Validation of the use of Pap-stained vaginal smears for diagnosis of bacterial vaginosis

Papanicolaou-stained cervicovaginal smears (Pap smears) are used to screen for cervical cancer. Since there is a lack of consensus in published reports respecting the efficacy of Pap-stained smears in BV diagnostics, there is a need to validate their use for diagnosis of BV. Slides from the international BV00 workshop were Pap stained and independently analyzed by four investigators under a phase-contrast microscope. All workshop slides--whether Pap-stained, Gram-stained or rehydrated air-dried smears--were scored according to the same Nugent classification. The diagnostic accuracy of Pap smears for diagnosis of BV had a sensitivity of 0.85 and a specificity of 0.92, with a positive and negative predictive value of 0.84 and 0.93, respectively. The interobserver weighted kappa index was 0.86 for Pap-stained smears compared to 0.81 for Gram-stained smears, and 0.70 for rehydrated air-dried smears using the mean Nugent score as the criterion standard. Provided that the samples are taken from equivalent locations (the vaginal fornix) and analyzed according to the same scoring criteria, there is no discernable difference in the diagnostic accuracy of the three smear-staining methods. The Pap-stained vaginal smears can be used as a wholly adequate alternative to Gram-stained smears for BV diagnosis.

A randomised double blind trial comparing misoprostol or placebo in the management of early miscarriage

OBJECTIVES

To study if misoprostol 400 microg, administered vaginally, increased the successful resolution of early miscarriage compared with placebo.

DESIGN

Randomised, double blind placebo controlled study.

SETTING

Sahlgrenska University Hospital, Göteborg, Sweden.

SAMPLE

One hundred and twenty-six women seeking medical attention for early miscarriage.

METHOD

Women with a non-viable, first trimester miscarriage were randomised to vaginal administration of misoprostol 400 microg or placebo.

MAIN OUTCOME MEASURES

Main outcome measure was the proportion of successful complete resolution of miscarriage. Secondary outcomes were incidence of infection, bleeding, gastrointestinal side effects, pain, use of analgesics and length of sick leave between groups.

RESULTS

Sixty-four patients were randomised to misoprostol and 62 to placebo. Eighty-one percent in the misoprostol and 52% in the placebo group had a complete miscarriage within one week of the primary visit (RR 1.57; 95% CI 1.20-2.06). Patients in the misoprostol group reported more pain as assessed on a visual analogue scale (60.4 [31.0] vs 43.8 [37.1] mm; P < 0.007) and required analgesics more often (83%vs 61%, RR 1.35; 95% CI 1.08-1.70). There were no significant differences in the occurrence of gastrointestinal side effects, infection, reduction in haemoglobin or sick leave between the groups.

CONCLUSIONS

Treatment with 400 mug misoprostol administered vaginally increased the success rate of resolvement of uncomplicated early miscarriages compared with placebo. However, women who received misoprostol experienced more pain and required more analgesics than those who did not.

Evaluation of regret after tubal sterilization

Many different criteria and profiles have been suggested for the possible cause of regret and requests for reversal after tubal sterilization. Evaluation of data obtained from 2253 women who had undergone tubal sterilization showed a strong correlation between regrets and youthful age and to changes in marital situation. Previously demonstrated risk factors, such as sterilization in connection with abortion or labor were not related to regret in this study material.

Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study

BACKGROUND

Bacterial vaginosis (BV) and intermediate flora is known risk-factor for postoperative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy.

AIM

To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion.

DESIGN

Prospective, double-blinded, placebo-controlled, multicenter study.

MATERIAL AND METHODS

Consecutive women attending for surgical termination prior to 11+4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables.

RESULTS

Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal flora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group.

CONCLUSION

Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora).

IL-1beta, IL-6, TNFalpha, fetal fibronectin, and endotoxin in the lower genital tract of pregnant women with bacterial vaginosis

BACKGROUND

In our studies on women with bacterial vaginosis (BV) in early pregnancy a strong association has been found between BV and the levels of endotoxin or interleukin-1alpha (IL-1alpha) in the lower genital tract. In the present study we investigated if an association could be found between BV and other cytokines (IL-1beta, IL-6, tumor necrosis factor alpha, TNF) or fetal fibronectin (FFN). The cytokine-inducing capacity of endotoxins present in the cervical mucus was explored in a monocytic cell assay.

METHODS

Cervical mucus or cervicovaginal fluid was collected from women with (BV) and without BV (nonBV) attending a family planning unit for first trimester abortion. The concentrations of IL-1beta, IL-6, TNF and FFN were determined by quantitative enzyme immunoassays. TNF was determined in 63 women (BV, n=25) out of whom 37 (BV, n=11) were analyzed for IL-1beta and the remaining 26 for IL-6 (BV, n=14). FFN was determined in another 36 women (BV, n= 19). The cytokine-inducing capacity of endotoxin-containing cervical mucus and purified endotoxin of Prevotella bivia were studied by an in vitro cell assay using a human monocytic cell line (THP-1).

RESULTS

IL-lbeta and IL-6 were found in almost all women. The levels of IL-1beta, but not IL-6, TNF or FFN, were significantly increased in women with BV compared with the nonBV women (p<0.05). Purified endotoxin from P. bivia, and cervical mucus from BV women containing high levels of endotoxin were able to induce a cytokine response (IL-6) in monocytic cells in vitro.

CONCLUSION

BV is associated with increased levels of IL-1beta in the lower genital tract of pregnant women in the first trimester. The ability of BV-associated endotoxins to induce cytokine production in monocytic cells may partly explain the increased IL-1beta levels.

Interleukin-1alpha, interleukin-6 and interleukin-8 in cervico/vaginal secretion for screening of preterm birth in twin gestation

BACKGROUND

The purpose was to determine the prognostic value of interleukin (IL) 1-alpha, IL-6 and IL-8 in cervico/vaginal secretion for preterm birth (<37 weeks of gestation) in twin pregnancies.

METHODS

The study included screening of 121 women with twin pregnancies with sampling at 24, 26, 28, 30, 32 and 34 weeks of gestation. IL-1alpha, IL-6 and IL-8 was analyzed with ELISA immunoassays. The detection limit was 30 pg/mL for IL-1 and IL-8 and 40 pg/mL for IL-6. Vaginal fluid was smeared and dried for later evaluation of bacterial vaginosis (presence of clue cells).

RESULTS

Spontaneous preterm birth occurred in 36 women and 65 women were delivered at term. IL-8 was significantly higher (p=0.03) in samples from women delivered preterm (median 3.72 ng/g mucus, range <0.07-220.00) compared with samples from women delivered at term (median 3.03 ng/g mucus, range <0.08-378.60). At 28 weeks of gestation, IL-8 (cut off 1.75 ng/g mucus) was associated with preterm delivery (relative risk 2.2, CI 95% 1.1-4.5) with a sensitivity, specificity, positive and negative predictive value of 78.8, 45.8, 44.8 and 79.4%, respectively. The levels of IL-1alpha and IL-6 were not significantly associated with preterm birth. Bacterial vaginosis was found in 47/541 (8.7%) samples analyzed. The levels of IL-1alpha and IL-8 were significantly higher in samples positive for bacterial vaginosis than in negative samples (p<0.0001 and p<0.01, respectively). There was no significant association between the level of IL-6 and bacterial vaginosis.

CONCLUSIONS

IL-8, but not IL-1alpha and IL-6, was associated with preterm delivery but the relationship was too weak to be of predictive value for preterm birth in twin pregnancies. IL-1alpha and IL-8, but not IL-6, were associated with bacterial vaginosis.

Unsuccessful treatment of missed abortion with a combination of an antiprogesterone and a prostaglandin E1 analogue

In a prospective clinical trial the effectiveness of a combination of 400 mg of mifepristone (antiprogesterone) and 400 g misoprostol (synthetic prostaglandin E1 analogue), both taken orally, was evaluated for the treatment of missed abortion. Of the 31 patients included, 16 (52%) had an empty uterine cavity at follow up six days after inclusion, 11 (35%) required surgical evacuation for retained intrauterine products of conception found at follow up, and four (13%) required emergency surgical evacuation due to severe pain or bleeding. The results do not support the use of mifepristone and misoprostol for women wishing the miscarriage to be resolved quickly.

Prostaglandin E and F2 alpha concentration in the cervical mucus and mechanism of cervical ripening

OBJECTIVE

To study the mechanism of cervical ripening by determination of prostaglandin E (PGE) and F2 alpha (PGF2 alpha) concentrations in cervical mucus during the course of pregnancy.

STUDY DESIGN

Cervical mucus was collected from 99 pregnant women attending the mother care unit of the department. Women with sexual intercourse within the last 24 hours before sampling and subjects with bacterial vaginosis were analysed separately.

RESULTS

Eleven women had sexual intercourse within 24 hours before sampling. The concentration of PGE in their cervical mucus was high corresponding to 2000-4000 pg/mg w w lasting for a period of 10-12 hours postcoitally, whereas the levels of PGF 2 alpha only increased slightly. Bacterial vaginosis was accomplished by a slight but significant elevation of PGF2 alpha levels but only of a minor increment of the PGE values. The prostaglandin concentrations in the mucus from the remaining 68 women were for PGE 102.75 +/- 111.51 and for PGF2 alpha 97.54 +/- 82.48 pg/mg w w (mean +/- SD). Although the values were scattered the concentrations remained at approximately the same level throughout pregnancy and there was no tendency towards an increment during the last weeks of pregnancy when cervical maturation is apparent.

CONCLUSION

Cervical softening seems not to be accomplished by a massive local release of prostaglandins but rather the result of a number of different mechanisms more or less influenced by minor alterations of prostaglandin synthesis and release. Involved in these mechanisms are probably neutrophil-derived collagenases.

Infections after hysterectomy. A prospective nation-wide Swedish study. The Study Group on Infectious Diseases in Obstetrics and Gynecology within the Swedish Society of Obstetrics and Gynecology

BACKGROUND

An increased use of prophylactic antibiotics to avoid postoperative infections in women undergoing hysterectomy has been observed in Sweden. This investigation was performed a) to study the infection rate to enable future evaluation of the effect of prophylactic antibiotic regimens and b) to identify subgroups suitable for intervention.

METHOD

A prospective study comprising all women undergoing pelvic surgery with hysterectomy during a two month period at forty-two Departments of Obstetrics and Gynecology in Sweden. Relevant information regarding the surgical procedure and the postoperative course was included in a standardized form at discharge from hospital and at a follow-up visit 4 to 6 weeks after surgery.

RESULTS

Of the 1060 women included in the study, 23% developed postoperative infections: 9.4% had wound-, cuff-, and/or deep infections, 13% urinary tract infections, and 4% other infections unrelated to the surgical site. Only half of the wound/cuff-/deep infections were diagnosed before discharge from the hospital. Wertheim-Meigs procedures, bleedings per-operatively exceeding 1000 ml, and presence of bacterial vaginosis (BV) were associated with an increased risk of postoperative infections. Among women undergoing abdominal hysterectomy for benign reasons, (n = 159), wound-cuff/deep infection was significantly associated with preoperative BV, i.e. 7 of 28 (25%) vs. 11 of 131 (8%), respectively (relative risk = 3.0, p = 0.01). Infection was associated with prolonged postoperative hospital stay. Antibiotics were given pre- or postoperatively to 236 (22%) of the 1060 women. Reduction in the postoperative infection rate was seen among women undergoing vaginal hysterectomy who were given pre- or postoperative antibiotics.

CONCLUSION

The postoperative infection rate after hysterectomy was clinically significant in this population. Wertheim-Meigs procedures, peroperative bleeding > 1000 ml and BV were identified as risk factors for postoperative infections after hysterectomy.

Is misoprostol the drug of choice for induced cervical ripening in early pregnancy termination?

BACKGROUND

To study the effectiveness of three different cervical ripening agents in terms of dilatation ability and patient discomfort in connection with legal first trimester abortion.

METHODS

Three randomized trials among unselected nulliparous women were performed 1: hygroscopic tent versus gemeprost, 2: misoprostol versus gemeprost and 3: misoprostol administered orally 17 versus 10 hours before vacuum curettage was performed.

MAIN OUTCOMES

Dilatation ability, frequent gastrointestinal side effects, severe pain (patients' perception).

RESULTS

In Trial 1, there was a tendency of a greater dilatation ability using the hygroscopic tent, while the experience of pain was a greater problem with gemeprost. In Trials 2 and 3, there were no significant differences in the dilatation abilities or gastrointestinal patient discomfort. There was a tendency towards a higher demand for narcotic analgesics in patients treated with gemeprost compared with all other groups.

CONCLUSIONS

Gemeprost and misoprostol showed almost identical ability to dilate and caused patient-experienced discomfort to the same degree. The use of misoprostol may be preferred as it has the advantage of being both less expensive and easier to administer.

Inflammatory signs in wet smear and Pap-smear compared with the histopathology from the female lower genital tract

In order to define the relationship between various criteria of female lower genital tract inflammation, we examined wet smears, cervical smears and biopsies from 131 patients. The presence of clue cells in rehydrated dry smears showed a positive correlation to the presence of clue cells in Papanicolaou stained smears, and to some extent with cytological evidence of inflammation (Kappa 0.48). Cytological inflammatory findings correlated well with the presence of clue cells in rehydrated dry smears, but signs of inflammation diagnosed by histopathology did not correspond to findings in cytological smears, probably because these methods reveal inflammation at different sites.

Dilapan tent-gemeprost regimen vs. combinations of extra-amniotic Rivanol-Laminaria/Lamicel and oxytocin for second trimester abortion

OBJECTIVE

To compare a new regimen for second trimester abortion using Dilapan and vaginal gemeprost suppositories with extra-amniotic Rivanol instillation and oxytocin i.v. immediately or 16 h after instillation.

METHODS

A prospective study was performed in 153 women to analyze the induction-abortion interval, the use of analgesics and the complication rate. Wilcoxon's rank sum test was used for statistical evaluation.

RESULTS

The mean induction-abortion interval was significantly shorter in the Dilapan-gemeprost-treated women than in the immediate or 16-h Rivanol-oxytocin-treated women, 12.5 vs. 23.3 and 26.8 h, respectively. The 24-h cumulative abortion rate was 91% in the former group vs. 49% and 61%, respectively. The use of analgesics was less frequent among the Dilapan-gemeprost-treated women, whereas the complication rate did not differ.

CONCLUSIONS

The Dilapan-gemeprost treatment was advantageous with respect to a shorter induction-abortion interval and ease of handling. However a minority of women do not respond to this treatment and it is therefore necessary to employ alternative methods to complete the abortion in these cases.

Detection of bacterial vaginosis in wet mount, Papanicolaou stained vaginal smears and in gram stained smears

In a prospective study of 107 women, bacterial vaginosis was clinically diagnosed in 34 women. Compared with clinical diagnosis of bacterial vaginosis, detection of clue cells in Papanicolaou stained vaginal smears showed a sensitivity of 88.2%, a specificity of 98.6%, a positive predictive value of 96.8% and a negative predictive value of 94.7%. The corresponding values for detection of bacterial vaginosis in Gram stained smears compared with the clinical diagnosis were 100%, 97.3%, 94.4% and 100%, respectively. Compared with clue cells in wet smears, identification of clue cells in Papanicolaou stained vaginal smears showed a Kappa index of 0.87 and compared with Gram stain criteria a Kappa index of 0.94. The correlation between Gram stain and Papanicolaou stained vaginal smears showed a Kappa index of 0.89. In contrast to the results of earlier investigators our studies indicate that the demonstration of clue cells in Papanicolaou stained vaginal smears correlate reasonably well with the conventional clinical criteria. However, the Gram stain method may be more reliable than the Papanicolaou method.

Expanded gold standard in the diagnosis of Chlamydia trachomatis in a low prevalence population: diagnostic efficacy of tissue culture, direct immunofluorescence, enzyme immunoassay, PCR and serology

OBJECTIVE

To evaluate the diagnostic efficacy of chlamydia culture, direct immunofluorescence (DFA), direct enzyme immunoassay (EIA), polymerase chain reaction (PCR) and serology by defining positive culture or at least two positive non-culture tests as true positive.

SETTING

Three gynaecological departments located in separate areas of Sweden.

PATIENTS AND DESIGN

All pregnant women requesting abortion during a six month period were included. In cases with unconfirmed non-culture tests, reculture with multiple passage and PCR on the culture transport medium was performed for confirmation. Serum was analysed for chlamydial antibodies type IgG, IgM and IgA using microimmunofluorescence.

RESULTS

18 of 419 (4.3%) patients were positive for chlamydia according to the defined criteria. Twelve of 419 (2.9%) were positive in standard culture (primary inoculation). The sensitivity of standard culture, DFA, EIA and PCR were 66.7%, 77.8%, 64.7% and 71.4% respectively. The specificity 100% (by definition), 99.5%, 100%, 100% respectively. The positive predictive value 100% (by definition), 87.5%, 100%, 100% respectively. Negative predictive value 98.5%, 99.0%, 98.5%, 98.9% respectively. Serum IgG titre of > or = 64 and > or = 1024 gave positive predictive values of 10% and 21% respectively.

CONCLUSIONS

When an expanded gold standard is used, the specificity and positive predictive value of the non-culture tests used are comparable with that of standard culture even in this low prevalence population. Standard culture underestimated the chlamydia prevalence by 33%. The prevalence found represents a decrease from 10 to 2.9% of culture verified chlamydia during four years in comparable populations. Chlamydial antibodies of certain immunological classes are not necessarily present in cases with chlamydia.

Bacterial vaginosis and cervical intraepithelial neoplasia

METHODS

In an attempt to investigate an association between the finding of clue cells in Papanicolaou-stained (PAP) smears and cervical intraepithelial neoplasia (CIN), a total of 6150 smears from 1976 were re-investigated.

RESULTS

Clue cells representing bacterial vaginosis were present in 10% of the PAP-smears. CIN II and III alone, as well as all CIN cases, were more common in women with bacterial vaginosis (p < 0.001). Histologically CIN III/carcinoma in situ was found in nine patients with and in 16 patients without bacterial vaginosis. The relative risk of having CIN III/carcinoma in situ if the women had bacterial vaginosis was 5.0 with 95% confidence interval of 2.2-11.6.

CONCLUSIONS

The possibility exists that bacterial vaginosis is in some way associated with the development of cervical intraepithelial neoplasia, i.e. as a cofactor to human papilloma virus. Therefore, bacterial vaginosis must be taken in consideration in future studies on CIN.

Endotoxin and interleukin-1 alpha in the cervical mucus and vaginal fluid of pregnant women with bacterial vaginosis

OBJECTIVE

The purpose of our study was to determine the concentrations of endotoxin and interleukin-1 alpha in the cervical mucus and vaginal fluid of pregnant women who either did or did not have bacterial vaginosis.

STUDY DESIGN

Samples of cervical mucus and vaginal fluid were collected from women in early pregnancy who had signs of bacterial vaginosis and from healthy control subjects. The samples were analyzed for the concentrations of endotoxin and interleukin-1 alpha. In addition, wet mounts were examined for signs of inflammation indicated by increased numbers of leukocytes.

RESULTS

Both endotoxin and interleukin-1 alpha occurred in much higher concentrations (p < 0.0001, p < 0.0002) in both the cervical mucus and the vaginal fluid of women with signs of bacterial vaginosis than they did in healthy control subjects. A correlation was found between the interleukin-1 alpha concentrations in the vaginal fluid and the number of leukocytes as judged by a semi-quantitative evaluation of wet mounts (p = 0.0365). The concentrations of endotoxin correlated with those of interleukin-1 alpha in both fluids (vaginal fluid, p < 0.01; cervical mucus, p < 0.01).

CONCLUSION

Our study shows that concentrations of endotoxin and interleukin-1 alpha in cervical mucus and vaginal fluid of women in early pregnancy who have bacterial vaginosis are significantly higher than the corresponding levels in control subjects.

A longitudinal follow-up of bacterial vaginosis during pregnancy

Bacterial vaginosis (BV) has been considered by many investigators to be a risk factor for preterm labor. We have followed vaginal pH and the persistence of clue cells in Papanicolaou stained smears in 119 pregnant women during the course of pregnancy. Of 19 patients with clue cells in their smears during the first trimester, 11 (58%) still had clue cells at the second visit during the third trimester. Of the 100 patients without clue cells during their first trimester, none exhibited clue cells during the third trimester. If the persistence of clue cells is truly a risk factor for adverse pregnancy outcome, screening in the first trimester would identify a risk group of 15%. This risk group diminishes to 9% at the time of the third trimester. Vaginal pH > 4.5 had a recovery sensitivity of 76% and specificity of 83%. If clue cells can be considered as the identifying standard for bacterial vaginosis, the sensitivity and specificity of pH is 89% and 94%, respectively. The establishment of the diagnosis of BV during pregnancy and, in some cases, the treatment of the condition may be important as routine procedures in the antenatal center.

Increased prostaglandin concentrations in the cervical mucus of pregnant women with bacterial vaginosis

Microorganisms associated with bacterial vaginosis are commonly recovered from the amniotic fluid and chorion-amnion of patients who deliver prematurely. Bacteria closely related to those causing bacterial vaginosis may play a role in the initiation of uterine contractions, ripening of the cervix and weakening of the fetal membranes by stimulating prostaglandin synthesis. In the present investigation, cervical mucus was collected by brush from early pregnant women with and without bacterial vaginosis. The concentrations of PGE2, PGF2 alpha and 6-keto-PGF1 alpha were determined in the mucus samples by methyl oximation and then radioimmunoassay, utilizing antibodies raised against oximated prostaglandins. It was found that the concentration of PGE2 and PGF2 alpha was significantly higher in the mucus of women with bacterial vaginosis compared with healthy women. The concentration of 6-keto-PGF1 alpha was similar in both study groups. All patients had been instructed to abstain from sexual intercourse for 24 hours before sampling. However, it may be that women with high concentrations in their mucus may have had intercourse anyway. However, it is fairly well possible that the significant differences in the PGE2 and PGF2 alpha values are causally related to the higher rate of preterm labor in women with the commonplace infection of bacterial vaginosis.

Incidence of pelvic inflammatory disease after first-trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: a double-blind, randomized study

OBJECTIVE

The purpose of this study was to evaluate the effect of metronidazole treatment on the incidence of postoperative pelvic inflammatory disease after first-trimester abortion in women with bacterial vaginosis.

STUDY DESIGN

A double-blind, randomized, multicenter study was conducted on 231 women undergoing first-trimester legal abortion and fulfilling the criteria for bacterial vaginosis. The women were randomized to either metronidazole 500 mg three times daily for 10 days or placebo. Treatment was started at the outpatient visit the week before the operation.

RESULTS

Among the 174 women who could be evaluated, pelvic inflammatory disease developed in 14 after the abortion. In the treatment group there were three infections (3.8%) compared with 11 (12.2%) in the placebo group (p less than 0.05).

CONCLUSION

These data suggest that patients with bacterial vaginosis should be treated in conjunction with first-trimester abortion because treatment with metronidazole reduces the postoperative infection rate more than three times.

Bacterial vaginosis and the vaginal leucocyte/epithelial cell ratio in women attending an outpatient gynaecology clinic

In order to investigate the usefulness of vaginal leucocytosis as a sign of genital infection, vaginal wet smears were obtained from 230 consecutive non-pregnant women attending an outpatient gynaecology clinic. Although 52 (22.6%) of the women were diagnosed as having bacterial vaginosis, none had symptoms of cervicitis or genital infection. Of the patients with bacterial vaginosis 19 (36.5%) had vaginal leucocytosis compared to 37.1% of the women without bacterial vaginosis. In a further study, bacterial vaginosis was also diagnosed in 104 of 384 women (33.3%) attending for first trimester legal abortions. Of the women with bacterial vaginosis 37.5% had vaginal leucocytosis compared to 31.8% for those without bacterial vaginosis (P greater than 0.05). There was no correlation between vaginal leucocytosis and the presence of cervical Chlamydia trachomatis; however, the presence of C. trachomatis did correlate with bacterial vaginosis. Vaginal leucocytes varies with factors unrelated to genital infection. This fact must be taken into consideration when wet smears from patients with suspected genital tract infection are evaluated.

Is bacterial vaginosis a sexually transmitted disease?

The sexual behaviour of 400 women with and 400 women without bacterial vaginosis from a health screening programme was investigated by a questionnaire to see if women with bacterial vaginosis had similar behaviours to women considered at risk for STDs. These patients were randomly selected from computer records. Eight hundred questionnaires were distributed and 641 women answered. The age of first sexual intercourse was lower among women with bacterial vaginosis (17.8 years) than those without (18.6 years; P less than 0.001). Number of lifetime sexual partners was higher among women with bacterial vaginosis (P less than 0.001). Women with bacterial vaginosis smoked or had smoked more often. These results indicate that women with bacterial vaginosis have similar sexual behaviour to those at risk for STDs.

Clue cells in predicting infections after abdominal hysterectomy

Seventy women scheduled for abdominal hysterectomy were examined for the presence of clue cells in the vaginal discharge in an attempt to identify a possible risk group for development of postoperative infection. Seven of 20 women (35%) with clue cells developed vaginal cuff infections or wound infections, compared with four of 50 women (8%) without clue cells (P less than .01). Women with bacterial vaginosis, diagnosed by air-dried vaginal smears, are therefore at risk for postoperative infection.

The vaginal pH and leucocyte/epithelial cell ratio vary during normal menstrual cycles

A higher proportion white blood cells (WBC) than vaginal epithelial cells in wet smears has been accepted as a sign which, together with clinical signs, can be useful in the diagnosis of infections in the genital tract such as cervicitis or salpingitis. However, little is known about the normal variation among healthy women without any symptoms or signs of genital-tract infection. By taking frequent wet smears from three healthy asymptomatic women during four menstrual cycles we found that vaginal leucocytosis usually occurred once each cycle. Normal vaginal leucocytosis must thus be taken into consideration when evaluating wet smear of patients for genital tract infections.

Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration

In a prospective clinical investigation of 2,144 deliveries, we elucidate the indications for episiotomy and how different methods of anesthesia affect the frequency of episiotomy and the perineal problems after episiotomy compared with those after spontaneous perineal laceration. We found a significantly higher infection rate (p less than 0.001) and a longer healing period in the episiotomy group. These differences remain even if only primigravida or the indication, imminent perineal laceration, is studied. The results indicate that many women will unnecessarily suffer after an episiotomy. The patient's subjective problems are significantly increased, both immediately and at the 3-month postoperative follow-up.

Enumeration of clue cells in rehydrated air-dried vaginal wet smears for the diagnosis of bacterial vaginosis

Among 235 women attending an outpatient clinic, the diagnosis of bacterial vaginosis was made using three of the following four criteria: typical discharge, pH more than 4.5, positive amine sniff test, and clue cells in a wet smear. These findings were correlated with the finding of clue cells in air-dried wet smears rehydrated more than 1 month after the visit. The rehydrated specimens had the same microscopic appearance as a nonpreserved wet smear. The demonstration of clue cells in the rehydrated smears correlated with the composite diagnosis of bacterial vaginosis with a sensitivity of 96% and specificity of 98%. In a busy multi-physician setting, the scoring of clue cells in stored and rehydrated smears can be used to obtain consistent readings for wet-smear diagnostics, thus simplifying teaching and increasing the utility of wet smears in clinical research.

Detection of bacterial vaginosis in Papanicolaou smears

In a prospective study of 145 women, bacterial vaginosis was clinically diagnosed in 46 women. Compared with clinical diagnosis of bacterial vaginosis, detection of so-called clue cells in Papanicolaou smears showed a sensitivity of 90% and a specificity of 97%. The positive and negative predictive values were 94% and 95%, respectively. The study results indicate that demonstration of clue cells in Papanicolaou smears is a useful method for identification of women with probable bacterial vaginosis. This provides a basis for the use of archival material in retrospective studies with regard to possible links between bacterial vaginosis and development of cervical cancer.

Mobiluncus and clue cells as predictors of PID after first-trimester abortion

Women attending our Department for a first-trimester abortion were examined for the presence of Mobiluncus species. C. trachomatis or clue cells in vaginal discharge in an attempt to identify risk groups for development of pelvic inflammatory disease (PID) after first-trimester abortion. A correlation was found between the presence of Mobiluncus and clue cells in vaginal discharge and the incidence of PID after first-trimester abortions. These women were also older than those in whom C. trachomatis was identified. Our study indicates that screening for C. trachomatis and clue cells in vaginal discharge will identify two different risk groups for developing PID after first-trimester abortion.