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bacterial vaginosis -does it warrant routine swabs&treatment in all pregnant women?
- Aparna devi Gumma (13 December 2002)
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Re: bacterial vaginosis -does it warrant routine swabs&treatment in all pregnant women?
- Hans R Verstraelen, University Hospital, Ghent University, B-9000 Gent, Belgium (14 December 2002)
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DUTY OF CARE TO WOMEN
- Claudia Cheng, Suzanne M. Garland, Julie A. Quinlivan, Rodney W. Petersen, Les Reti (2 April 2003)
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Aparna devi Gumma, senior SHO in Obstetrics&Gynecology Rochdale infirmary, OL!"OPR
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Dear sir I read with interest the article linking Bacterial vaginosis to early miscarriages. It was a known fact that Bacterial vaginosis Is associated with late miscarraiges and preterm labour.Several cohort studies and prospective studies in the past showed that Bacterial vaginosis was found in women who had early miscarraiges. The million dollar question is whether it would or not warrants routine testing with swabs in all pergnant women in early pregnancy or high risk screening and treatment to reduce this risk. large group studies are needed to form guidelines regarding this issue. Competing interests: None declared |
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Hans R Verstraelen, obstetrical epidemiologist Department of OB/GYN, University Hospital, Ghent University, B-9000 Gent, Belgium
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Dear Sir, Screening for bacterial vaginosis in early pregnancy is indeed an appealing strategy in identifying patients at increased risk for reproductive failure and preterm delivery in particular. For one reason, the relative risk of preterm birth associated with bacterial vaginosis is inversely related with gestational age, which might explain why metronidazole administration beyond 20 weeks’ gestation showed no significant reduction in the preterm birth rate (1). Secondly, the recurrence risk of adverse pregnancy outcome extends from first trimester abortion, over late abortion and intra-uterine fetal death to preterm delivery (2), suggesting that a subgroup of patients at increased risk for these outcomes may be identified in early pregnancy. Self-administered vaginal smears (3) and self-collected vaginal tampon species (4) have now proven usefull tools that meet the feasibility criteria of good screening and may therefore allow for broad-scaled population-based studies as demonstrated by Oakeshott et al. (3). Longitudinal studies involving repeated self-testing by these means may also further elucidate our understanding of the clinical significance of this evanescent condition during early pregnancy, for instance in assessing the number of episodes of bacterial vaginosis-like perturbation of the vaginal ecosystem. At this time however, the pathogenetic relationship between bacterial vaginosis and adverse pregnancy outcome is meagerly documented. It remains to be established whether bacterial vaginosis is a true independent risk factor to miscarriage and preterm labour. There is also increasing evidence that bacterial vaginosis defined by conventional citeria does not consitute a homogeneous clinical entity (5) and hence the bacterial vaginosis associated risk is likely to be unevenly distributed among women diagnosed with this condition. As a result, non-elective treatment of bacterial vaginosis is likely to expose an unjustified large number of women that may not incur the alleged risk. Of note is that, albeit population-based studies are actually lacking, prevalence estimates for bacterial vaginosis range from 5 to 50%. The first trimester bacterial vaginosis associated odds for fetal loss increasing with gestational age in the study by Oakeshott et al. (3) give further to support to the Trojan Horse appearance of bacterial vaginosis. It is readily visible at first, but the attack becomes increasingly apparent as pregnancy advances. So, the million dollar question is not so much if we should attack the horse as soon as we see it, but rather why its soldiers attack only some women even until late in pregnancy. (1) Carey JC, Klebanoff MA, Hauth JC, Hillier SL, Thom EA, Ernest JM, et al. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med 2000;342:534-40 (2) Whitley E, Doyle P, Roman E, De Stavola B.The effect of reproductive history on future pregnancy outcomes. Hum Reprod 1999;14:2863 -7 (3) Oakeshott P, Hay P, Hay S, Steinke F, Rink E, and Kerry S. Association between bacterial vaginosis or chlamydial infection and miscarriage before 16 weeks' gestation: prospective community based cohort study. BMJ 2002; 325: 1334 (4) Sturm PD, Moodley P, Nzimande G, Balkistan R, Connolly C, Sturm AW. Diagnosis of bacterial vaginosis on self-collected vaginal tampon specimens. Int J STD AIDS 002;13:559-63 (5) Cauci S, Guaschino S, Driussi S, De Santo D, Lanzafame P, Quadrifoglio F. Correlation of local interleukin-8 with immunoglobulin A against Gardnerella vaginalis hemolysin and with prolidase and sialidase levels in women with bacterial vaginosis. J Infect Dis 2002;185:1614-20 Competing interests: None declared |
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Claudia Cheng, RANZCOG trainee The Royal Women's Hospital, Victoria, Australia, Suzanne M. Garland, Julie A. Quinlivan, Rodney W. Petersen, Les Reti
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Suzanne M. Garland1, Julie A. Quinlivan2, Rodney W. Petersen2, Les Reti2, Claudia Cheng2. Departments of Microbiology & Infectious Diseases 1 and Obstetrics and Gynaecology 2, The Royal Women's Hospital, 132 Grattan St, Carlton 3053 Victoria, Australia Dear Editor, We reviewed the paper by Oakeshott et al (1) (7th December) at our journal club and would like to raise the following issues. In the study, 29 of the 1214 women screened for Chlamydia trachomatis before 10 weeks gestational age were positive. However, as per the method, this information was not disclosed to the women until 16 weeks gestational age. We have concerns over the ethics of delayed disclosure to women (several of whom were teenagers) that they had acquired a sexually transmitted infection (STI). The question of whether chlamydia is associated with early miscarriage could never be answered by the study, as described, due to a lack of statistical power. This makes the decision to screen and delay treatment questionable. Chlamydia is associated with morbidity in women and their partners and the delay in diagnosis may lead to the spread of infection. The authors do not disclose whether the women with positive results subsequently received a full sexually transmitted infection (STI) screen, contact tracing and counseling. The latter is important as in our experience, the diagnosis of a STI in early pregnancy will lead some women to decide in favour of pregnancy termination rather than continuation of a pregnancy in the setting of possible infidelity or relationship instability. We wonder about the duty of care to these women. Several other points should be clarified. Were any of the women in the study symptomatic? Had they experienced vaginal bleeding, pain or any signs of infection such as discharge? These symptoms could be important in understanding the role of screening versus treatment of bacterial vaginosis (BV). Finally, the box summarizing the information the study adds to the literature makes the comment that non-invasive screening for BV and chlamyial infection by using self-administered vaginal swabs is feasible in pregnant women. Self-collected sampling, particularly for the diagnoses of STIs using the highly sensitive amplification assays such as PCR or LCR have been well described for over a decade(2) and for pregnant patients(3). REFERENCES 1. P Oakeshott, P Hay, S Hay, et al. Association between bacterial vaginosis or chlamydia infection and miscarriage before 16 weeks' gestation: prospective community based cohort study. BMJ 2002;325:1334- 1338. 2. SN Tabrizi, S Chen, C Fairley, AJ Borg, G Migliorini, M Lees, SM Garland. Tampon-collected genital cells in detection of Chlamydia trachomatis by polymerase chain reaction. J Infect Dis. 1993;168:796-797. 3. SM Garland, S Tabrizi, J Hallo, S Chen . Assessment of Chlamydia trachomatis prevalence by PCR and LCR in women presenting for termination of pregnancy. Sex Transm Infect. 2000;76:173-176. Yours sincerely, Suzanne M. Garland, Julie A. Quinlivan, Rodney W. Petersen, Les Reti, Claudia Cheng. Competing interests: None declared |
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