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2ODRIGO 0AUPERIO 3OARES DE #AMARGO *OSÏ !NTONIO 3IMÜES *OSÏ 'UILHERME #ECATTI 6ALÏRIA -ORAES .ADER !LVES 3EBASTIAN &ARO
)MPACT OF TREATMENT FOR BACTERIAL VAGINOSIS ON PREMATURITY AMONG "RAZILIAN PREGNANT WOMEN A RETROSPECTIVE COHORT STUDY $EPARTMENT OF /BSTETRICS AND 'YNECOLOGY 5NIVERSIDADE %STADUAL DE #AMPINAS #AMPINAS 3áO 0AULO "RAZIL
-/, / #/.4%84 !.$ /"*%#4)6% "ACTERIAL VAGINOSIS HAS BEEN ASSOCIATED WITH PREMATURITY AND OTHER PERINATAL COMPLICATIONS (OWEVER THE EFlCACY OF THE TREATMENT FOR PREVENTING SUCH COMPLICA TIONS HAS NOT YET BEEN WELL ESTABLISHED 4HE OBJECTIVE OF THIS STUDY WAS TO EVALUATE THE IMPACT OF TREATMENT FOR BACTERIAL VAGINOSIS ON A LOW RISK POPULATION OF "RAZILIAN PREGNANT WOMEN IN ORDER TO PREVENT PREMATURITY AND OTHER PERINATAL COMPLICATIONS $%3)'. !.$ 3%44).' /BSERVATIONAL RETROSPEC TIVE COHORT STUDY AT THE /BSTETRIC AND 'YNECOL OGY $EPARTMENT 5NIVERSIDADE %STADUAL DE #AMPINAS 5NICAMP -%4(/$3 6AGINAL BACTERIOSCOPY RESULTS FROM LOW RISK PREGNANT WOMEN WERE STUDIED 4HREE DIFFERENT GROUPS OF WOMEN WERE IDENTI lED WITHOUT BACTERIAL VAGINOSIS DURING PREGNANCY WITH BACTERIAL VAGINOSIS TREATED USING IMIDAZOLES METRONIDAZOLE TINIDAZOLE OR SECNIDAZOLE DURING PREGNANCY AND WITH BAC TERIAL VAGINOSIS NOT TREATED DURING PREGNANCY 4HE DIAGNOSIS OF BACTERIAL VAGINOSIS WAS BASED ON .UGENTS CRITERIA FROM THE VAGINAL BACTERIOSCOPY PERFORMED DURING THE lRST PRENATAL CARE VISIT 2%35,43 4HE FREQUENCY OF PREMATURITY WAS AMONG THE WOMEN WITHOUT BACTERIAL VAGINOSIS AMONG THOSE WITH UNTREATED BACTERIAL VAGINOSIS AND AMONG THOSE WITH TREATED BACTERIAL VAGINOSIS 4HE RISK RATIOS FOR PERINATAL COMPLICATIONS WERE SIGNIlCANTLY HIGHER IN THE GROUP WITH UNTREATED BACTERIAL VAGINOSIS PRE MATURE RUPTURE OF MEMBRANES #) PRETERM LABOR #) PRETERM BIRTH #) AND LOW BIRTH WEIGHT #) #/.#,53)/. 4HE TREATMENT OF BACTERIAL VAGINO SIS SIGNIlCANTLY REDUCED THE RATES OF PREMATURITY AND OTHER PERINATAL COMPLICATIONS AMONG THESE LOW RISK "RAZILIAN PREGNANT WOMEN REGARDLESS OF THE HISTORY OF PREVIOUS PRETERM DELIVERY +%9 7/2$3 "ACTERIAL VAGINOSIS 0REGNANCY 0REMATURE INFANT 0ERINATAL CARE 0REGNANCY COMPLICATIONS
/," 1 /" 7HILE A DRASTIC REDUCTION IN NEONATAL MORTALITY HAS BEEN OBSERVED OVER RECENT YEARS ESPECIALLY IN DEVELOPED COUNTRIES THE INCIDENCE OF PREMATURITY HAS REMAINED PRACTI CALLY CONSTANT !LTHOUGH VARIOUS PROGRAMS AND THERAPEUTIC REGIMENS HAVE BEEN IMPLEMENTED TO REDUCE THE INCIDENCE OF PREMATURE BIRTH THE RATE REMAINS BETWEEN AND 4HESE PREMATURE BIRTHS ACCOUNT FOR OF ALL NEONATAL DEATHS )N THE CITY OF #AMPINAS 3TATE OF 3AO 0AULO "RAZIL A SURVEY INDICATED THAT OF NEWBORNS HAD LOW BIRTH WEIGHT AND WERE PREMATURE 4HE MULTIPLE RISK FACTORS ASSOCIATED WITH PREMATURITY INCLUDE PREMATURE RUPTURE OF THE MEMBRANES PREVIOUS PREMATURE BIRTH HEAVY PHYSICAL WORK BLACK ETHNICITY AND AGE GREATER THAN YEARS OLD 4O PREVENT PREMATURITY THE IDEAL COURSE OF ACTION WOULD BE TO PREDICT WHICH PATIENTS ARE AT RISK OF PREMATURE DELIVERY AND THEN IMPLEMENT EFFECTIVE INTERVENTION )N SEVERAL STUDIES BACTERIAL VAGINOSIS HAS BEEN ASSOCIATED WITH PREMATURITY AND OTHER ADVERSE OUTCOMES INDEPENDENT OF OTHER KNOWN RISK FACTORS 7HILE BACTERIAL VAGINO SIS HAS BEEN ASSOCIATED WITH PRETERM DELIVERY AND LOW BIRTH WEIGHT RANDOMIZED TRIALS FOR THE TREATMENT OF BACTERIAL VAGINOSIS DURING PREGNANCY HAVE NOT ALWAYS DEMONSTRATED A REDUCTION IN SUCH OUTCOMES 4HE TREATMENT OF CHOICE FOR BACTERIAL VAGI NOSIS HAS BEEN METRONIDAZOLE IN THE 5NITED 3TATES 4RIALS HAVE FOUND A SIGNIlCANT REDUC TION IN THE RATE OF PREMATURE BIRTHS AMONG PREGNANT WOMEN WHO PRESENTED HIGH RISK OF PREMATURITY AND WHOSE BACTERIAL VAGINOSIS WAS TREATED WITH METRONIDAZOLE /N THE OTHER HAND THERE ARE SIMILAR TRIALS THAT DID NOT lND A DECREASE IN THE PREMATURITY RATES AMONG LOW RISK POPULATIONS 4HE LACK OF BENElCIAL EFFECT FROM METRONIDAZOLE MAY HOWEVER BE RELATED TO THE DOSING REGIMENS USED
! RECENT META ANALYSIS THAT COMPARED TREATMENT OF BACTERIAL VAGINOSIS WITH PLACEBO FOUND THAT THE EVIDENCE DID NOT SUPPORT SYS TEMATIC SCREENING FOR AND TREATMENT OF BACTE RIAL VAGINOSIS FOR ALL PREGNANT WOMEN AIMED AT PREVENTING PREMATURE BIRTH POSTPARTUM INFECTION AND NEONATAL SEPSIS (OWEVER THERE WAS EVIDENCE THAT INDICATED THAT FOR WOMEN WITH A HISTORY OF PREMATURE BIRTH TREATMENT OF BACTERIAL VAGINOSIS COULD PREVENT SUBSEQUENT PRETERM BIRTH ! "RAZILIAN STUDY HAS FOUND PREVA LENCE OF BACTERIAL VAGINOSIS AMONG ASYMP TOMATIC PREGNANT WOMEN )N ADDITION A SIGNIlCANTLY INCREASED RISK OF NEONATAL COM PLICATIONS WAS FOUND AMONG THIS POPULATION 4HE PRESENT STUDY WAS CONDUCTED TO EVALUATE THE IMPACT OF TREATMENT FOR BACTERIAL VAGINOSIS AMONG A POPULATION OF "RAZILIAN PREGNANT WOMEN IN ORDER TO PREVENT PREMATURITY AND OTHER UNDESIRED OUTCOMES FROM PREGNANCY /" )N AN ATTEMPT TO DETERMINE WHETHER THE TREATMENT OF BACTERIAL VAGINOSIS DURING PRENATAL CARE REDUCED THE INCIDENCE OF PRETERM DELIVERY WE CONDUCTED THE PRESENT OBSERVATIONAL RETRO SPECTIVE COHORT STUDY AMONG ALL WOMEN WHO WERE ATTENDING THE /BSTETRIC 3ERVICE AT THE 5NIVERSIDADE %STADUAL DE #AMPINAS 5NICAMP "RAZIL BETWEEN *ANUARY AND -ARCH 4HE STUDY MADE USE OF THE RESULTS FROM VAGINAL 'RAM STAINS AVAILABLE IN THE PATIENTS RECORDS 4HEWOMENWERECATEGORIZEDINTHREEDIFFERENT GROUPS THAT WERE IDENTIlED WITH REGARD TO BACTERIAL VAGINOSIS ONE GROUP WITHOUT DETECTION OF BACTE RIAL VAGINOSIS AT THE lRST PRENATAL CARE VISIT WOMEN ONE GROUP WITH BACTERIAL VAGINOSIS TREAT ED WITH IMIDAZOLIC ANTIBIOTICS DURING PREGNANCY WOMEN AND ONE GROUP WITH BACTERIAL VAGINOSIS THAT WAS NOT TREATED DURING THE GESTATION WOMEN )NSTITUTIONAL 2EVIEW "OARD APPROVAL WAS OBTAINED FOR THE STUDY
3AO 0AULO -ED *
'&/
4HE DIAGNOSIS OF BACTERIAL VAGINOSIS WAS BASED ON 'RAMS STAIN USING .UGENTS CRITE RIA 6AGINAL SWAB SAMPLES HAD BEEN COLLECTED FROM EACH PREGNANT WOMAN DURING THE lRST PRENATAL CARE VISIT 4HE DECISION REGARDING WHICH ANTIPROTOZOAL AGENT TO USE METRONI DAZOLE TINIDAZOLE OR SECNIDAZOLE WAS BASED ON THE ATTENDING PHYSICIANS CHOICE AND THE AVAILABILITY OF THE AGENTS AT THE CLINIC 7OMEN WERE NOT INCLUDED IN THIS STUDY IF THEY HAD GESTATIONAL AGE GREATER THAN WEEKS AT THE lRST PRENATAL CARE VISIT DIABETES ARTERIAL HYPERTENSION OF ANY ETIOLOGY MULTIPLE GESTATIONS POLYHYDRAMNIOS PLACENTA PREVIA ABRUPTIO PLACENTAE FETAL MALFORMATION OR INFECTION OF THE GENITAL TRACT BY 4RICHOMONAS VAGINALIS #HLAMYDIA TRACHOMATIS OR .EISSERIA GONORRHOEAE !LL THESE EXCLUSION CRITERIA WERE BASED ON THE APPEARANCE OF SUCH DIAGNOSES IN THE PATIENTS CHART 4INIDAZOLE AND SECNIDAZOLE HAVE BEEN AP PROVED FOR USE IN "RAZIL AND ALSO IN %UROPE AND ARE COMPARABLE TO METRONIDAZOLE WITH REGARD TO EFlCACY 4INIDAZOLE AND SECNIDAZOLE ARE FREQUENTLY USED AS AN ALTERNATIVE TO METRO NIDAZOLE DEPENDING ON THEIR AVAILABILITY IN THE HOSPITAL PHARMACY AND THEY ARE DISPENSED TO PATIENTS AT 5NICAMP WITHOUT CHARGE !S THERE ARE ESSENTIALLY NO KNOWN DIFFER ENCES IN THE TREATMENT REGIMENS WITH REGARD TO THEIR EFlCACY FOR TREATING BACTERIAL VAGI NOSIS AT THE TIME OF THE STUDY WE FOUND THAT SEVERAL THERAPEUTIC REGIMENS HAD BEEN USED METRONIDAZOLE MGDAY ORALLY FOR SEVEN DAYS WOMEN METRONIDAZOLE TINIDAZOLE OR SECNIDAZOLE G ORALLY SINGLE DOSE THREE FOUR AND FOUR WOMEN RESPECTIVELY OR MET RONIDAZOLE OR TINIDAZOLE GEL ONE FULL APPLICATOR INTRAVAGINALLY ONCE A DAY FOR SEVEN DAYS AND NINE WOMEN RESPECTIVELY 4HE IMIDAZOLE ADMINISTRATION ROUTE WAS NOT STATED IN THE CLINICAL RECORD lLES FOR PATIENTS WITH TREATED BACTERIAL VAGINOSIS 4HE THERAPEUTIC REGIMEN WAS CHOSEN AT THE DISCRETION OF THE ATTENDING CLINICIAN 4HEY HAD GREATLY DIFFERING OPINIONS REGARDING TREATMENT 3INCE AT THAT TIME TREATMENT WAS NOT CONSID ERED TO BE MANDATORY SEVERAL ATTENDING PHYSI CIANS DID NOT TREAT CASES OF BACTERIAL VAGINOSIS &URTHERMORE SOME WOMENS CLINICAL RECORDS CONlRMED THAT BACTERIAL VAGINOSIS HAD BEEN TREATED USING ONE OF THESE DRUGS BUT THE IMID AZOLE ADMINISTRATION ROUTE WAS NOT STATED 0RETERM PREMATURE RUPTURE OF MEMBRANES WAS DElNED AS RUPTURE OF THE AMNIOTIC MEM BRANES BEFORE THE TH WEEK OF PREGNANCY AND BEFORE THE ONSET OF LABOR 0REMATURE LABOR WAS DElNED AS THE OC CURRENCE OF REGULAR AND PERSISTENT UTERINE
3AO 0AULO -ED *
TREATED BACTERIAL VAGINOSIS AND WITH UNTREATED BACTERIAL VAGINOSIS %IGHTY TWO PERCENT OF THE SAMPLES WERE COLLECTED BEFORE WEEKS OF GESTATION AND THE MEAN GESTATIONAL AGE AT THE TIME OF COLLECTION WAS WEEKS 4HERE WERE NO STATISTICALLY SIGNIlCANT DIFFER ENCES BETWEEN THE THREE GROUPS WITH REGARD TO THE SOCIODEMOGRAPHIC CHARACTERISTICS HABITS AND OBSTETRIC ANTECEDENTS EXCEPT FOR THE SMOKING HABIT WHICH WAS HIGHER IN THE GROUPS WITH BACTERIAL VAGINOSIS 4HERE WERE NO SIGNIFICANT DIFFERENCES IN PRETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES PREMATURE LABOR PREMATURE BIRTH AND LOW BIRTH WEIGHT NEWBORNS BETWEEN THE GROUP WITHOUT BACTERIAL VAGINOSIS AND THE TREATED GROUP /N THE OTHER HAND THERE WAS A STATISTICALLY SIGNIlCANT DIFFERENCE BETWEEN THE GROUPS WITH TREATED AND UNTREATED BACTERIAL VAGINOSIS WITH REGARD TO ADVERSE PERINATAL OUTCOMES 4ABLE 4HE MULTIPLE LOGISTICAL REGRESSION ANALYSIS FOR THE TREATED AND UNTREATED BACTERIAL VAGI NOSIS GROUPS IDENTIlED YOUNGER AGE AND UN TREATED BACTERIAL VAGINOSIS AS FACTORS THAT WERE ASSOCIATED WITH PRETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES 4HE FACTORS ASSOCIATED WITH PREMATURE LABOR WERE PRETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES AND UNTREATED BACTERIAL VAGINOSIS WHILE THE FACTORS ASSOCIATED WITH PREMATURE BIRTH WERE PRETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES PRETERM LABOR AND UNTREATED BACTERIAL VAGINOSIS &INALLY THE REGRESSION MODEL ONLY IDENTIlED PREMATURE BIRTH AS A STATISTICALLY SIGNIlCANT FACTOR ASSOCI ATED WITH LOW BIRTH WEIGHT 4HERE WAS NO OCCURRENCE OF PUERPERAL INFECTION OR AMNIONITIS IN THE GROUP WITH TREATED BACTERIAL VAGINOSIS AND LOW FREQUENCY OF THIS IN THE GROUP WITHOUT BACTERIAL VAGI
CONTRACTIONS BEFORE THE TH WEEK OF PREGNANCY )N ADDITION THE PATIENT HAD TO DEMONSTRATE CERVICAL DILATATION AND EFFACEMENT THAT RE QUIRED TREATMENT USING TOCOLYTICS ! PREMATURE BIRTH WAS DElNED AS A NEW BORN WITH LESS THAN WEEKS DAYS OF GES TATION 4HE LENGTH OF GESTATION WAS DETERMINED FROM THE DATE OF THE LAST MENSTRUAL PERIOD OBSTETRIC SONOGRAPHY ANDOR EXAMINATION OF THE NEWBORN USING THE #APURRO METHOD .EWBORNS WEIGHING LESS THAN G WERE CONSIDERED TO HAVE LOW BIRTH WEIGHT )NFANTS WERE CONSIDERED TO PRESENT NEO NATAL MORBIDITY IF THEY DEVELOPED COMPLICA TIONS DURING THE NEWBORN PERIOD REQUIRING ADMISSION TO THE NEONATAL SEMI INTENSIVE ANDOR INTENSIVE CARE UNIT FOR EXAMPLE DUE TO RESPIRATORY DISTRESS NEONATAL ANOXIA HYPO GLYCEMIA OR SEPSIS -ATERNAL MORBIDITY WAS CONSIDERED TO BE PRESENT IF THERE WAS THE PRESENCE OF ENDOMETRI TIS ANDOR INFECTION OF A SURGICAL WOUND THAT REQUIRED HOSPITAL ADMISSION #HORIOAMNIONITIS WAS DElNED AS MATERNAL FEVER TEMPERATURE r # AND AMNIOTIC mUID WITH ODOR 4HE STATISTICAL ANALYSIS WAS PERFORMED US ING THE CHI SQUARED AND &ISHER EXACT TESTS FOR CATEGORY VARIABLES AND VARIANCE ANALYSIS FOR QUANTITATIVE VARIABLES &OR THE MAIN DEPENDENT VARIABLES THE RISK RATIO WAS CALCULATED WITH A CONlDENCE INTERVAL &URTHERMORE MULTI PLE LOGISTICAL REGRESSION ANALYSIS WAS PERFORMED TO COMPARE THE GROUPS WITH TREATED BACTERIAL VAGINOSIS AND UNTREATED BACTERIAL VAGINOSIS , -1 /4HE AVERAGE AGES IN YEARS WERE p p AND p RESPECTIVELY FOR THE GROUPS WITHOUT BACTERIAL VAGINOSIS WITH
4ABLE #OMPARISON OF ADVERSE PERINATAL OUTCOMES BETWEEN PREGNANT WOMEN GROUPS WITH TREATED AND UNTREATED BACTERIAL VAGINOSIS IN A UNIVERSITY HOSPITAL IN "RAZIL !DVERSE PERINATAL OUTCOMES
0RETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES
4REATED BACTERIAL VAGINOSIS N
5NTREATED BACTERIAL VAGINOSIS N
P VALUE
0REMATURE LABOR
o
0REMATURE BIRTH
p
,OW BIRTH WEIGHT
e
0UERPERAL INFECTION
!MNIONITIS
,ENGTH OF STAY IN NEONATAL INTENSIVE CARE UNIT r DAYS .EONATAL MORBIDITY
2ISK 2ATIO #) o p e
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NOSIS #ONVERSELY THE OCCURRENCE OF PUER PERAL INFECTION AMNIONITIS AND NEONATAL MORBIDITY AND THE LENGTH OF STAY IN NEONATAL INTENSIVE CARE UNITS WAS SIGNIlCANTLY HIGHER IN THE GROUP WITH UNTREATED BACTERIAL VAGI NOSIS THAN IN THE GROUP WITH TREATED BACTERIAL VAGINOSIS 4ABLE !N ANALYSIS OF THE SUBGROUPS EXCLUDING WOMEN WITH A HISTORY OF PREVIOUS PRETERM DELIVERY WAS ALSO PERFORMED .O SIGNIlCANT DIFFERENCES IN THE INCIDENCE OF PERINATAL COMPLICATIONS WAS FOUND BETWEEN THE GROUPS WITHOUT BACTERIAL VAGINOSIS AND WITH TREATED BACTERIAL VAGINOSIS EXCEPT WITH RESPECT TO PRETERM PREMATURE RUPTURE OF AMNIOTIC MEM BRANES VERSUS P /N THE OTHER HAND THE INCIDENCE OF MOST PERINATAL COMPLICATIONS WAS SIGNIFICANTLY HIGHER IN THE GROUP WITH UNTREATED BACTERIAL VAGINOSIS THAN IN THE GROUP WITH TREATED BACTE RIAL VAGINOSIS 4ABLE 4HE RELATIONSHIP BETWEEN THE INCIDENCE OF PERINATAL COMPLICATIONS AND THE DIFFERENT ROUTES OF TREATMENT ORAL OR VAGINAL WAS ALSO ANALYZED .O SIGNIFICANT DIFFERENCES WERE FOUND WITH REGARD TO PRETERM PREMATURE RUP TURE OF MEMBRANES PREMATURE LABOR AND LOW BIRTH WEIGHT IN THE GROUPS WITH ORAL OR VAGINAL TREATMENT 0REMATURE BIRTH WAS SIGNIlCANTLY MORE FREQUENT IN THE SUBGROUP WITH VAGINAL TREATMENT P
NANT WOMEN WITH TREATED BACTERIAL VAGINOSIS THAN AMONG THOSE WITH UNTREATED BACTERIAL VAGINOSIS &URTHERMORE THE FREQUENCIES WERE SIMILAR BETWEEN THE WOMEN WITH TREATED BACTE RIAL VAGINOSIS AND THE CONTROLS THOSE WITHOUT BACTERIAL VAGINOSIS 4HE THREE GROUPS OF WOMEN WERE HOMO GENEOUS WITH REGARD TO OBSTETRIC AND SOCIODE MOGRAPHIC CHARACTERISTICS )N GENERAL THESE VARIABLES HAD HOMOGENEOUS DISTRIBUTION IN THE SAMPLE EXCEPT FOR SMOKING %VEN SO WHEN SMOKING WAS COMPARED ONLY BETWEEN THE TWO GROUPS WITH BACTERIAL VAGINOSIS TREATED AND UNTREATED THE DIFFERENCE WAS NOT SIGNIlCANT FOR THIS VARIABLE EITHER 3INCE THESE TWO GROUPS DID NOT DIFFER IN DEMOGRAPHIC CHARACTERISTICS WE CAN ASSUME THAT THESE DEMOGRAPHIC CHAR ACTERISTICS HAD NO IMPACT OR ASSOCIATION WITH PRETERM BIRTH IN THIS STUDY 4HE WOMEN WERE NOT RANDOMIZED AND THERE WERE NO CRITERIA USED IN MAKING THE DECISION OF WHETHER TO TREAT AND WHICH ROUTE TO USE FOR THE IMIDAZOLE OR NOT TO TREAT 4HE ATTENDING PHYSICIAN HAD THE RESPONSIBILITY FOR MAKING THESE DECISIONS AND THIS MAY HAVE INTRODUCED A SIGNIlCANT SELECTION BIAS 0RETERM LABOR WAS THE MOST PREVALENT NEO NATAL OUTCOME FOR ALL GROUPS 4HE OCCURRENCE OF PRETERM LABOR WAS THREE TIMES HIGHER IN THE GROUP WITH UNTREATED BACTERIAL VAGINOSIS THAN AMONG THE TREATED WOMEN 0RETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES OCCURRED SEVEN TIMES MORE FREQUENTLY IN THE GROUP WITH UNTREATED BACTERIAL VAGINOSIS THAN IN THE GROUP WITH TREATED BACTERIAL VAGINOSIS ! RECENT PUBLICATION HAS ALSO DEMONSTRATED THAT TREAT MENT OF BACTERIAL VAGINOSIS DURING THE PRENATAL PERIOD RESULTED IN A REDUCTION IN THE RATE OF PREMATURE RUPTURE OF THE MEMBRANES BUT ONLY FOR WOMEN AT HIGHER RISK OF PREMATURITY IE THOSE WITH A HISTORY OF PRETERM BIRTH 4HIS
- 1--" 4HE RESULTS OF THIS STUDY HAVE DEMONSTRAT ED THAT THE TREATMENT OF BACTERIAL VAGINOSIS HAD A FAVORABLE IMPACT ON REDUCING THE OCCURRENCE OF PRETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES PREMATURE LABOR AND BIRTH LOW BIRTH WEIGHT AND NEONATAL MORBIDITY AMONG "RAZILIAN WOMEN 4HESE COMPLICATIONS WERE SIGNIlCANTLY LESS FREQUENT AMONG THE PREG
4ABLE #OMPARISON OF ADVERSE PERINATAL OUTCOMES BETWEEN THE PREGNANT WOMEN GROUPS WITH TREATED AND UNTREATED BACTERIAL VAGINOSIS EXCLUDING THE WOMEN WITH A HISTORY OF PRETERM DELIVERY IN A UNIVERSITY HOSPITAL IN "RAZIL !DVERSE PERINATAL OUTCOMES
4REATED BACTERIAL VAGINOSIS
5NTREATED BACTERIAL VAGINOSIS
P VALUE
N
N
0REMATURE LABOR
0REMATURE BIRTH
,OW BIRTH WEIGHT
0UERPERAL INFECTION
!MNIONITIS
0RETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES
.EONATAL MORBIDITY
&OURTEEN WOMEN HAD PREVIOUS PRETERM DELIVERY AMONG THE WOMEN WITH TREATED BACTERIAL VAGINOSIS AND lVE IN THE UNTREATED BACTERIAL VAGINOSIS GROUP
SUGGESTS THAT WOMEN AT RISK OF PRETERM DELIVERY SHOULD BE SCREENED IF POSSIBLE PRIOR TO CONCEP TION OR EARLY IN THE PREGNANCY AND TREATED 7OMEN WITH A HISTORY OF PRETERM DELIVERY AND BACTERIAL VAGINOSIS MAY HAVE SUBCLINICAL OR ASYMPTOMATIC ENDOMETRITIS AND THEREFORE MAY EXPERIENCE AN INmAMMATORY RESPONSE WHEN BECOMING PREGNANT $EVELOPING RECUR RENT EPISODES OF BACTERIAL VAGINOSIS MAY INDUCE AN ENHANCED INmAMMATORY RESPONSE THEREBY RESULTING IN PREMATURE RUPTURE OF AMNIOTIC MEMBRANES AND PRETERM LABOR OR PRETERM LABOR WITH INTACT AMNIOTIC MEMBRANES +ORN ET AL SHOWED THE EXISTENCE OF ASYMPTOMATIC ENDOMETRITIS IN NON PREGNANT WOMEN 4HE ESTIMATED RISK OF PRETERM BIRTH WAS SIX TIMES HIGHER AMONG WOMEN WITH UNTREATED BACTERIAL VAGINOSIS THAN IN THE GROUP WITH TREATED BACTERIAL VAGINOSIS 4HE HIGH RATE OF PRETERM BIRTH AMONG WOMEN WITH UNTREATED BACTERIAL VAGINOSIS IS PERHAPS EXPLAINED IN PART BY THE DESIGN LIMITATIONS OF THE STUDY 4HE RELATIVE RISK OF PRETERM BIRTH AMONG WOMEN WITH BACTERIAL VAGINOSIS RANGES FROM TO IN MOST OF THE PUBLISHED STUD IES 4HESE RATES ARE RATHER LOWER THAN THE RATE FOUND IN THE PRESENT STUDY (OWEVER (AY ET AL ALSO FOUND A RELATIVE RISK OF WHICH IS VERY SIMILAR TO OUR RESULTS )N ADDITION OTHER PUBLISHED DATA HAVE ALSO SUGGESTED THAT TREAT MENT OF BACTERIAL VAGINOSIS DURING PREGNANCY CAN REDUCE THE RISK OF NEONATAL COMPLICATIONS ESPECIALLY PREMATURITY 4HE INCIDENCE OF LOW BIRTH WEIGHT INFANTS WAS FOUR TIMES HIGHER IN THE GROUP OF WOMEN WITH UNTREATED BACTERIAL VAGINOSIS THAN AMONG THOSE WITH TREATED BACTERIAL VAGINOSIS ,OW BIRTH WEIGHT HAS BEEN ASSUMED TO BE A RESULT OF THE PRETERM PREMATURE RUPTURE OF AMNIOTIC MEMBRANES AND THE PRETERM BIRTH RATHER THAN A DIRECT COMPLICATION OF BACTERIAL VAGINOSIS 0UERPERAL INFECTION WAS A SIGNIFICANT OUTCOME IN THIS STUDY IN THE GROUP WITH UNTREATED BACTERIAL VAGINOSIS )N ALL CASES OF PUERPERAL INFECTION THE DELIVERY WAS BY MEANS OF CESAREAN SECTION )T IS IMPORTANT TO HIGHLIGHT THAT ALL THE WOMEN WHO UNDERWENT CESAREAN SECTION RECEIVED CEPHAZOLIN G )6 IN A SINGLE DOSE IMMEDIATELY AFTER CUTTING THE UMBILICAL CORD AS A ROUTINE PROPHYLACTIC PROCEDURE OF OUR SERVICE )T SEEMS THAT THIS ANTIBIOTIC PROPHYLAXIS IS NOT AS EFFECTIVE AS EXPECTED IN PREVENTING PUERPERAL INFECTION AMONG WOMEN WITH BACTERIAL VAGINOSIS AT THE TIME OF DELIVERY )N THE LITERATURE THERE IS ALSO EVIDENCE THAT BACTERIAL VAGINOSIS CAN BE AN IMPORTANT RISK FACTOR FOR ENDOMETRITIS AFTER CESAREAN DELIVERIES IN SPITE OF ANTIBIOTIC PROPHYLAXIS USING CEPHALOSPORIN
3AO 0AULO -ED *
'''
#OMPARING THE ORAL AND INTRAVAGINAL TREATMENT REGIMENS PREMATURITY OCCURRED MORE FREQUENTLY AMONG WOMEN TREATED WITH INTRAVAGINAL ANTIBIOTIC 4HERE WAS A LIMITA TION ON THIS EVALUATION BECAUSE PATIENTS WITH TREATED BACTERIAL VAGINOSIS HAD NO DATA AVAILABLE ON THEIR CHARTS TO SHOW THE ROUTE OF IMIDAZOLE ADMINISTRATION !LSO THE PATIENTS WHO WERE TREATED WITH ANTIBIOTICS RECEIVED ONE OF SIX POSSIBLE REGIMENS 3UCH VARIANCE IN TREAT MENT MAKES IT DIFlCULT TO DRAW CONCLUSIONS ABOUT WHAT ACTUAL EFFECT THERE WAS .EVERTHE LESS THIS RESULT IS IN AGREEMENT WITH A RECENT META ANALYSIS DEMONSTRATING THAT SYSTEMIC TREATMENT DURING PREGNANCY WAS MORE EFlCA CIOUS THAN INTRAVAGINAL METRONIDAZOLE /N THE OTHER HAND #AREY ET AL DID NOT lND A REDUCTION IN THE RATES OF PREMATURITY OR OTHER NEONATAL COMPLICATIONS (OWEVER THEY USED G OF METRONIDAZOLE TWICE FOR TREATMENT OF BACTERIAL VAGINOSIS 4REATMENT OF BACTERIAL VAGINOSIS WITH A SINGLE DOSE OF METRONIDAZOLE
IS ASSOCIATED WITH HIGHER RATES OF RELAPSE THAN IS TREATMENT OVER A LONG PERIOD OF TIME ESPECIALLY WHEN LONG TERM CURE RATES ARE ANALYZED !DMISSION OF THE NEWBORN TO THE NEO NATAL INTENSIVE CARE UNIT WAS SIGNIFICANTLY MORE FREQUENT FOR THE GROUP OF WOMEN WITH UNTREATED BACTERIAL VAGINOSIS ! REDUCTION IN NEONATAL INTENSIVE CARE UNIT ADMISSIONS CAN SIGNIlCANTLY REDUCE COSTS -ÓLLER ET AL RECENTLY DEMONSTRATED THE COST BENEFIT OF DIAGNOSIS AND TREATMENT OF BACTERIAL VAGINOSIS DURING PREGNANCY FOR REDUCING ADMISSIONS TO THE NEONATAL INTENSIVE CARE UNIT IN 'ERMANY 4HIS CAN HAVE AN EVEN GREATER IMPORTANCE IN DEVELOPING COUNTRIES (OWEVER THE ISSUE OF SCREENING FOR AND TREATING BACTERIAL VAGINOSIS AMONG PREGNANT WOMEN REMAINS UNSETTLED 4HE CURRENT LITERA TURE SUGGESTS THAT ONLY WOMEN WITH A HISTORY OF PRETERM BIRTH CAN BENElT FROM TREATMENT OF BACTERIAL VAGINOSIS )N THE PRESENT STUDY AN ANALYSIS OF WOMEN NOT AT RISK OF PRETERM BIRTH
"ROCKLEHURST 0 (ANNAH - -C$ONALD ( )NTERVENTION FOR TREATING BACTERIAL VAGINOSIS IN PREGNANCY )N 4HE #OCHRANE ,IBRARY UPDATE SOFTWARE /XFORD )SSUE 3IMOES *! 'IRALDO 0# #ECATTI *' #AMARGO 203 &AUNDES ! !SSOCIATION BETWEEN PERINATAL COMPLICATIONS AND BACTERIAL VAGINOSIS IN "RAZILIAN PREGNANT WOMEN )NT * 'YNECOL /BSTET SUPPL 3 #AREY *# +LEBANOFF -! (AUTH *# ET AL -ETRONIDAZOLE TO PREVENT PRETERM DELIVERY IN PREGNANT WOMEN WITH ASYMPTOMATIC BACTERIAL VAGINOSIS .ATIONAL )NSTITUTE OF #HILD (EALTH AND (U MAN $EVELOPMENT .ETWORK OF -ATERNAL &ETAL -EDICINE 5NITS . %NGL * -ED GUIDELINES FOR TREATMENT OF SEXUALLY TRANSMITTED DISEASES #ENTERS FOR $ISEASE #ONTROL AND 0REVENTION --72 2ECOMM 2EP 22 -ORALES 7* 3CHORR 3 !LBRITTON * %FFECT OF METRONIDAZOLE IN PATIENTS WITH PRETERM BIRTH IN PRECEDING PREGNANCY AND BACTERIAL VAGINOSIS A PLACEBO CONTROLLED DOUBLE BLIND STUDY !M * /BSTET 'YNECOL DISCUSSION (AUTH *# 'OLDENBERG 2, !NDREWS 77 $U"ARD -" #OOPER 2, 2EDUCED INCIDENCE OF PRETERM DELIVERY WITH METRONIDAZOLE AND ERYTHROMYCIN IN WOMEN WITH BACTERIAL VAGINOSIS . %NGL * -ED -C$ONALD (- /,OUGHLIN *! 6IGNESWARAN 2 ET AL )MPACT OF METRONIDAZOLE THERAPY ON PRETERM BIRTH IN WOMEN WITH BACTERIAL VAGINOSIS mORA 'ARDNERELLA VAGINALIS A RANDOMIZED PLACEBO CONTROLLED TRIAL "R * /BSTET 'YNAECOL -C#LEAN ( )MPACT OF METRONIDAZOLE THERAPY ON PRETERM BIRTH IN WOMEN WITH BACTERIAL VAGINOSIS mORA "R * /BSTET 'YNAECOL 3IMOES *! 'IRALDO 0# &A¢NDES ! 0REVALENCE OF CERVICOVAGINAL INFECTIONS DURING GESTATION AND ACCURACY OF CLINICAL DIAGNOSIS )NFECT $IS /BSTET 'YNECOL .UGENT 20 +ROHN -! (ILLIER 3, 2ELIABILITY OF DIAG NOSING BACTERIAL VAGINOSIS IS IMPROVED BY A STANDARDIZED METHOD OF GRAM STAIN INTERPRETATION * #LIN -ICROBIOL
IE WITH NO HISTORY OF PREVIOUS PREMATURITY FOUND THAT THESE WOMEN ALSO BENElTED FROM TREATMENT FOR BACTERIAL VAGINOSIS
" 1-" 4HIS STUDY SHOWS THAT TREATING BACTERIAL VAGINOSIS DURING PREGNANCY COULD SIGNIlCANTLY REDUCE THE RISK OF PREMATURITY AMONG "RA ZILIAN PREGNANT WOMEN 4REATING BACTERIAL VAGINOSIS IN THESE PREGNANT WOMEN RESULTED IN A SIGNIlCANT REDUCTION IN PREMATURE RUPTURE OF THE MEMBRANES PRETERM BIRTH POSTPAR TUM ENDOMETRITIS AND NEONATAL SEPSIS 4HIS POSITIVE EFFECT WAS ALSO DEMONSTRATED AMONG PREGNANT WOMEN WITHOUT A HISTORY OF PREMA TURE BIRTH (OWEVER BECAUSE THE CURRENTLY AVAILABLE KNOWLEDGE IS STILL CONTROVERSIAL AND THIS STUDY HAD SOME LIMITATIONS SIMILAR STUD IES ARE NEEDED IN DISTINCT POPULATIONS BEFORE UNIVERSAL SCREENING AND TREATMENT OF BACTERIAL VAGINOSIS AMONG PREGNANT WOMEN IN DEVELOP ING COUNTRIES CAN BE RECOMMENDED
, ,
-ARTIUS * %SCHENBACH $! 4HE ROLE OF BACTERIAL VAGINOSIS AS A CAUSE OF AMNIOTIC mUID INFECTION CHORIOAMNIONITIS AND PREMA TURITY A REVIEW !RCH 'YNECOL /BSTET "ICALHO -ARIOTONI '' "ARROS &ILHO !! .ASCER EM #AMPINAS ANÕLISE DE DADOS DO 3ISNAC ;,IVEBORN IN #AMPINAS 3)3.!# = 2EV 0AUL 0EDIATR -C'REGOR *! &RENCH *) 0ARKER 2 ET AL 0REVENTION OF PREMATURE BIRTH BY SCREENING AND TREATMENT FOR COMMON GENITAL TRACT INFECTIONS RESULTS OF A PROSPECTIVE CONTROLLED EVALUATION !M * /BSTET 'YNECOL -EIS 0* 'OLDENBERG 2, -ERCER "- ET AL 4HE PRETERM PREDICTION STUDY RISK FACTORS FOR INDICATED PRETERM BIRTHS -A TERNAL &ETAL -EDICINE 5NITS .ETWORK OF THE .ATIONAL )NSTITUTE OF #HILD (EALTH AND (UMAN $EVELOPMENT !M * /BSTET 'YNECOL 'OLDENBERG 2, )AMS *$ -IODOVNIK - ET AL 4HE PRETERM PREDICTION STUDY RISK FACTORS IN TWIN GESTATIONS .ATIONAL )NSTI TUTE OF #HILD (EALTH AND (UMAN $EVELOPMENT -ATERNAL &ETAL -EDICINE 5NITS .ETWORK !M * /BSTET 'YNECOL 0T 0EACEMAN !- !NDREWS 77 4HORP *- ET AL &ETAL lBRONECTIN AS A PREDICTOR OF PRETERM BIRTH IN PATIENTS WITH SYMPTOMS A MULTICENTER TRIAL !M * /BSTET 'YNECOL 7ENNERHOLM 5" (OLM " -ATTSBY "ALTZER ) ET AL )NTERLEU KIN ALPHA INTERLEUKIN AND INTERLEUKIN IN CERVICOVAGINAL SECRETION FOR SCREENING OF PRETERM BIRTH IN TWIN GESTATION !CTA /BSTET 'YNECOL 3CAND (ILLIER 3, .UGENT 20 %SCHENBACH $! ET AL !SSOCIATION BETWEEN BACTERIAL VAGINOSIS AND PRETERM DELIVERY OF LOW BIRTH WEIGHT INFANT 4HE 6AGINAL )NFECTIONS AND 0REMATURITY 3TUDY 'ROUP . %NGL * -ED -EIS 0* 'OLDENBERG 2, -ERCER " ET AL 4HE PRETERM PREDICTION STUDY SIGNIlCANCE OF VAGINAL INFECTIONS .ATIONAL )NSTITUTE OF #HILD (EALTH AND (UMAN $EVELOPMENT -ATERNAL &ETAL -EDICINE 5NITS .ETWORK !M * /BSTET 'YNECOL 3TRAY 0EDERSEN " )S SCREENING FOR GENITAL INFECTIONS IN PREGNANCY NECESSARY !CTA /BSTET 'YNECOL 3CAND 3UPPL
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#APURRO ( +ONICHEZKY 3 &ONSECA $ #ALDEYRO "ARCIA 2 ! SIMPLIlED METHOD FOR DIAGNOSIS OF GESTATIONAL AGE IN THE NEWBORN INFANT * 0EDIATR +ORN !0 (ESSOL .! 0ADIAN .3 ET AL 2ISK FACTORS FOR PLASMA CELL ENDOMETRITIS AMONG WOMEN WITH CERVICAL .EISSERIA GONOR RHOEAE CERVICAL #HLAMYDIA TRACHOMATIS OR BACTERIAL VAGINOSIS !M * /BSTET 'YNECOL 'RAVETT -' .ELSON (0 $E2OUEN 4 #RITCHLOW # %SCHENBACH $! (OLMES ++ )NDEPENDENT ASSOCIATIONS OF BACTERIAL VAGINOSIS AND #HLAMYDIA TRACHOMATIS INFECTION WITH ADVERSE PREGNANCY OUTCOME *!-! 'RATÕCOS % &IGUERAS & "ARRANCO - ET AL 3PONTANEOUS RECOVERY OF BACTERIAL VAGINOSIS DURING PREGNANCY IS NOT ASSOCIATED WITH AN IMPROVED PERINATAL OUTCOME !CTA /BSTET 'YNECOL 3CAND (AY 0% ,AMONT 2& 4AYLOR 2OBINSON $ -ORGAN $* )SON # 0EARSON * !BNORMAL BACTERIAL COLONISATION OF THE GENITAL TRACT AND SUBSEQUENT PRETERM DELIVERY AND LATE MISCARRIAGE "-* 7ATTS $( +ROHN -! (ILLIER 3, %SCHENBACH $! "ACTERIAL VAGINOSIS AS A RISK FACTOR FOR POST CESAREAN ENDOMETRITIS /BSTET 'YNECOL -ÓLLER % "ERGER + $ENNEMARK . /LEEN "URKEY - #OST OF BACTERIAL VAGINOSIS IN PREGNANCY $ECISION ANALYSIS AND COST EVALUATION OF A CLINICAL STUDY IN 'ERMANY * 2EPROD -ED
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