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JOGC

No. 211-Screening and Management of Bacterial Vaginosis in Pregnancy

  • Mark H. Yudin
    Correspondence
    Corresponding Author: Dr. Mark Yudin, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON.
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  • Deborah M. Money
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  • Author Footnotes
    ∗ Infectious Diseases Committee: Marc Boucher, MD, Montréal, QC; Beatrice Cormier, MD, Montréal, QC; Andrée Gruslin, MD, Ottawa, ON; Deborah M. Money, MD, Vancouver, BC; Gina Ogilvie, MD, Vancouver, BC; Caroline Paquet, RM, Trois-Rivières, QC; Audrey Steenbeek, RN, Halifax, NS; Nancy Van Eyk, MD, Halifax, NS; Julie van Schalkwyk, MD, Vancouver, BC; Thomas Wong, MD, Ottawa, ON; Mark H. Yudin (Chair), MD, Toronto, ON. Disclosure statements have been received from all members of the committee.

      Abstract

      Objective

      To review the evidence and provide recommendations on screening for and management of bacterial vaginosis in pregnancy.

      Options

      The clinical practice options considered in formulating the guideline.

      Outcomes

      Outcomes evaluated include antibiotic treatment efficacy and cure rates, and the influence of the treatment of bacterial vaginosis on the rates of adverse pregnancy outcomes such as preterm labour and delivery and preterm premature rupture of membranes.

      Evidence

      Medline, EMBASE, CINAHL, and Cochrane databases were searched for articles, published in English before the end of June 2007 on the topic of bacterial vaginosis in pregnancy.

      Values

      The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

      Benefits, Harms, and Costs

      Guideline implementation will assist the practitioner in developing an approach to the diagnosis and treatment of bacterial vaginosis in pregnant women. Patients will benefit from appropriate management of this condition.

      Validation

      These guidelines have been prepared by the Infectious Diseases Committee of the SOGC, and approved by the Executive and Council of the SOGC.

      Sponsors

      The Society of Obstetricians and Gynaecologists of Canada.

      Recommendations

      There is currently no consensus as to whether to screen for or treat bacterial vaginosis in the general pregnant population in order to prevent adverse outcomes, such as preterm birth.
      • 1.
        In symptomatic pregnant women, testing for and treatment of bacterial vaginosis is recommended for symptom resolution. Diagnostic criteria are the same for pregnant and non-pregnant women (I-A).
      • 2.
        Treatment with either oral or vaginal antibiotics is acceptable for achieving a cure in pregnant women with symptomatic bacterial vaginosis who are at low risk of adverse obstetric outcomes (I-A).
      • 3.
        Asymptomatic women and women without identified risk factors for preterm birth should not undergo routine screening for or treatment of bacterial vaginosis (I-B).
      • 4.
        Women at increased risk for preterm birth may benefit from routine screening for and treatment of bacterial vaginosis (I-B).
      • 5.
        If treatment for the prevention of adverse pregnancy outcomes is undertaken, it should be with metronidazole 500 mg orally twice daily for seven days or clindamycin 300 mg orally twice daily for seven days. Topical (vaginal) therapy is not recommended for this indication (I-B).
      • 6.
        Testing should be repeated one month after treatment to ensure that cure was achieved (III-L).

      Key Words

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      References

        • Rein M.F.
        • Holmes K.K.
        Non-specific vaginitis, vulvovaginal candidiasis, and trichomoniasis: clinical features, diagnosis and management.
        Curr Clin Top Infect Dis. 1983; 4: 281-315
        • Fleury F.J.
        Adult vaginitis.
        Clin Obstet Gynecol. 1987; 24: 407-438
        • Hillier S.L.
        • Nugent R.P.
        • Eschenbach D.A.
        • et al.
        • for the Vaginal Infections and Prematurity Study Group
        Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant.
        N Engl J Med. 1995; 333: 1737-1742
        • Gravett M.G.
        • Hammel D.
        • Eschenbach D.A.
        • et al.
        Preterm labor associated with subclinical amniotic fluid infection and with bacterial vaginosis.
        Obstet Gynecol. 1986; 67: 229-237
        • Minkoff H.
        • Brunebaum A.N.
        • Schwartz R.H.
        • et al.
        Risk factors for prematurity and premature rupture of membranes: a prospective study of the vaginal flora in pregnancy.
        Am J Obstet Gynecol. 1984; 150: 965-972
        • Leitich H.
        • Bodner-Adler B.
        • Brunbauer M.
        • et al.
        Bacterial vaginosis as a risk factor for preterm delivery: a meta-analysis.
        Am J Obstet Gynecol. 2003; 189: 139-147
        • Hillier S.L.
        • Martius J.
        • Krohn M.A.
        • et al.
        A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity.
        N Engl J Med. 1988; 319: 972-978
        • Watts D.H.
        • Krohn M.A.
        • Hillier S.L.
        • et al.
        Bacterial vaginosis as a risk factor for postcesarean endometritis.
        Obstet Gynecol. 1990; 75: 52-58
        • Soper D.E.
        • Bump R.C.
        • Hunt W.G.
        Bacterial vaginosis and trichomonas vaginitis are risk factors for cuff cellulites after abdominal hysterectomy.
        Am J Obstet Gynecol. 1990; 163: 1016-1023
        • Korn A.P.
        • Bolan G.
        • Padian N.
        • et al.
        Plasma cell endometritis in women with symptomatic bacterial vaginosis.
        Obstet Gynecol. 1995; 85: 387-390
        • Wiesenfeld H.C.
        • Hillier S.L.
        • Krohn M.A.
        • et al.
        Lower genital tract infection and endometritis: Insight in to subclinical pelvic inflammatory disease.
        Obstet Gynecol. 2002; 100: 456-463
        • Woolf S.H.
        • Battista R.N.
        • Angerson G.M.
        • et al.
        • Canadian Task Force on Preventive Health Care
        New grades for recommendations from the Canadian Task Force on Preventive Health Care.
        CMAJ. 2003; 169: 207-208
        • Spiegel C.A.
        • Amsel R.
        • Eschenbach D.
        • et al.
        Anaerobic bacteria in nonspecific vaginitis.
        N Engl J Med. 1980; 303: 601-607
        • Eschenbach D.A.
        Bacterial vaginosis: Emphasis on upper genital tract complications.
        Obstet Gynecol Clin North Am. 1989; 16: 593-610
        • Hill G.B.
        • Eschenbach D.A.
        • Holmes K.K.
        Bacteriology of the vagina.
        Scand J Urol Nephrol Suppl. 1985; 86: 23-39
        • Hillier S.L.
        Diagnostic microbiology of bacterial vaginosis.
        Am J Obstet Gynecol. 1993; 169: 455-459
        • Bump R.C.
        • Zuspan F.P.
        • Buesching 3rd, W.J.
        • et al.
        The prevalence, six-month persistence, and predictive values of laboratory indicators of bacterial vaginosis (nonspecific vaginitis) in asymptomatic women.
        Am J Obstet Gynecol. 1984; 150: 917-924
        • Hill L.H.
        • Ruperalia H.
        • Embil J.A.
        Nonspecific vaginitis and other genital infections in three clinic populations.
        Sex Transm Dis. 1983; 10: 114-118
        • Amsel R.
        • Totten P.A.
        • Spiegel C.A.
        • et al.
        Nonspecific vaginitis: Diagnostic criteria and microbial and epidemiologic associations.
        Am J Med. 1983; 74: 14-22
        • Eschenbach D.A.
        • Hillier S.
        • Critchlow C.
        • et al.
        Diagnosis and clinical manifestations of bacterial vaginosis.
        Am J Obstet Gynecol. 1988; 158: 819-828
        • Embree J.
        • Caliando J.J.
        • McCormack W.M.
        Nonspecific vaginitis among women attending a sexually transmitted diseases clinic.
        Sex Transm Dis. 1984; 11: 81-84
        • Paavonen J.
        • Heinonen P.K.
        • Aine R.
        • et al.
        Prevalence of nonspecific vaginitis and other cervicovaginal infections during the third trimester of pregnancy.
        Sex Transm Dis. 1986; 13: 5-8
        • Kurki T.
        • Sivonen A.
        • Renkonen O.-V.
        • et al.
        Bacterial vaginosis in early pregnancy and pregnancy outcome.
        Obstet Gynecol. 1992; 80: 173-177
        • Platz-Christensen J.J.
        • Pernevi P.
        • Hagmar B.
        • et al.
        A longitudinal follow-up of bacterial vaginosis during pregnancy.
        Acta Obstet Gynecol Scand. 1993; 72: 99-102
        • Meis P.J.
        • Goldenberg R.L.
        • Mercer B.
        • et al.
        The preterm prediction study: significance of vaginal infections.
        Am J Obstet Gynecol. 1995; 173: 1231-1235
        • Wenman W.M.
        • Tataryn I.V.
        • Joffres M.R.
        • et al.
        Demographic, clinical and microbiological characteristics of maternity patients: a Canadian clinical cohort study.
        Can J Infect Dis. 2002; 13: 311-318
        • Goldenberg R.
        • Klebanoff M.
        • Nugent R.
        • et al.
        • for the Vaginal Infections and Prematurity Study Group
        Bacterial colonization of the vagina during pregnancy in four ethnic groups.
        Am J Obstet Gynecol. 1996; 174: 1618-1621
        • Jonsson M.
        • Karlsson R.
        • Rylander E.
        • et al.
        The associations between risk behavior and reported history of sexually transmitted diseases, among young women: a population based study.
        Int J STD AIDS. 1997; 8: 501-505
        • Bump R.
        • Buesching III, W.B.
        Bacterial vaginosis in virginal and sexually active adolescent females: evidence against exclusive sexual transmission.
        Am J Obstet Gynecol. 1988; 158: 935-939
        • Hawes S.E.
        • Hillier S.L.
        • Benedetti J.
        • et al.
        Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections.
        J Infect Dis. 1996; 174: 1058-1063
        • Nugent R.P.
        • Krohn M.A.
        • Hillier S.L.
        Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation.
        J Clin Microbiol. 1991; 29: 297-301
        • Van Schalkwyk J.
        • Money D.M.
        Pregnancy.
        in: Canadian guidelines on sexually transmitted infections. 2006 edition. Public Health Agency of Canada, Ottawa2006: 273-291
        • Caro-Paton T.
        • Carvajal A.
        • Martin de Diego I.
        • et al.
        Is metronidazole teratogenic: a meta-analysis.
        Br J Clin Pharmacol. 1997; 44: 179-182
        • Burtin P.
        • Taddio A.
        • Ariburnu O.
        • et al.
        Safety of metronidazole in pregnancy: a meta-analysis.
        Am J Obstet Gynecol. 1995; 172: 525-529
        • Sarwal S.
        Vaginal discharge (bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis).
        in: Canadian guidelines on sexually transmitted infections. 2006 edition. Public Health Agency of Canada, Ottawa2006: 106-121
        • Guise J.M.
        • Mahon S.M.
        • Aickin M.
        • et al.
        Screening for bacterial vaginosis in pregnancy.
        Am J Prev Med. 2001; 20: 62-72
        • McGregor J.A.
        • French J.I.
        • Jones W.
        • et al.
        Bacterial vaginosis is associated with prematurity and vaginal fluid mucinase and sialidase: results of a controlled trial of topical clindamycin cream.
        Am J Obstet Gynecol. 1994; 170: 1048-1060
        • Hauth J.C.
        • Goldenberg R.L.
        • Andrews W.W.
        • et al.
        Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis.
        N Engl J Med. 1995; 333: 1732-1736
        • McDonald H.M.
        • O'Loughlin J.A.
        • Vigneswaran R.
        • et al.
        Bacterial vaginosis in pregnancy and efficacy of short-course oral metronidazole treatment: a randomized controlled trial.
        Obstet Gynecol. 1994; 84: 343-348
        • Carey J.C.
        • Klebanoff M.A.
        • Hauth J.C.
        • et al.
        Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis.
        N Engl J Med. 2000; 342: 534-540
        • Klebanoff M.A.
        • Hauth J.C.
        • MacPherson C.A.
        • et al.
        Time course of the regression of asymptomatic bacterial vaginosis in pregnancy with and without treatment.
        Am J Obstet Gynecol. 2004; 190: 363-370
        • McGregor J.A.
        • French J.I.
        • Parker R.
        • et al.
        Prevention of premature birth by screening and treatment for common genital tract infections: Results of a prospective controlled evaluation.
        Am J Obstet Gynecol. 1995; 173: 157-167
        • Ugwumadu A.
        • Reid F.
        • Hay P.
        • et al.
        Natural history of bacterial vaginosis and intermediate flora in pregnancy and effect of oral clindamycin.
        Obstet Gynecol. 2004; 104: 114-119
        • Joesef M.R.
        • Hillier S.L.
        • Wiknjosastro G.
        • et al.
        Intravaginal clindamycin treatment for bacterial vaginosis: Effects on preterm delivery and low birth weight.
        Am J Obstet Gynecol. 1995; 173: 1527-1531
        • Kekki M.
        • Kurki T.
        • Pelkonen J.
        • et al.
        Vaginal clindamycin in preventing preterm birth and peripartal infections in asymptomatic women with bacterial vaginosis: a randomized, controlled trial.
        Obstet Gynecol. 2001; 97: 643-648
        • Kurkinen-Räty M.
        • Vuopala S.
        • Koskela M.
        • et al.
        A randomised controlled trial of vaginal clindamycin for early pregnancy bacterial vaginosis.
        BJOG. 2000; 107: 1427-1432
        • Lamont R.F.
        • Jones B.M.
        • Mandal D.
        • et al.
        The efficacy of vaginal clindamycin for the treatment of abnormal genital tract flora in pregnancy.
        Infect Dis Obstet Gynecol. 2003; 11: 181-189
        • Yudin M.H.
        • Landers D.V.
        • Meyn L.
        • et al.
        Clinical and cervical cytokine response to treatment with oral or vaginal metronidazole for bacterial vaginosis during pregnancy: a randomized trial.
        Obstet Gynecol. 2003; 102: 527-534
        • Guaschino S.
        • Ricci E.
        • Franchi M.
        • et al.
        Treatment of asymptomatic bacterial vaginosis to prevent pre-term delivery: a randomized trial.
        Eur J Obstet Gynecol Reprod Biol. 2003; 110: 149-152
        • Morales W.J.
        • Schorr S.
        • Albritton J.
        Effect of metronidazole in patients with preterm birth in preceding pregnancy and bacterial vaginosis: a placebo-controlled, double-blind study.
        Am J Obstet Gynecol. 1994; 171: 345-347
        • McDonald H.
        • Brocklehurst P.
        • Parsons J.
        • et al.
        Antibiotics for treating bacterial vaginosis in pregnancy.
        Cochrane Database Syst Rev. 2007; : CD000262
        • Okun N.
        • Gronau K.A.
        • Hannah M.E.
        Antibiotics for bacterial vaginosis or trichomonas vaginalis in pregnancy: a systematic review.
        Obstet Gynecol. 2005; 105: 857-868
        • Shennan A.
        • Crawshaw S.
        • Briley A.
        • et al.
        A randomised controlled trial of metronidazole for the prevention of preterm birth in women positive for cervicovaginal fetal fibronectin: the PREMET trial.
        BJOG. 2006; 113: 65-74
        • Morency A.
        • Bujold E.
        The effect of second-trimester antibiotic therapy on the rate of preterm birth.
        J Obstet Gynaecol Can. 2007; 29: 35-44
        • Vermeulen G.
        • Bruinse H.
        Prophylactic administration of clindamycin 2% vaginal cream to reduce the incidence of spontaneous preterm birth in women with an increased recurrence risk: A randomized placebo controlled double blind trial.
        Br J Obstet Gynaecol. 1999; 106: 652-657
        • Lamont R.F.
        • Duncan S.L.B.
        • Mandal D.
        • et al.
        Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora.
        Obstet Gynecol. 2003; 101: 516-522
        • Leitich H.
        • Brunbauer M.
        • Bodner-Adler B.
        • et al.
        Antibiotic treatment of bacterial vaginosis in pregnancy: a meta-analysis.
        Am J Obstet Gynecol. 2003; 188: 752-758