020; 8:225. [PMID: 32612969 PMCID: PMC7308476 DOI: 10.3389/fpubh.2020.00225] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/14/2020] [Indexed: 01/12/2023] Open
Abstract
The microbiome of the female genital tract may undergo changes in pregnancy due to metabolic, endocrinological, and immunological alterations. These dysbiotic states may cause infections which may ascend upwards to the feto-placental unit or may be seeded hematogenously. These low grade and often low virulent infectious states lead to chronic inflammatory states and maybe associated with adverse maternal and neonatal outcome. Organisms have been isolated from amniotic fluid and placentae from women delivering pre-term; however the possibility of contamination cannot be conclusively ruled out. Common vaginal dysbiotic states often cause symptoms that are overlooked and often untreated. Vulvovaginal Candidiasis (VVC), Bacterial Vaginosis (BV), and Trichomonas Vaginitis (TV) are the commonly occurring dysbiotic states leading to vaginal infective states in pregnancy. With the advent of novel technologies like Next Generation sequencing (NGS), it will soon be possible to comprehensively map the vaginal microbiome and assess the interplay of each microbial state with their effects in pregnancy. This may open new avenues for antibiotic recommendations, probiotics and potential alternate therapies for dysbiotic states leading to pregnancy complications.
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Affiliation(s)
- Rashmi Bagga
- Department of Obstetrics & Gynaecology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Parul Arora
- Reproductive Medicine, Nova IVF Fertility, Ahmedabad, India
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5
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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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Lamont RF. Spontaneous preterm labour that leads to preterm birth: An update and personal reflection. Placenta 2019; 79:21-29. [PMID: 30981438 DOI: 10.1016/j.placenta.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective was to provide an update of progress made over time (including personal reflection) of our attempts to reduce the mortality and morbidity associated with spontaneous preterm labour that leads to preterm birth. METHODS An experienced and evidence based approach was taken to provide an overview of progress made over a generation (∼40 years) in our understanding of spontaneous preterm labour. RESULTS It is evident that we have made significant progress in our understanding of the aetiology, the measurement of the burden, the basic science, systems biology and mechanical pathways of the preterm parturition syndrome. We have better ways of predicting, preventing and managing spontaneous preterm labour than existed a generation ago. CONCLUSIONS The profile of spontaneous preterm labour that leads to preterm birth, thanks to organisations such as the March of Dimes, WHO and PREBIC is much more evident than before. However, while we have come a long way, we must not be complacent, and clinicians and basic scientists must continue to work in harmony, while recruiting and encouraging young investigators to join the effort to improve survival and handicap in what is one of the Great Obstetric Syndromes.
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Affiliation(s)
- Ronald F Lamont
- Department of Gynaecology and Obstetrics, University of Southern Denmark, Odense University Hospital, Odense, Denmark, and Division of Surgery, University College London, Northwick Park Institute for Medical Research Campus, London, UK.
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Milliken S, Allen RM, Lamont RF. The role of antimicrobial treatment during pregnancy on the neonatal gut microbiome and the development of atopy, asthma, allergy and obesity in childhood. Expert Opin Drug Saf 2019; 18:173-185. [PMID: 30739516 DOI: 10.1080/14740338.2019.1579795] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of antibiotics prenatally, during pregnancy, or neonatally may have adverse effects on the neonatal gut microbiome, and adversely affect the development of the infant immune system, leading to childhood atopy, asthma, allergy and obesity. AREAS COVERED Vaginal eubiosis and dysbiosis from molecular-based, cultivation-independent techniques, and how this affects the neonatal gut microbiome and early development of the immune system, the association between maternal antibiotics and the beneficial role of vitamin D in the development of atopy, asthma, allergy and obesity, efforts to reduce the use of antibiotics in pregnancy and therapeutic interventions such as vaginal 'seeding', probiotics, breastfeeding and neonatal dietary supplementation. EXPERT OPINION Currently available research gives insufficient attention to confounding variables. There remains uncertainty as to whether it is relevant that the mother suffered from the same condition as the purported infant outcome variable, for which she may have received antibiotics. In most studies, there is a lack of control for the number of antibiotic courses administered, the timing of use, the use of broad spectrum or narrow range antibiotics, the indication for antibiotics, the dose-dependent nature of the effect, the class of antibiotics used, or a varying degree of risk.
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Affiliation(s)
- Sarah Milliken
- a Department of Obstetrics and Gynaecology, Simpsons Centre for Reproductive Health , Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Ruridh M Allen
- b Department of Gastroenterology, Division of Medicine , Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Ronald F Lamont
- c Division of Surgery , University College London, Northwick Park Institute of Medical Research Campus , London , UK.,d Institute of Clinical Research , University of Southern Denmark , Odense , Denmark
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Lamont RF, Luef BM, Jørgensen JS. Re: Clindamycin to reduce preterm birth in a low resource setting: a randomised placebo-controlled clinical trial. BJOG 2018; 125:1632-1633. [PMID: 30302931 DOI: 10.1111/1471-0528.15439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Ronald F Lamont
- Research Unit of Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics, Institute of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark.,Division of Surgery, Northwick Park Institute of Medical Research Campus, University College London, London, UK
| | - Birgitte Møller Luef
- Division of Surgery, Northwick Park Institute of Medical Research Campus, University College London, London, UK
| | - Jan Stener Jørgensen
- Division of Surgery, Northwick Park Institute of Medical Research Campus, University College London, London, UK
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Sohn K, Underwood MA. Prenatal and postnatal administration of prebiotics and probiotics. Semin Fetal Neonatal Med 2017; 22:284-289. [PMID: 28720399 PMCID: PMC5618799 DOI: 10.1016/j.siny.2017.07.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Colonization of the neonatal gut by beneficial bacteria is important for the establishment and maintenance of the mucosal barrier, thus protecting the neonate from enteric pathogens and local and systemic inflammation. The neonatal microbiome is influenced by infant diet, environment, and the maternal microbiome. Dysbiosis in pregnancy increases the risk of pre-eclampsia, diabetes, infection, preterm labor, and later childhood atopy. Dysbiosis of the neonatal gut plays an important role in colic in the term infant, in the disease processes which plague preterm infants, including necrotizing enterocolitis and sepsis, and in the long-term outcomes of neonates. Administration of enteral prebiotics, probiotics, and synbiotics during pregnancy, lactation, and postnatal life appears to be a safe and feasible method to alter the maternal and neonatal microbiome, thus improving pregnancy and neonatal outcomes.
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Affiliation(s)
| | - Mark A. Underwood
- Corresponding author. Address: Department of Pediatrics, University of California Davis School of Medicine, 2516 Stockton Blvd, Suite 253, Sacramento, CA 95817, USA. Tel.: +1 916 734 8672; fax: +1 916 456 4490. (M.A. Underwood)
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Abstract
Preterm birth (PTB) remains a major obstetric healthcare problem and a significant contributor to perinatal morbidity, mortality, and long-term disability. Over the past few decades, the perinatal outcomes of preterm neonates have improved markedly through research and advances in neonatal care, whereas rates of spontaneous PTB have essentially remained static. However, research into causal pathways and new diagnostic and treatment modalities is now bearing fruit and translational initiatives are beginning to impact upon PTB rates. Successful PTB prevention requires a multifaceted approach, combining public health and educational programs, lifestyle modification, access to/optimisation of obstetric healthcare, effective prediction and diagnostic modalities, and the application of effective, targeted interventions. Progress has been made in some of these areas, although there remain areas of controversy and uncertainty. Attention is now being directed to areas where greater gains can be achieved. In this mini-review, we will briefly and selectively review a range of PTB prevention strategies and initiatives where progress has been made and where exciting opportunities await exploitation, evaluation, and implementation.
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Affiliation(s)
- Jeff A Keelan
- Division of Obstetrics & Gynaecology, School of Medicine, University of Western Australia King Edward Memorial Hospital, Perth, Australia
| | - John P Newnham
- Division of Obstetrics & Gynaecology, School of Medicine, University of Western Australia King Edward Memorial Hospital, Perth, Australia
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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. Appreciable uncertainty regarding benefits and risks in the treatment of bacterial vaginosis to prevent preterm birth. Acta Obstet Gynecol Scand 2017; 96:251-252. [DOI: 10.1111/aogs.13076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Thor Haahr
- The Fertility Clinic; Skive Regional Hospital; Skive Denmark
- Statens Serum Institute; 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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