JOURNAL READING

Bacterial Vaginosis in Pregnancy: Current Findings and Future Directions

Epidemiologic Reviews, 2002, Vol. 24
Pembimbing Penyusun : dr. Eko Krisnarto, Sp.KK : Hernita Ferliyani ( 030.07.107 )

INRODUCTION
Bacterial vaginosis (BV) is the number one cause of vaginitis among both pregnant and nonpregnant women. Prevalence of BV among non pregnant women to range from 15% to 30 %,

Up to 50% of pregnant women have been found to have BV.

Related to many gynecologic conditions and complications of pregnancy including pelvic inflammatory disease, endometritis, preterm delivery, preterm labor, and spontaneous abortion.

BACKGROUND
BV is a polymicrobial, superficial vaginal infection involving a reduction in the amount of hydrogen-peroxide producing Lactobacillus and an overgrowth of anaerobic and Gram-negative or Gram-variable bacteria. Reduced number of Lactobacillus anaerobic bacteria, including Mycoplasma hominis, Gardnerella vaginalis,etc

The most important predictor in subsequent BV development

No studies pregnant women to describe the changes in vaginal flora or BV prevalence during gestation

The presence of BV at a particular gestational age may be a factor in the subsequent development of pregnancy complications,

DIAGNOSIS

TREATMENT
Metronidazole, given a 7-day, twice-daily course of 500 mg of metronidazole ranges from 84% to 96% Clindamycin reported that a 300mg, twice-daily course of clindamycin for 7 days resulted in a 94% cure rate

Oral
Metronidazole during the first trimester of pregnancy before the completion of organogenesis no evidence of longterm teratogenic effects.

All of the efficacy studies have been conducted among nonpregnant women, with the assumption that the cure rate for BV among pregnant woman is similar.

TOPIKAL
Metronidazole 0.75% vaginal gel Clindamycin 2 % vaginal cream

A twice-daily, 5-day therapy of vaginal metronidazole had a reported cure rate of 7581 %

Clindamycin cream was reported to resolve 8296 % of cases of BV

These topical treatments result in the resolution of lower genital tract infection but do not treat BV occurring in the upper genital tract

EPIDEMIOLOGY : RISK FACTORS

Race

Education

Sexual activitty

Vaginal douching

Socio
Economic/ Stress

Reported prevalence of BV among pregnant women ranges from 10 to 35 %, with higher rates occurring among African-American women, lowincome women, or women with prior sexually transmitted diseases

The Vaginal Infections and Prematurity Study, which measured BV among pregnant women between 23 and 26 weeks of gestation, found a 2.0- to 2.5-fold increased risk of BV among African-American compared with White pregnant women.

Numerous studies have confirmed at least a twofold increased risk of BV among African-American women presumably due to environmental/behavioral exposures or stressors

RISK FACTORS

RISK FACTORS

In recent studies among obstetrics populations, the reported prevalence of BV ranged from a low of 10 percent among private patient to a high of 35 percent among women reporting low monthly incomes and low educational levels.

Epidemiologic studies have found that early sexual activity, a high number of lifetime sexual partners, women with a new sexual partner, and women with a prior sexually transmitted disease are also at increased risk of BV.

Some behaviors, such as vaginal douching, have been examined as potential risk factors for BV. Vaginal douching may change the vaginal flora, reduce the amount of Lactobacillus, and create an environment promoting excessive anaerobic growth

EPIDEMIOLOGY : ADVERSE PREGNANCY OUTCOMES Bacterial Vaginosis Related to :

An increased potential for other vaginal pathogens to gain access to the upper genital tract
The presence of enzymes that reduce the ability of leukocytes to reduce infection An increased level of endotoxins stimulating cytokine and prostaglandin production

EPIDEMIOLOGY : ADVERSE PREGNANCY OUTCOMES

Many studies twofold increased risk of preterm delivery among women diagnosed with BV in the early second trimester
A recent meta-analysis reviewing studies examining the role of BV and the risk of preterm delivery reported a summary odds ratio of 1.6, indicating a 60 percent increased risk of preterm delivery among pregnant women with BV One study examining several pregnancy outcomes related to BV diagnosed during the first trimester of 2.6 fold increased risk of preterm labor, a 6.9-fold increased risk of preterm delivery, and a 7.3 fold increased risk of preterm, premature rupture of the membranes
Studies have reported a three to fivefold increased risk of spontaneous abortion among pregnant women with BV in the first trimester Another study found that BV diagnosed in the second trimester was associated with an increased risk of preterm delivery and premature rupture of the membranes and that BV that BV accounted for 83 percent of the attributable risk for preterm birth

a recent clinical trial did not find a reduction in the occurrence of preterm delivery among either high-risk or low-risk asymptomatic pregnant women following treatment with oral metronidazole

CONCLUSION
BV is an enormous public health problem, accounting for the majority of cases of vaginitis and vaginal discharge in the United States. Current studies relating BV to adverse pregnancy outcomes have measured and categorized BV positivity from samples of the lower genital tract. These lower genital tract measurements of BV have been moderately related to the risk of adverse events, with the corresponding assumption being the eventual ascension of these organisms to the upper genital tract. Currently, BV is related to many gynecologic conditions and complications of pregnancy including pelvic inflammatory disease, endometritis, preterm delivery, preterm labor, and spontaneous abortion.