Commentary on a combined approach to the problem of developing biomarkers for the prediction of spontaneous preterm labor that leads to preterm birth

INTRODUCTION

Globally, preterm birth has replaced congenital malformation as the major cause of perinatal mortality and morbidity. The reduced rate of congenital malformation was not achieved through a single biophysical or biochemical marker at a specific gestational age, but rather through a combination of clinical, biophysical and biochemical markers at different gestational ages. Since the aetiology of spontaneous preterm birth is also multifactorial, it is unlikely that a single biomarker test, at a specific gestational age will emerge as the definitive predictive test.

METHODS

The Biomarkers Group of PREBIC, comprising clinicians, basic scientists and other experts in the field, with a particular interest in preterm birth have produced this commentary with short, medium and long-term aims: i) to alert clinicians to the advances that are being made in the prediction of spontaneous preterm birth; ii) to encourage clinicians and scientists to continue their efforts in this field, and not to be disheartened or nihilistic because of a perceived lack of progress and iii) to enable development of novel interventions that can reduce the mortality and morbidity associated with preterm birth.

RESULTS

Using language that we hope is clear to practising clinicians, we have identified 11 Sections in which there exists the potential, feasibility and capability of technologies for candidate biomarkers in the prediction of spontaneous preterm birth and how current limitations to this research might be circumvented.

DISCUSSION

The combination of biophysical, biochemical, immunological, microbiological, fetal cell, exosomal, or cell free RNA at different gestational ages, integrated as part of a multivariable predictor model may be necessary to advance our attempts to predict sPTL and PTB. This will require systems biological data using "omics" data and artificial intelligence/machine learning to manage the data appropriately. The ultimate goal is to reduce the mortality and morbidity associated with preterm birth.

Cost-effectiveness of incisional negative pressure wound therapy compared with standard care after caesarean section in obese women: a trial-based economic evaluation

OBJECTIVE

To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section.

DESIGN

A cost-effectiveness analysis conducted alongside a clinical trial.

SETTING

Five obstetric departments in Denmark.

POPULATION

Women with a pregestational body mass index (BMI) ≥30 kg/m² .

METHOD

We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth.

MAIN OUTCOME MEASURES

Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained.

RESULTS

The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m² .

CONCLUSION

Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m² .

TWEETABLE ABSTRACT

Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.

Prophylactic incisional negative pressure wound therapy reduces the risk of surgical site infection after caesarean section in obese women: a pragmatic randomised clinical trial

Objective

To evaluate the reduction of surgical site infections by prophylactic incisional negative pressure wound therapy compared with standard postoperative dressings in obese women giving birth by caesarean section.

Design

Multicentre randomised controlled trial.

Setting

Five hospitals in Denmark.

Population

Obese women (prepregnancy body mass index (BMI) ≥30 kg/m²) undergoing elective or emergency caesarean section.

Method

The participants were randomly assigned to incisional negative pressure wound therapy or a standard dressing after caesarean section and analysed by intention‐to‐treat. Blinding was not possible due to the nature of the intervention.

Main outcome measures

The primary outcome was surgical site infection requiring antibiotic treatment within the first 30 days after surgery. Secondary outcomes included wound exudate, dehiscence and health‐related quality of life.

Results

Incisional negative pressure wound therapy was applied to 432 women and 444 women had a standard dressing. Demographics were similar between groups. Surgical site infection occurred in 20 (4.6%) women treated with incisional negative pressure wound therapy and in 41 (9.2%) women treated with a standard dressing (relative risk 0.50, 95% CI 0.30–0.84; number needed to treat 22; P = 0.007). The effect remained statistically significant when adjusted for BMI and other potential risk factors. Incisional negative pressure wound therapy significantly reduced wound exudate whereas no difference was found for dehiscence and quality of life between the two groups.

Conclusion

Prophylactic use of incisional negative pressure wound therapy reduced the risk of surgical site infection in obese women giving birth by caesarean section.

Tweetable abstract

RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI.

RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI.

Meta-analysis of negative-pressure wound therapy for closed surgical incisions

Background

Postoperative wound complications are common following surgical procedures. Negative‐pressure wound therapy (NPWT) is well recognized for the management of open wounds and has been applied recently to closed surgical incisions. The evidence base to support this intervention is limited. The aim of this study was to assess whether NPWT reduces postoperative wound complications when applied to closed surgical incisions.

Methods

This was a systematic review and meta‐analysis of randomized clinical trials of NPWT compared with standard postoperative dressings on closed surgical incisions.

Results

Ten studies met the inclusion criteria, reporting on 1311 incisions in 1089 patients. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0·54, 95 per cent c.i. 0·33 to 0·89) and seroma formation (RR 0·48, 0·27 to 0·84) compared with standard care. The reduction in wound dehiscence was not significant. The numbers needed to treat were three (seroma), 17 (dehiscence) and 25 (infection). Methodological heterogeneity across studies led to downgrading of the quality of evidence to moderate for infection and seroma, and low for dehiscence.

Conclusion

Compared with standard postoperative dressings, NPWT significantly reduced the rate of wound infection and seroma when applied to closed surgical wounds. Heterogeneity between the included studies means that no general recommendations can be made yet.

Good for closed wounds too

Video Abstract

Increasing use of antibiotics in pregnancy during the period 2000-2010: prevalence, timing, category, and demographics

OBJECTIVE

The aim of this study was to describe the use of antibiotics in a national population-based cohort of pregnant Danish women between 2000 and 2010.

DESIGN

Register-based, population-wide, cohort study.

SETTING

Denmark, from 2000 to 2010.

POPULATION

All pregnancies among Danish residents during the period 2000-2010 were included for analysis.

METHODS

Data were obtained from the Danish Medical Birth Registry, the Danish National Patient Registry, and the Registry of Medicinal Product Statistics. The filled prescriptions for systemic antibacterial, antimycotic, and antiviral drugs, as well as intravaginally applied antibiotics, were analysed. Associations with demographic variables were assessed using multivariate analysis.

MAIN OUTCOME MEASURES

Filled prescriptions for antibiotic drugs during pregnancy.

RESULTS

We included 987 973 pregnancies in Denmark from 2000 to 2010; 38.9% of women with a delivery and 14.8% of women with a miscarriage or termination of pregnancy had one or more antibiotic treatments during pregnancy. Systemic antibacterial drugs were the most frequently used drug group, with filled prescriptions for 33.4% of all deliveries and 12.6% of all abortions. This proportion increased from 28.4% in 2000 to 37.0% in 2010 among deliveries. The biggest change was seen for pivmecillinam, which increased among deliveries from 6.3% in 2000 to 19.5% in 2010. Obese (odds ratio 1.51; 95% CI 1.47-1.56), young (odds ratio 1.35; 95% CI 1.30-1.39), and low-educated women (odds ratio 1.37; 95% CI 1.35-1.1.39) tended to fill more prescriptions of antibiotics during pregnancy.

CONCLUSIONS

Overall, the number of women who filled prescriptions of antibiotics increased during the 11-year study period. In 2010, at least 41.5% of all deliveries were exposed to antibiotic therapy during pregnancy.

Rescreening for abnormal vaginal flora in pregnancy and re-treating with clindamycin vaginal cream significantly increases cure and improvement rates

We investigated 199 pregnant women with bacterial vaginosis (BV) who received clindamycin vaginal cream (CVC) for three days and compared with 205 women treated with placebo. The vaginal flora was assessed at each visit. At the second visit, 71% in the CVC group were cured/improved, compared with 12% in the placebo group (P < 0.001). At visit 3 about 90% who responded to initial CVC treatment were still cured/improved. Of women who initially failed to respond to CVC and were given an additional seven-day course, 33% were cured/improved by the third visit, compared with 15% who failed to respond to placebo initially and were given a further seven-day course (P = 0.02). By visit 4, half the women in the CVC group who received additional treatment remained cured/improved, compared with 26% who had additional placebo (P = 0.004). In the CVC group, a change from abnormal to normal rose from 71% (visit 2) to 76% (visit 3) and 79% (visit 4). A similar trend was seen in women who received placebo but the proportions were significantly lower (12%, 24% and 33%, respectively). There is value in rescreening and re-treating women who remain BV-positive after initial clindamycin treatment.

A comparison of sexual and reproductive health services provided by genitourinary and family planning clinics for adolescents

The purpose of the study was to assess the use of sexual and reproductive health services by adolescents aged 15 years and younger. A case-note review was conducted at both a genitourinary medicine clinic and a family planning clinic in Edinburgh, UK. The demographics of the attendees, reasons for attending, risk factors, diagnostic tests undertaken and contraceptive advice given differed between the two clinics. Approximately 73% of attendees with documented responses used alcohol and 21% used recreational drugs, 5% reported self-harm, 25% reported being victims of sexual assault, 13% had a current sexually transmitted infection and 6% of girls had already been pregnant. While this group of young people understand the differences in emphasis between the clinics, adolescents may be intimidated and discouraged from attending or may fail to return, and the combination of overlap, together with omissions in cross-clinic function, suggests that for this age group the services of these clinics should be combined.

The vaginal microbiome: new information about genital tract flora using molecular based techniques

Vaginal microbiome studies provide information that may change the way we define vaginal flora. Normal flora appears dominated by one or two species of Lactobacillus. Significant numbers of healthy women lack appreciable numbers of vaginal lactobacilli. Bacterial vaginosis (BV) is not a single entity, but instead consists of different bacterial communities or profiles of greater microbial diversity than is evident from cultivation-dependent studies. BV should be considered a syndrome of variable composition that results in different symptoms, phenotypical outcomes, and responses to different antibiotic regimens. This information may help to elucidate the link between BV and infection-related adverse outcomes of pregnancy.

The effect of exclusion of cases with unrecorded best estimate of gestational age on the estimates of preterm birth rate

OBJECTIVES

To investigate the effect of excluding cases with unrecorded best estimate of gestational age at birth on pregnancy outcome reporting and to determine the reasons for unrecorded gestational age data.

DESIGN

Prospective study.

SETTING

Fifteen maternity units in North West London.

POPULATION

497,105 women who booked for antenatal care from 1988 to 1998.

METHOD

Multiple logistic regression analysis.

MAIN OUTCOME MEASURES

Preterm birth rate of, and the factors associated with, cases with unrecorded best estimate of gestational age at birth.

RESULTS

Of the 53,981 cases with an unrecorded best estimate of gestational age at birth, by using additional data, it was possible to compute a new best estimate of gestational age in 80%. In this latter group, the preterm birth rate was 42% (95% CI 41.5-42.6). The corrected, overall preterm birth rate in North West London (9.8%, 9.7-9.9) was higher than the original estimate (7.6%, 7.5-7.7), which included only cases with recorded data on gestational age at birth. The most significant factors associated with an unrecorded gestational age were no ultrasound scan (OR 49, P < 0.001), and preterm birth <31 weeks (OR 30, P < 0.001).

CONCLUSIONS

The incidence of preterm birth are likely to be under-reported in studies where only cases with readily available gestational age data are included. In routinely collected maternity data, human omission is an important contributing factor for an unrecorded best estimate of gestational age at birth. This is associated with the urgent transfer of babies to the neonatal intensive care unit.

Secondary repair of the perineum following childbirth

The aim of the study was to evaluate secondary repair of the perineum following perineal trauma at childbirth. Patients who underwent secondary repair reported with symptoms of superficial dyspareunia, vulvo-vaginal pain, vaginal stenosis and broken or gaping wound. The study included 103 women over a 16-year period that underwent refashioning of the perineum at Northwick Park Hospital by the same surgeon. Among the cases, 81.6% were nulliparous and 18.4% were multiparous. Labour was induced in 30.1%, and 38% of the women required instrumental delivery. The length of the second stage of labour was 89 +/- 60 min for nulliparae and 50 +/- 48 min for multiparae. In 53.4% of the women, an episiotomy was performed. Catgut sutures were used in 69% of primary repairs. Predisposing factors for the need for secondary repair included nulliparity, forceps delivery, episiotomy, prolonged second stage of labour, surgeons' inexperience and the choice of suture material. Secondary repair is associated with a good result. A majority of women who required refashioning of the perineum for superficial dyspareunia presented late after the onset of the problem. In carefully selected women, such cases of superficial dyspareunia are easily treatable and surgery needs to be considered as an option.

Use of C-reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of membranes: a systematic review

BACKGROUND

Studies examining the use of C-reactive protein (CRP) as a predictor of chorioamnionitis in preterm prelabour rupture of membranes (PPROM) report highly conflicting results. Despite this, CRP is commonly used for the early diagnosis of chorioamnionitis.

OBJECTIVE

To determine the diagnostic accuracy of CRP in the detection of chorioamnionitis in women with PPROM.

DESIGN

Systematic review.

SEARCH STRATEGY

Studies were identified from MEDLINE (1966-2006), EMBASE (1974-2006), PubMed and the Cochrane Library (2005) and from reference lists from primary studies and reviews.

SELECTION CRITERIA

Only studies of good methodological quality that evaluated the diagnostic performance of CRP in chorioamnionitis in women with PPROM were selected.

DATA COLLECTION AND ANALYSIS

Positive and negative likelihood ratios (LR) and diagnostic odds ratios (DOR) were calculated. An attempt was made at pooling data for meta-analysis, but this was considered inappropriate due to the significant unexplained heterogeneity between studies.

MAIN RESULTS

There were eight primary studies comprising 610 cases which met the inclusion criteria. There was wide variation in the positive and negative LR and DOR between the studies, with significant lack of precision demonstrated by wide confidence intervals. Three of the studies concluded that CRP was a useful diagnostic tool for chorioamnionitis (DOR ranging from 4.2 to 191.6), although one of them suggested a higher CRP threshold. The other five studies concluded the opposite (DOR ranging from 1.4 to 17.7).

AUTHOR'S CONCLUSIONS

There is no clear evidence to support the use of CRP for the early diagnosis of chorioamnionitis. Further research is required to address the contradictory findings of diagnostic accuracy.

A quality assessment tool to evaluate tocolytic studies

Over the past 15 years, the use of beta-agonists has declined worldwide. Following the Royal College of Obstetricians and Gynaecologists guidelines in 2002, clinicians in the UK and beyond were faced with the dilemma of continuing to use beta-agonists, desist from using tocolytic therapy completely or choosing to change to atosiban or calcium channel blockers (CCBs). While grade A level 1 evidence exists to show that atosiban is significantly more efficacious than placebo and significantly safer than beta-agonists for the treatment of spontaneous preterm labour, the evidence for CCBs, such as nifedipine, is much less robust and no placebo-controlled trials have been performed. Published studies on nifedipine are largely investigator-led studies of small sample size, which lack sufficient power. As a result, most of the evidence has been based on meta-analyses of these studies, which look retrospectively at pooled data and are only as good as the quality of the studies included. In light of this, a tool was developed to produce a systematic review of studies on tocolytic effectiveness, which can and should be applied to all tocolytics and which considered both method- and topic-specific markers of quality. In the process of applying this tool to nifedipine, an extensive literature search identified 31 studies for a systematic review of the quality of nifedipine studies assessed by eight paired reviewers with wide experience in the subject of spontaneous preterm labour and preterm birth. Forty topic- and method-specific items of quality were assessed. The paucity of good quality studies of nifedipine used for the treatment of spontaneous preterm labour should be highlighted in meta-analyses or systematic reviews, which measure efficacy and should limit and influence the degree to which recommendations and guidelines are made on the basis of such studies.

Setting up a preterm prevention clinic: a practical guide

In gynaecology, specialist menopause, urogynae, colposcopy, infertility, pelvic pain and cancer, rapid access clinics exist at many teaching and busy district general hospitals in the UK. Similarly, in obstetrics many busy maternity units have fetal medicine clinics, dedicated twins clinics and maternal medicine clinics, incorporating various general medical conditions and conditions peculiarly appropriate to pregnancy such as haematological disorders, diabetes and epilepsy. In contrast, in very few hospitals is there a dedicated clinic for women at increased risk of preterm birth, yet this is the major cause of neonatal mortality and morbidity in the developed world. Such a situation may be due to the confusion created by the fact that preterm birth is a heterogeneous condition with multiple aetiologies and hence multiple therapeutic interventions. It is possible to identify a group of women at particularly high risk of preterm birth in whom screening and interventional techniques have the potential to reduce the mortality and morbidity associated with spontaneous preterm labour and preterm birth.

Infection in the prediction and antibiotics in the prevention of spontaneous preterm labour and preterm birth

Preterm birth is the major cause of perinatal mortality and morbidity in the developed world. Infection is a significant cause of spontaneous preterm labour in up to 40% of cases. Women with abnormal genital tract flora diagnosed by bacterial vaginosis on gram stain of vaginal secretions in pregnancy are at increased risk of late miscarriage and preterm birth. The earlier in pregnancy at which spontaneous preterm labour occurs, the more likely this is to be due to a pathological signal or trigger like infection. The earlier in pregnancy at which abnormal genital tract flora is detected, the greater is the risk of a subsequent infective adverse outcome. Even if abnormal genital tract flora in early pregnancy subsequently reverts to normal, there is a greater risk of an adverse outcome when compared to women whose vaginal flora was always normal. It follows that if antibiotics are to be used in pregnancy to treat abnormal genital tract flora, these should be used early in pregnancy before the inflammatory response leading to irreversible tissue damage has occurred. Historically, antibiotic studies have failed because the wrong antibiotics were used in the wrong women too late in pregnancy. Three recent randomized controlled trials have shown that clindamycin used in early pregnancy even in women at low risk of preterm birth can reduce the risk by 40-60%.

The association between isolated fetal echogenic cardiac foci on second-trimester ultrasound scan and trisomy 21 in low-risk unselected women

OBJECTIVES

To determine the prevalence of and the association between trisomy 21 and isolated fetal echogenic cardiac foci (FECF) identified in the second trimester in an unselected low-risk population.

METHODS

All cases with isolated FECF were collected by reviewing the antenatal ultrasound database for 3 consecutive years. In order to include all trisomy 21 cases for the same period, the regional cytogenetics database and pediatric databases were examined. A 2 x 2-table analysis was performed to establish the sensitivity, specificity and positive and negative predictive values of isolated FECF as a screening test for trisomy 21 in a low-risk unselected population.

RESULTS

In the 3-year period of the study the total number of deliveries was 11,105, of which 10,769 (97%) had a routine detailed anomaly scan between 16 and 24 weeks' gestation. There were 311 cases (2.9%) of isolated FECF. Among these there was only one case (0.3%) of trisomy 21. In the same period, the total number of trisomy 21 cases was 14. Accordingly, the sensitivity of isolated FECF for detecting trisomy 21 was 7.1% and the specificity was 97.1%. Positive and negative predictive values of FECF were 0.3% and 99.9%, respectively.

CONCLUSION

In an otherwise healthy pregnancy, the finding of isolated FECF on a routine second-trimester anomaly scan is normal and should not be considered as a risk factor for trisomy 21 in an unselected low-risk population.

Relation between Gram-stain and clinical criteria for diagnosing bacterial vaginosis with special reference to Gram grade II evaluation

The aim of this study was to analyse how the results of Gram-staining vaginal smears correlated with the clinical criteria for determining the existence of bacterial vaginosis (BV) and, in particular, how the category defined as 'intermediate' or Gram grade II did so and its significance. Women attending an antenatal clinic with an abnormal vaginal flora, that is those who had Gram-stains of grades II or III, the latter considered to equate with BV, were given clindamycin or a placebo intravaginally and examined again on up to three occasions. Gram-stain readings of grade III correlated with the clinical criteria for BV on 356 (91.7%) of 388 occasions. Grade II readings covered the spectrum of clinical criteria and correlated with those for BV on 35 (37.2%) of 94 occasions. Grade I, recorded 231 times and seen usually after clindamycin treatment, was associated with BV only once. The sensitivity, specificity, positive predictive value and negative predictive value of the Gram stain for the diagnosis of BV, based on a combination of grades II and III, were 99.7%, 71.6%, 81% and 99.6%, respectively; based on grade III only, the values were 99.7%, 87.7%, 91.6% and 99.6%, respectively. Women reported a malodorous vaginal discharge on 49.2% of the occasions a grade III flora was seen and 13.3% of the times grade II was recorded. It was not associated with grade I and would seem a useful adjunct to the accepted clinical criteria for diagnosing BV. Each of the clinical criteria was found in about equal proportions (87%-91%) for women whose Gram grade was III. For grade II, an increased discharge was noted most often (76.5%) and 'clue' cells least often (24.5%). A positive amine test was the most specific, being associated with <1% of grade I smears. Of women with grade III status, 91% reverted to grade I after treatment with clindamycin for three days. In contrast, of women with grade II status, 53% reverted to grade I, as did 47% of those who were given a placebo. The 'intermediate' (grade II) category is a Gram-stain diagnosis and not one that can be made clinically. It is important to recognize as a distinct entity not only because amalgamation with grade III diminishes the specificity and positive predictive value of the Gram-stain for diagnosing BV, but also because women of grade II status usually fail to respond to clindamycin treatment, whereas those of grade III do not.

The association between fetal pyelectasis on second trimester ultrasound scan and aneuploidy among 25,586 low risk unselected women

OBJECTIVE

To determine the association of fetal pyelectasis FP found at the time of second trimester detailed ultrasound scan with aneuploidy in an unselected low-risk population.

DESIGN

Retrospective study of ultrasonographic reports, films and hospital notes over an eight-year period from 1991 to 1998.

SETTING

District general hospital obstetric department with 3500 deliveries annually serving a low-risk cosmopolitan population.

MAIN OUTCOME MEASURE

The prevalence of aneuploidy in cases of fetal pyelectasis.

METHODS

The obstetric ultrasound reports and films of 29,591 cases were reviewed to identify those with FP at their detailed anomaly scan between 18 and 24-weeks gestation. The study sample included women whose scan showed the fetal renal pelvis of either kidney to be five millimetres or more in the anteroposterior diameter. Demographic data and other ultrasonographic abnormalities were noted. The genotype and phenotype of the babies were traced from a combination of cytogenetic reports and paediatric notes.

RESULTS

There were 320 cases of FP among the 25,586 low-risk study population available in the studied gestational period (18-24 weeks) giving a prevalence of 1.25 percent. Of these, 301 cases of FP were found in isolation and 19 were found in association with another ultrasonographic marker. None of the 315 cases delivering at the Northwick Park & St. Mark's Hospital had aneuploidy. Pyelectasis was more likely to be bilateral (57%), and more in male fetuses (72%). The mean diameter for the pyelectasis at diagnosis was 6.5 mm (1.4 SD) ranging between 5 and 15 mm. One hundred and thirty seven cases (43%) resulted in spontaneous resolution.

CONCLUSION

The prevalence of FP at the anomaly scan in an unselected low-risk population is not high (1.25%). Our data suggest that the risk of aneuploidy associated with isolated FP in a low-risk, unselected population is so small that it should not be an indication for invasive prenatal karyotyping.

Bacterial vaginosis in climacteric and menopausal women

The objective was to determine how frequently an abnormal vaginal flora occurred in women attending a menopause clinic and whether any abnormality might be related to a particular risk factor. Women completed a questionnaire on their gynaecological, sexual and medical history. Whether they were perimenopausal or postmenopausal was determined on the basis of symptomatology, duration of amenorrhoea and on a follicle-stimulating hormone (FSH) assay when clinically indicated. A speculum examination of the vagina was undertaken, at which time a smear of vaginal secretion was Gram stained and the bacterial flora graded as follows: grade 1, normal; grade 2, intermediate, and grade 3, bacterial vaginosis (BV). Of 100 women examined, 44 had grade 1 flora, 17 had grade 2 flora and 18 had BV. An apparent absence of, or very scanty, vaginal bacteria in which grading was not possible was found in 21 women. Women with BV had had more sexual partners than the others, but otherwise there were no discernible factors associated with the occurrence of BV. Women with vaginal atrophy were more likely to have an apparent absence of vaginal bacteria, but a few had BV.

A prospective randomised trial to compare the efficacy and safety of hemabate and syntometrine for the prevention of primary postpartum haemorrhage

In a prospective, open-label, assessor-blind, randomised parallel group study the efficacy and safety of Hemabate (Pharmacia-Upjohn Pharmaceuticals, Milton Keynes, Buckinghamshire) an analogue of 15-methyl-prostaglandin (PGF2alpha) analogue was compared with Syntometrine (Alliance Pharmaceuticals, Chippenham, Wilts) the standard combination of ergometrine and syntocinon used for the active management of the third stage of labour and the prevention of primary postpartum haemorrhage (PPH). The study was set in a district general hospital with approximately 4,000 deliveries annually. The study was discontinued at the time of the interim analysis because of unacceptable gastrointestinal side effects. At the time of the interim analysis, a total of 529 women had completed the study with 263 randomised to receive PGF2alpha and 266 to receive ergometrine and syntocinon. In a pre-specified subgroup analysis, women delivered vaginally were further subdivided into those considered to be at high or low risk of primary PPH. The measured blood loss and incidence of PPH was similar in both treatment groups whether delivered by caesarean section or vaginally independent of whether women were considered to be at high or low risk. Adverse gastrointestinal events were recorded more often in the Hemabate group. The most common symptom was diarrhoea which occurred in 21% of women who received Hemabate compared to only 0.8% of Syntometrine users. PGF2alpha is as effective as Syntometrine in the prophylaxis of primary PPH in all groups studied but there was a statistically significantly increased risk of diarrhoea among users of PGF2alpha.

Prevalence of bacterial vaginosis in women attending one of three general practices for routine cervical cytology

A prospective observational study of asymptomatic women from three different general practices was set up to establish the incidence of bacterial vaginosis (BV). The study group comprised 287 women recalled to their general practitioner's surgery for routine cervical smears. The prevalence of an abnormal vaginal flora was about the same in women attending the 3 practices. Nearly 14% of women had abnormal vaginal flora and about 9% had BV on gram stain examination of vaginal secretions. This was 2-3 times more common than findings consistent with vaginal candidiasis (3.8%). Significant numbers of women with BV had received antifungal therapy suggesting a misdiagnosis. Because of its potential complications, women should be offered screening for BV in a well-women setting and, if found, should be treated if symptomatic or at risk of adverse obstetric or gynaecological sequelae.

Adverse obstetric sequelae of bacterial vaginosis

Bacterial vaginosis is increasingly associated with adverse sequelae in obstetrics such as preterm prelabour rupture of membranes, preterm labour and preterm birth. It is important to diagnose the condition early in pregnancy where appropriate treatment can be administered to women who are symptomatic or who are at high risk of adverse sequelae.