Late miscarriage and preterm birth after treatment with clindamycin: a randomised consent design study according to Zelen

OBJECTIVE: To screen for bacterial vaginosis (BV) and to investigate the effect of treatment with vaginal clindamycin in order to observe the effect on late miscarriage and delivery prior to 37 completed weeks (primary outcome). DESIGN: Randomised consent design for clinical trials according to Zelen. SETTING: Southeast region of Sweden. POPULATION: A total of 9025 women were screened in early pregnancy. METHODS: A total of 819 women with a Nugent score of 6 and above were considered to have BV and treated according to Zelen allocation. The incidence of late miscarriage and spontaneous (noniatrogenic) preterm birth was assessed. MAIN OUTCOME MEASURES: Late miscarriage and spontaneous preterm delivery before 37 weeks. RESULTS: Therapy with vaginal clindamycin had no significant impact on the incidence of spontaneous preterm delivery prior to 37 completed weeks; OR 0.90, 95% CI 0.40-2.02 (primary outcome variable). However, only 1 of 11 women in the treatment group versus 5 of 12 in the control group delivered prior to 33 completed weeks; OR 0.14, 95% CI 0.02-0.95. Treatment was associated with 32 days longer gestation for the 23 participants who had late miscarriage or spontaneous preterm birth (P= 0.024, Mann-Whitney U test) and significantly fewer infants had a birthweight below 2,500 g (secondary outcome). A follow up of infants born preterm 4 years postnatally indicated that extending gestational age did not increase the number of sequelae. CONCLUSIONS: Clindamycin vaginal cream therapy was associated with significantly prolonged gestation and reduced cost of neonatal care in women with BV. Early screening for BV and treatment with clindamycin saved approximately 27 euro per woman.     

The Effect of Second-Trimester Antibiotic Therapy on the Rate of Preterm Birth

ObjectiveAs many as 50% of spontaneous preterm births are infection-related, with Mycoplasma species being the most common microbial isolates from the amniotic cavity. The goal of our study was to evaluate the effect of macrolides, a specific group of antibiotics known to be effective against Mycoplasma species, on the rate of preterm births.MethodsWe performed a systematic review of the literature and a meta-analysis. We searched PubMed, Medline (1965–March 2006), Embase, and the Cochrane Library, using the key words “pregnancy,” “macrolides,” “erythromycin,” “azithromycin,” and “clarithromycin.” The research was limited to randomized controlled trials and to human females. Studies included for analysis were of women in the second trimester of pregnancy who received either macrolides or placebo (or no treatment) in order to prevent preterm delivery with at least 95% of patient follow-up. We excluded studies involving women with preterm premature rupture of membranes or regular uterine contractions. Meta-analysis of the retrieved data was performed using RevMan 4.2.8 (Cochrane Collaboration) with dichotomous analyses and delivery prior to 37 weeks’ gestation as the primary outcome. The analysis was subsequently repeated using the same methodology for clindamycin and metronidazole administered during the second trimester.ResultsOf the 61 articles yielded by our search, three original papers, investigating a total of 1807 women, examined macrolide utilization and met our criteria. Women included in our analysis were all considered to be at higher risk for preterm delivery (vaginal fetal fibronectin positivity, urogenital Mycoplasma infection, prior preterm delivery, and/or pregestational maternal weight < 50 kg). Compared with placebo, macrolides were associated with a lower rate of preterm births (odds ratio [OR] 0.72; 95% confidence intervals [CI] 0.56–0.93), as was clindamycin (OR 0.68; 95% CI 0.49–0.95). On the other hand, metronidazole (OR 1.10; 95% CI 0.95–1.29) was not linked with significant changes in the rate of preterm births. A higher rate of preterm delivery was found when mid-trimester metronidazole was the only antibiotic administered (OR 1.31; 95% CI 1.08–1.58).ConclusionMacrolides and clindamycin, given during the second trimester of pregnancy, are associated with a lower rate of preterm delivery, whereas second-trimester metronidazole used alone is linked with a greater risk of preterm delivery in a high-risk population. Use of metronidazole, a common treatment for bacterial vaginosis and Trichomonas vaginalis, should be avoided during the second trimester of pregnancy in this population.     

Risk scoring, fetal fibronectin, and bacterial vaginosis to predict preterm delivery

OBJECTIVE: To determine the value of markers for predicting spontaneous preterm birth. METHODS: One hundred forty asymptomatic gravidas were recruited from 20-24 weeks' gestation. Risk score was assessed, vaginal swabs were analyzed for bacterial vaginosis, and cervical and vaginal swab were tested for fetal fibronectin FDC-6, X18A4, and CAF. Univariate analysis was used to determine potential predictors (and combinations of predictors) of outcome. Multiple logistic regression was done to identify independent predictors of spontaneous preterm birth. Sensitivity, specificity, positive and negative predictive values; and odds and likelihood ratios were calculated for significant predictors. RESULTS: Predictors significantly associated with the primary outcome were preterm birth-risk score and vaginal fetal fibronection FDC-6 (logistic regression odds ratio [OR] 16.9 [95% confidence interval (CI) 3.1, 92.8]) and 8.0 ([95% CI 1.6, 38.2], respectively). Bacterial vaginosis, fetal fibronectin X18A4, fibronectin CAF, and cervical fetal fibronectin FDC-6 were not associated with spontaneous preterm birth; however, the statistical power to assess these variables was limited. The combination of positive preterm birth-risk score and vaginal fetal fibronectin FDC-6 had a sensitivity of 44.4%, specificity of 97.7%, positive predictive value of 57.1%, negative predictive value of 96.2%, and a significant likelihood ratio for a positive test of 19.4 (95% CI 5.1, 73.8). CONCLUSION: The combination of preterm birth-risk score and vaginal fetal fibronectin FDC-6 predicted spontaneous preterm birth. Intervention trials are required to determine whether a combination of screening tests will reduce rates of spontaneous preterm birth.     

Risk of preterm birth that is associated with vaginal douching

OBJECTIVE: The purpose of this study was to examine the association between vaginal douching and preterm birth. STUDY DESIGN: We enrolled hospitalized women after delivery in a case-control study. Women who were delivered of a live preterm singleton infant were assigned as cases. Women who were delivered at term were randomly selected as control subjects. We surveyed women about their douching habits and risk factors for preterm birth and abstracted data from the records. RESULTS: After adjustment, vaginal douching within 6 months of pregnancy was not significantly associated with preterm birth (odds ratio, 1.1; 95% CI, 0.8-1.6). However, in secondary analyses, douching more than once per week (odds ratio, 4.0; 95% CI, 1.0-15.5) or longer than 10 years (odds ratio, 1.9; 95% CI, 1.1-3.2) was associated with preterm birth. CONCLUSION: Vaginal douching does not appear to be a strong risk factor for preterm birth. Further study is needed to confirm the risk that is associated with frequent or long-term douching.     

A high Nugent score but not a positive culture for genital mycoplasmas is a risk factor for spontaneous preterm birth

Objective.?This study was performed to evaluate the relationship among the Nugent score for the diagnosis of bacterial vaginosis (BV), the results of vaginal fluid culture for genital mycoplasmas, and the subsequent occurrence of preterm birth.

Methods.?The Nugent score and culture for genital mycoplasmas were performed in vaginal fluid obtained from 977 pregnant women (gestational age 13–30 weeks). Vaginal samples were obtained with sterile cotton swabs. The relationship among the Nugent score, vaginal fluid culture results and the occurrence of spontaneous preterm birth was examined.

Results.?(1) Of the 977 women, 14% (137) had a Nugent score of ≥8; (2) The prevalence of a positive vaginal culture for genital mycoplasmas was 30% (288); Ureaplasma urealyticum was isolated in 252 (88%), Mycoplasma hominis in 9 (3%), and both in 27 (9%) women; (3) Cases with a Nugent score of ≥8 had a higher rate of a positive vaginal culture for genital mycoplasmas than those with the lower Nugent score (55%vs. 25%; p < 0.001); (4) Women with a Nugent score of ≥8 had a significantly higher rate of spontaneous preterm birth <37 (10%vs. 4%), <34 (5%vs. 2%), and <32 (4%vs. 1%) weeks of gestation than those with the lower Nugent score (at each gestational age, p < 0.05); (5) In contrast, a positive vaginal culture for genital mycoplasmas was not associated with an increased risk for spontaneous preterm birth; (6) Among patients with a positive culture and a Nugent score of ≥8, the frequency of spontaneous preterm delivery (<37 weeks) was 10% (7/72); (7) There was no difference in the incidence of spontaneous preterm delivery according to the results of vaginal culture in patients with a Nugent score of ≥8, as well as in those with a lower Nugent score.

Conclusion.?A high Nugent score (≥8) for the detection of BV but not a positive vaginal culture for genital mycoplasmas is a risk factor for spontaneous preterm birth.     

Bacterial vaginosis: prevalence and predictive value for premature delivery and neonatal infection in women with preterm labour and intact membranes

OBJECTIVES: Assess the predictive values of bacterial vaginosis (BV) for preterm delivery (PD) and neonatal infection and compare them with standard markers of infection among women with preterm labour (PL). STUDY DESIGN: Prospective blinded study in a tertiary referral centre in Paris. Women hospitalised for PL with intact membranes at a term between 24 and 34 weeks were included. Vaginal fluid, collected at inclusion was Gram-stained, scored, and interpreted according to Nugent's criteria. RESULTS: Out of 354 women tested, 254 had normal flora (72.3%), 76 intermediate (21.7%) and 24 BV (6.8%). A history of spontaneous miscarriage after 14 weeks was the only risk factor significantly associated with BV. BV was not significantly associated with PD<35 weeks or neonatal infection. Very preterm delivery (before 33 weeks) was significantly associated with the flora grade (P=0.02): women with normal, intermediate and abnormal flora, respectively had 27 (10.6%), 14 (18.4%) and 6 (25.0%) births before 33 weeks. Of the markers tested, the highest risk of very preterm delivery was associated with BV (odds ratio 2.95, 95% CI (1.1-0.8.1)) and CRP>20mg/dl (4.23 95% CI (1.8-9.7)). Predictive value of BV for preterm birth before 33 weeks were: sensitivity 12.8%, specificity 95.0%, positive predictive value 35.3%, and negative predictive value 84.3%. CONCLUSIONS: The frequency of BV and its association with PD are probably very variable and must be interpreted differently from one population to another. While we found an association between BV results and delivery before 33 weeks, the predictive value of BV was disappointing. Although these findings reinforce the importance of a useful marker of subclinical infection, the usefulness of testing for BV in women with PL has not been demonstrated.     

Is a change in the vaginal flora associated with an increased risk of preterm birth?

OBJECTIVE: The purpose of this study was to determine if a change in the vaginal flora was associated with an increased risk of preterm birth, and to determine if metronidazole therapy before 32 weeks increased the risk of preterm birth. STUDY DESIGN: We compared cultures taken at 23 to 26 weeks of gestation with cultures taken at delivery from women enrolled in the Vaginal Infections and Preterm Birth study to analyze the association of changes in the vaginal flora with preterm birth. RESULTS: Metronidazole therapy before 32 weeks was associated with an increased risk of preterm birth (OR 1.5, 95%CI 1.05-2.1) in an unadjusted model. A change to heavy growth of Escherichia coli or Klebsiella pneumoniae at delivery was found to be associated with preterm birth (OR 2.4, 95%CI 1.6-3.8). After controlling for race, parity, prepregnancy weight <100 pounds, smoking or drinking during pregnancy, Trichomonas vaginalis, bacterial vaginosis, chlamydia, mycoplasmas, group B streptococcus, metronidazole therapy before 32 weeks, vaginal pH >5.0, and an increase in E coli or K pneumoniae , only prepregnancy weight <100 pounds (adjusted odds ratio [AOR] 2.07, 95%CI 1.01-4.21) and increased E coli or K pneumoniae in the vagina at delivery (AOR 2.99, 95%CI 1.37-6.53) were found to be significantly associated with preterm birth. CONCLUSION: An increase in E coli or K pneumoniae in the vagina is an independent risk factor for preterm birth. Changes in the vaginal flora may explain the increased risk of preterm birth seen with vaginal clindamycin or oral metronidazole therapy.     

A polymorphism in the promoter region of TNF and bacterial vaginosis: preliminary evidence of gene-environment interaction in the etiology of spontaneous preterm birth

OBJECTIVE: The rarer of 2 alleles of a polymorphism in the promoter of the tumor necrosis factor alpha gene (TNF) has been associated with spontaneous preterm birth following preterm premature rupture of the fetal membranes in some populations. The aim of this study was to assess if the presence of symptomatic bacterial vaginosis amplifies the risk of spontaneous preterm birth in those with a "susceptible" TNF genotype. STUDY DESIGN: A case-control study was performed at our institution. Cases (n=125) were defined as women who delivered before 37 weeks as a result of ruptured membranes or preterm labor, while control subjects (n=250) were defined as women who delivered after 37 weeks. DNA was collected from maternal blood and analyzed for the TNF genotype. Information on symptomatic bacterial vaginosis and other risk factors for preterm birth was obtained by review of the antenatal record. Multiple logistic regression was also used to test the interaction between bacterial vaginosis, the TNF genotype, and preterm birth. RESULTS: Maternal carriers of the rarer allele (TNF-2) were at a significantly increased risk of spontaneous preterm birth [odds ratio (OR) 2.7, 95% CI 1.7-4.5]. The association between TNF-2 and preterm birth was modified by the presence of bacterial vaginosis, such that those with a "susceptible" genotype and bacterial vaginosis had increased odds of preterm birth compared with those who did not (OR 6.1, 95% CI 1.9-21.0). CONCLUSION: This study provides preliminary evidence that an interaction between genetic susceptibilities (ie, TNF-2 carriers) and environmental factors (ie, bacterial vaginosis) is associated with an increased risk of spontaneous preterm birth.     

Multimodality Screening for Lower Genital Tract Infections Between 18 and 24 Weeks of Pregnancy and its Efficacy in Predicting Spontaneous Preterm Delivery

Background

Predicting spontaneous preterm birth (SPTB) during mid-trimester would be very useful. We used a multimodality screening approach mainly focusing on urogenital infections among unselected obstetric population between 18 and 24 weeks in a tertiary center.

Method

Diagnosis of lower genital tract infection (LGTI) was attempted among 228 pregnant women using several factors—symptom of vaginal discharge, characteristic appearance of discharge on speculum, point of care tests using Amsel’s criteria and gram staining of vaginal swab. Nugent’s scoring was taken as gold standard. Urine microscopy/culture was obtained. Serum inflammatory markers were done. Total leukocyte count, neutrophil/lymphocyte ratio and C-reactive protein were obtained. Data on cervical length were obtained from mid-trimester scan.

Results

Thirty patients complained of vaginal discharge. Speculum examination revealed discharge in 221 (96.92%), appearing pathological in 192 (86.87%). Amsel’s criteria showed poor sensitivity to detect full (57%) and partial (24%) bacterial vaginosis (BV). On gram staining, 104 (45.61%) showed evidence of LGTI; 14 full BV (6.1%); 45 partial BV (19.5%); 40 candidiasis (17.5%); and two each of trichomoniasis and aerobic vaginitis. Appearance of vaginal discharge and microscopic diagnosis of LGTI were poorly correlated. Forty women (17.5%) had SPTB, 24 following membrane rupture and 16 following spontaneous labor. The presence of BV (specifically partial) increased the likelihood of SPTB with OR of 3.347 (CI 1.642, 6.823). Three of seven women with short cervix delivered preterm. No other screening modality was associated with SPTB.

Conclusion

Active screening for LGTI between 18 and 24 weeks shows high prevalence of BV in Indian setting. There is a strong link between partial BV and SPTB.

     

Cannabis Use in Pregnancy in British Columbia and Selected Birth Outcomes

ObjectiveThis study sought to determine the association between cannabis use in pregnancy and stillbirth, small for gestational age (SGA) (<10th percentile), and spontaneous preterm birth (<37 weeks).MethodsThe study used abstracted obstetrical and neonatal medical records for deliveries in British Columbia from April 1, 2008 to March 31, 2016 that were contained in the Perinatal Data Registry of Perinatal Services British Columbia. Chi-square tests were conducted to compare maternal sociodemographic characteristics by cannabis use. Logistic regression was conducted to determine the association between cannabis use and SGA and spontaneous preterm births. Cox proportional hazards regression modelling was used to identify the association between cannabis use and stillbirth. Secondary analyses were conducted to ascertain differences by timing of stillbirth (Canadian Task Force Classification II-2).ResultsMaternal cannabis use has increased in British Columbia over the past decade. Pregnant women who use cannabis are younger and more likely to use alcohol, tobacco, and illicit substances and to have a history of mental illness. Using cannabis in pregnancy was associated with a 47% increased risk of SGA (adjusted OR 1.47; 95% CI 1.33–1.61), a 27% increased risk of spontaneous preterm birth (adjusted OR 1.27; 95% CI 1.14–1.42), and a 184% increased risk of intrapartum stillbirth (adjusted HR [aHR] 2.84; 95% CI 1.18–6.82). The association between cannabis use in pregnancy and overall stillbirth and antepartum stillbirth did not reach statistical significance, but it had comparable point estimates to other outcomes (aHR 1.38; 95% CI 0.95–1.99 and aHR 1.34; 95% CI 0.88–2.06, respectively).ConclusionCannabis use in pregnancy is associated with SGA, spontaneous preterm birth, and intrapartum stillbirth.     

Influence of early self-diagnosis and treatment of bacterial vaginosis on preterm birth rate

ObjectiveTo assess whether early self-diagnosis and treatment of bacterial vaginosis (BV) could lower the preterm birth rate among a group of Indonesian women.MethodsA randomized controlled trial of 331 pregnant women (14–18 weeks) was conducted. Participants were randomly assigned to either the active model group (n = 176) or the control group (n = 155). Women in the active model group were equipped with a kit to self-evaluate vaginal pH; those with a positive test result were treated with a twice daily dose of 500 mg of metronidazole for 7 days. The primary end point was preterm birth rate.ResultsThere were 6 (3.8%) and 8 (5.4%) preterm births in the active model and control groups, respectively (P = 0.468). No spontaneous abortions were recorded in either group. When compared with the gold standard (Gram staining), the vaginal acidity test had low ability to detect BV, with 88.7% specificity and 36.9% sensitivity. The positive predictive value of the test was 35.0% PPV, while the negative predictive value was 89.4%.ConclusionEarly self-diagnosis and treatment of BV did not reduce the preterm birth rate of the study group.ClinicalTrial.gov number: NCT01232192.     

Phenotypic Classification of preterm Birth Among Multiparous Women: A Population-Based Cohort Study

ObjectiveThe Global Alliance to Prevent Prematurity and Stillbirth developed a phenotypic classification for preterm birth using clinical presentation (rather than risk factors) to improve surveillance. The objective of this study was to determine distributions of preterm birth phenotypes and associations with Caesarean section, low Apgar score, and neonatal death in multiparous women, stratifying by first versus recurrent preterm births.MethodsThis population-based cohort study used the Better Outcomes Registry and Network (BORN) of multiparous women giving birth in hospital with a singleton after 20 weeks in Ontario from 2012 to 2014 (Canadian Task Force Classification II-2).ResultsIn multiparous women with preterm birth, 29.6% had a history of recurrence, of whom 66.2% had at least one clinical condition associated with the phenotypic model, compared with 63.5% of first preterm births. In recurrent preterm births, criteria for maternal, fetal, and placental conditions were met in 44.5%, 37.9%, and 8.2%, respectively, compared with 36.8%, 39.0%, and 10.4%, respectively, of first preterm births. Associations of preterm birth with Caesarean section, low Apgar score, and neonatal death varied across clinical conditions but were similar between first and recurrent preterm births; for example, for recurrent preterm birth, Caesarean section for maternal, fetal, and placental conditions had odds ratios of 1.66 (95% confidence interval [CI] 1.32–2.07), 1.09 (95% CI 0.80–1.49), and 3.92 (95% CI 1.98–7.78), compared with first preterm birth odds ratios of 1.21 (95% CI 1.03–1.41), 0.92 (95% CI 0.77–1.10), and 6.24 (95% CI 4.07–9.56).ConclusionThis study provides novel evidence of the utility of the preterm birth phenotypic classification model by using stratification for previous preterm birth, a robust predictor—with variation in phenotypes in initial and recurrent preterm births.     

Second Trimester Placental Growth Factor Levels and Placental Histopathology in Low-Risk Nulliparous Pregnancies

ObjectivePlacental growth factor (PlGF) levels are lower at delivery in pregnancies with preeclampsia or fetuses small for gestational age (SGA). These obstetrical complications are typically mediated by placental dysfunction, most commonly related to the specific placental phenotype termed placental maternal vascular malperfusion (MVM). The objective of this study was to determine the relationship between PlGF levels in the second trimester and the development of placental diseases that underlie adverse perinatal outcomes.MethodsWe performed a secondary analysis of the prospective Placental Health Study in unselected healthy nulliparous women (n = 773). Maternal demographic data, Doppler ultrasound measurements, and plasma PlGF levels at 15 to 18 weeks gestation were analyzed for association with pregnancy outcomes and placental pathology following delivery.ResultsLow PlGF levels in the second trimester (<10th percentile; <72 pg/mL) was associated with preterm delivery (<37 weeks; 26% vs. 6%, P < 0.001; unadjusted odds ratio (OR) 5.75, 95% CI 3.2–10.5), reduced mean birth weight (2998 vs. 3320 g, P < 0.001), SGA deliveries (25% vs. 11%, P = 0.001; OR 2.6, 95% CI 1.5–4.6), and preeclampsia (7% vs. 2%, P = 0.02; OR 4.3, 95% CI 1.5-12.8) relative to normal PlGF levels (≥10th percentile; ≥72 pg/mL). Low PlGF was associated with lower mean placental weight (447 vs. 471 g, P = 0.01), aberrant cord insertion (25% vs. 12%, P = 0.001) and a pathologic diagnosis of MVM (18% vs. 11%, P = 0.04; OR 1.9, 95% CI 1.01–3.55) but not with other placental pathologies.ConclusionMVM placental pathology and related adverse perinatal outcomes are associated with low PlGF in the early second trimester for healthy nulliparous women.     

Periodontal disease and bacterial vaginosis as genetic and environmental markers for the risk of spontaneous preterm labor and preterm birth

Objective.?The aim of this study was to review the evidence associating periodontal disease, and bacterial vaginosis with preterm birth, and the link with gene polymorphism, as well as the preventions and interventions which might reduce the risk of spontaneous preterm labor and preterm births in women with periodontal disease and/or bacterial vaginosis.

Background.?Preterm birth accounts for 70% of perinatal mortality, nearly 50% of long term neurological morbidity, and a significant impact on health care costs. There is evidence that spontaneous preterm labor and preterm birth are associated with intrauterine infection due to abnormal genital and/or oral colonization. Periodontal disease and bacterial vaginosis share microbiological similarities, and both conditions are associated with spontaneous preterm labor and preterm birth. In addition, periodontal disease and bacterial vaginosis have been linked through gene polymorphism.

Methods.?A review of the literature using widely accepted scientific search engines in English language.

Results.?Studies evaluating antibiotic administration to eradicate periodontal disease and/or bacterial vaginosis responsible organisms, and minimize the risk of preterm births have yielded conflicting results. With respect to bacterial vaginosis, the timing and the choice of antibiotic administration might partly explain the conflicting results. The use of scaling and/or root planning for women with periodontal disease appears to reduce the risk of preterm birth, but routine administration of antibiotics has not demonstrated any impact on preterm birth.

Conclusion.?Prospective studies evaluating the association of gene polymorphism with preterm birth, and the contribution of periodontal disease and bacterial vaginosis are needed.     

Effectiveness of dydrogesterone, 17-OH progesterone and micronized progesterone in prevention of preterm birth in women with a short cervix

Objective: To compare the efficacy of dydrogesterone, 17-OH progesterone (17OHP) and oral or vaginal micronized progesterone with cerclage for the prevention of preterm birth in women with a short cervix.

Methods: The study included 95 women with singleton gestation and cervical length (CL) ≤?25?mm. Among these, 35 women were asymptomatic at 15–24?weeks and 60 had symptoms of threatened late miscarriage (LM) or preterm delivery (PD) at 15–32 weeks. Patients were randomized to receive dydrogesterone, 17OHP or oral/vaginal micronized progesterone; after one week of therapy 15 women underwent cerclage.

Results: Efficacy of vaginal progesterone (VP) for the prevention of preterm birth reached 94.1%. In asymptomatic women pregnancy outcomes were comparable to cerclage. In women with threatened LM/PD, combination therapy with VP, indomethacin and treatment of bacterial vaginosis (BV) with the subsequent use VP until 36?weeks together with CL monitoring significantly decreased the rate of preterm birth (RR 0.01; 0.0001–0.24) and low birth weight (LBW) (RR 0.04; 0.01–0.96). CL increase during the first week of treatment with a subsequent plateau phase indicated treatment efficacy. Dydrogesterone, 17OHP, and micronized oral progesterone (OP) were associated with PD in 91.7% of women.

Conclusions: Combination management strategy including VP significantly benefits pregnancy outcomes in women with a short cervix compared with cerclage. Dydrogesterone, 17OHP, and OP were not found to be efficacious.     

A prospective study of vaginal pH as a predictor of preterm delivery

Objective: To test the usefulness of vaginal pH determinations in the prediction of the risk of preterm delivery at or before 36 weeks of gestation. Methods: This was a prospective study of asymptomatic pregnant women. Vaginal pH was determined using pH paper in a sterile speculum examination during prenatal visits. Patients were followed to delivery and hospital records were reviewed to extract obstetric information. A total of 308 women agreed to participate and met the criteria for enrolment. Preterm delivery was defined as delivery at or prior to 36 weeks of gestation. Abnormal pH was defined as a pH of > 5.0. Results: Abnormal vaginal pH was associated with increased risk of preterm delivery, (OR 3.3, 95% CI 1.15, 9.2; p = 0.02). In the first trimester, an abnormal vaginal pH was not associated with preterm delivery (p = 0.3). After the first trimester, a vaginal pH of 5.0 or greater was associated with increased risk of preterm delivery (OR 9.6, 95% CI 2.0, 45.5; p = 0.001) as well as delivering an infant of less than 2500 g (OR 3.1, 95% CI 1.2, 7.8; p = 0.015). History of a previous preterm delivery was associated with increased risk of preterm delivery (OR 6.2, 95% CI 1.6, 23.7; p = 0.02). A logistic regression model used to control for a history of preterm delivery and race showed abnormal vaginal pH to remain as an independent predictor of preterm delivery (p = 0.01). Conclusions: High vaginal pH (≥ 5.0) identified women at risk for preterm delivery.     

Elevated vaginal pH in the absence of current vaginal infection,still a challenging obstetrical problem

Abstract

Objective: To assess the association of vaginal pH?≥?5 in the absence of vaginal infection with systemic inflammation and adverse pregnancy outcome.

Methods: Four-hundred sixty pregnant women completed the study, upon enrollment Vaginal pH was measured for all women, maternal and umbilical sera were obtained for determining C-reactive protein (CRP) and uric acid levels. Umbilical blood was tested for gas parameters, 1 and 5?min Apgar scores, the need for neonatal resuscitation and neonatal intensive care unit (NICU) admission were recorded.

Results: Elevated vaginal pH was significantly associated with preterm birth (odds ratio (OR), 2.23; 95% confidence interval (CI), 1.04–4.76), emergency cesarean section (OR 2.57; 95% CI 1.32–5), neonatal resuscitation in the delivery room (OR 2.85; 95% CI 1.1–7.38), elevated cord base deficit (OR 8.01; 95% CI 1.61–39.81), low cord bicarbonate (OR 4.16, 95% CI 1.33–12.92) and NICU admission (OR 2.02; 95% CI 1.12–3.66). Increased vaginal pH was also significantly associated with maternal leukocytosis, hyperuricemia and elevated CRP levels in maternal and umbilical sera.

Conclusions: Elevated vaginal pH in the absence of current vaginal infection still constitutes a risk for adverse pregnancy outcome which is mediated by systemic inflammatory response.     

Asymptomatic bacterial vaginosis and intermediate flora as risk factors for adverse pregnancy outcome

We updated a previously published meta-analysis to evaluate bacterial vaginosis (BV) and intermediate vaginal flora as risk factors for adverse pregnancy outcome. Selection criteria were original, published, English-language reports of cohort studies or control groups of clinical trials including women <37 weeks' gestation with intact amniotic membranes. All women had to be screened for BV, diagnosed either by clinical criteria or by criteria based on Gram-stain findings. Outcomes were preterm delivery, late miscarriages, maternal or neonatal infections, and perinatal mortality. Fourteen new studies with results for 10,286 patients were included, so that results for 30,518 patients in 32 studies were available for this meta-analysis. BV more than doubled the risk of preterm delivery in asymptomatic patients (OR: 2.16, 95% CI: 1.56-3.00) and in patients with symptoms of preterm labor (OR: 2.38, 95% CI: 1.02-5.58). BV also significantly increased the risk of late miscarriages (OR: 6.32, 95% CI: 3.65-10.94) and maternal infection (OR: 2.53, 95% CI 1.26-5.08) in asymptomatic patients. No significant results were calculated for the outcomes of neonatal infection or perinatal mortality. Also, intermediate vaginal flora was not significantly associated with any outcome included. The results of this meta-analysis confirm that BV is a risk factor for preterm delivery and maternal infectious morbidity and a strong risk factor for late miscarriage.     

Bacterial vaginosis in early pregnancy is associated with low birth weight and small for gestational age, but not with spontaneous preterm birth: a population-based study on Danish women.

OBJECTIVE: To analyze the association between bacterial vaginosis (BV) in early pregnancy and preterm birth, low birth weight (LBW) and small for gestational age (SGA) in a Danish population. METHODS: A geographically defined population-based prospective study of Danish-speaking pregnant women over18 years of age enrolled before week 24 and followed until delivery. BV was diagnosed by Amsel's clinical criteria at enrolment. RESULTS: At enrolment, 13.7% had BV. BV was not associated with an increased risk of spontaneous preterm birth (crude OR 0.8 (0.5-1.5)). Nulliparity was found to affect birth weight to such a degree that this variable was used for stratification. In nulliparous women BV was associated with LBW (adj. OR 4.3 (1.5-12)) and SGA (adj. OR 1.6 (0.7-3.1)) compared to nulliparous without BV. No such associations were seen for multiparous women with BV. CONCLUSIONS: BV was not associated with spontaneous preterm birth, but was associated with both LBW and SGA in nulliparous women.     

Preterm birth in Sweden 1973-2001: rate, subgroups, and effect of changing patterns in multiple births, maternal age, and smoking

BACKGROUND: The objectives of this report are to evaluate changes in the preterm birth rate in Sweden 1973-2001. Furthermore, describe the proportion of spontaneous and indicated preterm births and assess risk factors for the subgroups of preterm birth during the period from 1991 to 2001. METHODS: A population-based register study of all births occurring in Sweden from 1973 to 2001 registered in the Swedish Medical Birth Register was designed. The analysis of subgroups was restricted to the period 1991-2001. Gestational age was calculated using last menstrual period and best estimate. Odds ratio for preterm birth related to risk factors was calculated for the subgroups' spontaneous and indicated preterm birth. RESULTS: After an increase in the beginning of the 1980s, the preterm birth rate has decreased from 6.3% in 1984 to 5.6% in 2001 (P < 0.0001). The proportion of multiple births born preterm of the total birth rate increased from 0.34% in 1973 to 0.71% in 2001 (P < 0.0001). Spontaneous preterm births account for 55.2% and iatrogenic preterm births for 20.2% of all preterm births. The strongest association with maternal smoking in early pregnancy was found at gestational age <28 weeks and spontaneous preterm birth [odds ratio (OR) smoking versus no smoking: 1.55, 95% confidence intervals (CI): 1.42-1.69]. The strongest association for maternal age was found between gestational age <28 weeks and indicated preterm birth (OR 5-year increase: 1.34, 95% CI: 1.21-1.47). CONCLUSIONS: The preterm birth rate in Sweden has decreased since the mid 1980s. The composition of different subtypes of preterm birth in a Scandinavian low-risk population seems to be similar to populations with higher incidence of preterm birth and perinatal infections.