Antibiotics for treating bacterial vaginosis in pregnancy

Synbiotics in patients at risk for spontaneous preterm birth: protocol for a multi-centre, double-blind, randomised placebo-controlled trial (PRIORI)

BACKGROUND

Prematurity remains one of the main causes of neonatal morbidity and mortality. Approximately two thirds of preterm births are spontaneous, i.e. secondary to preterm labour, preterm prelabour rupture of membranes (PPROM) or cervical insufficiency. Etiologically, the vaginal microbiome plays an important role in spontaneous preterm birth (sPTB). Vaginal dysbiosis and bacterial vaginosis are well-known risk factors for ascending lower genital tract infections and sPTB, while a Lactobacillus crispatus-dominated vaginal microbiome is associated with term deliveries. Synbiotics may help to achieve and/or maintain a normal, Lactobacillus-dominated vaginal microbiome.

METHODS

We will perform a multi-centre, double-blind, randomised, placebo-controlled trial. Women aged 18 years or older with a singleton pregnancy are eligible for inclusion at 80/7-106/7 weeks gestational age if they have one or more of the following risk factors for sPTB: previous sPTB at 240/7-356/7 weeks, prior PPROM before 360/7 weeks, or spontaneous pregnancy loss at 140/7-236/7 weeks of gestation. Exclusion criteria are multiple gestation, cervix conisation, inflammatory bowel disease, uterine anomaly, and the use of pro-/pre-/synbiotics. Patients will be randomised to oral synbiotics or placebo, starting before 11 weeks of gestation until delivery. The oral synbiotic consists of eight Lactobacillus species (including L. crispatus) and prebiotics. The primary outcome is the gestational age at delivery. Vaginal microbiome analysis once per trimester (at approximately 9, 20, and 30 weeks) and delivery will be performed using metataxonomic sequencing (16S rRNA gene) and microbial culture. Secondary outcomes include PPROM, the use of antibiotics, antenatal admission information, and neonatal outcomes.

DISCUSSION

This study will evaluate the effect of oral synbiotics on the vaginal microbiome during pregnancy in a high-risk population and correlate the microbial changes with the gestational age at delivery and relevant pregnancy outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05966649. Registered on April 5, 2024.

Maternal inflammatory and microbial drivers of low birthweight in low- and middle-income countries

BACKGROUND

Low birthweight (LBW) is when an infant is born too soon or too small, and it affects one in seven infants in low- and middle-income countries. LBW has a significant impact on short-term morbidity and mortality, and it impairs long-term health and human capital. Antenatal microbial and inflammatory exposure may contribute to LBW.

METHODS

Ovid-Medline, Embase and Cochrane databases were searched for English-language articles evaluating inflammatory, microbial or infective causes of LBW, small-for-gestational age, intra-uterine growth restriction or prematurity. Inclusion criteria were human studies including published data; conference abstracts and grey literature were excluded. A narrative synthesis of the literature was conducted.

RESULTS

Local infections may drive the underlying causes of LBW: for example, vaginitis and placental infection are associated with a greater risk of prematurity. Distal infection and inflammatory pathways are also associated with LBW, with an association between periodontitis and preterm delivery and environmental enteric dysfunction and reduced intra-uterine growth. Systemic maternal infections such as malaria and HIV are associated with LBW, even when infants are exposed to HIV but not infected. This latter association may be driven by chronic inflammation, co-infections and socio-economic confounders. Antimicrobial prophylaxis against other bacteria in pregnancy has shown minimal impact in most trials, though positive effects on birthweight have been found in some settings with a high infectious disease burden.

CONCLUSION

Maternal inflammatory and infective processes underlie LBW, and provide treatable pathways for interventions. However, an improved understanding of the mechanisms and pathways underlying LBW is needed, given the impact of LBW on life-course.

16S rRNA female reproductive microbiome investigation reveals Dalfopristin, Clorgyline, and Hydrazine as potential therapeutics for the treatment of bacterial vaginosis

Bacterial vaginosis (BV) is a prevalent vaginal illness resulting from a disruption in the vaginal microbial equilibrium. The vaginal microbiota has been shown to have a substantial impact on the development and continuation of BV. This work utilized 16S rRNA sequence analysis of vaginal microbiome samples (Control vs BV samples) utilizing Parallel-Meta 3 to investigate the variations in microbial composition. The unique genes identified were used to determine prospective therapeutic targets and their corresponding inhibitory ligands. Further, molecular docking was conducted and then MD simulations were carried out to confirm the docking outcomes. In the BV samples, we detected several anaerobic bacteria recognized for their ability to generate biofilms, namely Acetohalobium, Anaerolineaceae, Desulfobacteraceae, and others. Furthermore, we identified Dalfopristin, Clorgyline, and Hydrazine as potential therapeutic options for the management of BV. This research provides new insights into the causes of BV and shows the potential effectiveness of novel pharmacological treatments.

Urogenital cultures and preterm birth in women with cervical cerclage: a single center retrospective cohort study

BACKGROUND

The leading hypothesis of the pathogenesis of cervical insufficiency suggests a role of cervical inflammation. Urogenital tract infections could play a causative role in this process. To test this hypothesis in women with a cervical cerclage, we aimed to retrospectively examine the relationship between gestational age (GA) at delivery and positive urogenital cultures.

METHODS

This single center retrospective study reviewed the records of all women with a singleton pregnancy that underwent cervical cerclage (n = 203) between 2010 and 2020 at the University Hospital of Leuven, Belgium. Transvaginal cerclages were categorized as history indicated (TVC I, n = 94), ultrasound indicated (TVC II, n = 79) and clinically indicated (TVC III, n = 20). Additionally, ten women received transabdominal cerclage (TAC). Urogenital cultures (vaginal and urine) were taken before and after cerclage with 4-week intervals. Urogenital cultures were reported 'positive' if urine and/or vaginal cultures showed significant growth of a microorganism. Treatment decision depended on culture growth and clinical presentation. The primary aim was to evaluate the association between the urogenital culture results and the GA at delivery, for each of the cerclage groups. Secondarily, to investigate the effect of antibiotic treatment of positive cultures on GA at delivery.

RESULTS

Positive pre-cerclage urogenital cultures were associated with lower GA at delivery in TVC III (positive culture 26w4d ± 40d vs. negative 29w6d ± 54d, p = 0.036). For TVC I, GA at delivery was longer when pre-cerclage urogenital cultures were positive (positive culture 38w0d ± 26d vs. negative 35w4d ± 42d, p = 0.035). Overall post-cerclage urogenital cultures status was not associated with a different GA at delivery. Treating patients with pre- or post-cerclage positive urogenital cultures did also not change GA at delivery.

CONCLUSION

Positive urogenital cultures taken before clinically indicated cerclage intervention may be associated with lower GA at delivery. However, there seems to be no benefit of antibiotic treatment or routine urogenital cultures during follow-up of asymptomatic women after cerclage placement.

Extracellular vesicles from vaginal Gardnerella vaginalis and Mobiluncus mulieris contain distinct proteomic cargo and induce inflammatory pathways

Colonization of the vaginal space with bacteria such as Gardnerella vaginalis and Mobiluncus mulieris is associated with increased risk for STIs, bacterial vaginosis, and preterm birth, while Lactobacillus crispatus is associated with optimal reproductive health. Although host-microbe interactions are hypothesized to contribute to reproductive health and disease, the bacterial mediators that are critical to this response remain unclear. Bacterial extracellular vesicles (bEVs) are proposed to participate in host-microbe communication by providing protection of bacterial cargo, delivery to intracellular targets, and ultimately induction of immune responses from the host. We evaluated the proteome of bEVs produced in vitro from G. vaginalis, M. mulieris, and L. crispatus, identifying specific proteins of immunologic interest. We found that bEVs from each bacterial species internalize within cervical and vaginal epithelial cells, and that epithelial and immune cells express a multi-cytokine response when exposed to bEVs from G. vaginalis and M. mulieris but not L. crispatus. Further, we demonstrate that the inflammatory response induced by G. vaginalis and M. mulieris bEVs is TLR2-specific. Our results provide evidence that vaginal bacteria communicate with host cells through secreted bEVs, revealing a mechanism by which bacteria lead to adverse reproductive outcomes associated with inflammation. Elucidating host-microbe interactions in the cervicovaginal space will provide further insight into the mechanisms contributing to microbiome-mediated adverse outcomes and may reveal new therapeutic targets.

Reassessing Preterm Birth Prevention After the Withdrawal of 17-α Hydroxyprogesterone Caproate

The U.S. Food and Drug Administration has recently withdrawn approval for 17-α hydroxyprogesterone caproate for prevention of recurrent preterm birth, and recent studies have called into question benefits of the pessary in the setting of a short cervix. Obstetric health care professionals are once again left with limited remaining options for preterm birth prevention. This narrative review summarizes the best current evidence on the use of vaginal progesterone, low-dose aspirin, and cerclage for the prevention of preterm birth; attempts to distill possible lessons learned from studies of progesterone and pessary, as well as their implementation into practice; and highlights areas where inroads into preterm birth prevention may be possible outside of the progesterone-aspirin-cerclage paradigm.

Effectiveness and Costs of Molecular Screening and Treatment for Bacterial Vaginosis to Prevent Preterm Birth: The AuTop Randomized Clinical Trial

Importance

Bacterial vaginosis (BV) is a well-known risk factor for preterm birth. Molecular diagnosis of BV is now available. Its impact in the screening and treatment of BV during pregnancy on preterm births has not been evaluated to date.

Objective

To evaluate the clinical and economic effects of point-of-care quantitative real-time polymerase chain reaction screen and treat for BV in low-risk pregnant women on preterm birth.

Design, Setting, and Participants

The AuTop trial was a prospective, multicenter, parallel, individually randomized, open-label, superiority trial conducted in 19 French perinatal centers between March 9, 2015, and December 18, 2017. Low-risk pregnant women before 20 weeks' gestation without previous preterm births or late miscarriages were enrolled. Data were analyzed from October 2021 to November 2022.

Interventions

Participants were randomized 1:1 to BV screen and treat using self-collected vaginal swabs (n = 3333) or usual care (n = 3338). BV was defined as Atopobium vaginae (Fannyhessea vaginae) load of 108 copies/mL or greater and/or Gardnerella vaginalis load of 109 copies/mL or greater, using point-of-care quantitative real-time polymerase chain reaction assays. The control group received usual care with no screening of BV.

Main Outcomes and Measures

Overall rate of preterm birth before 37 weeks' gestation and total costs were calculated in both groups. Secondary outcomes were related to treatment success as well as maternal and neonate health. Post hoc subgroup analyses were conducted.

Results

Among 6671 randomized women (mean [SD] age, 30.6 [5.0] years; mean [SD] gestational age, 15.5 [2.8] weeks), the intention-to-treat analysis of the primary clinical and economic outcomes showed no evidence of a reduction in the rate of preterm birth and total costs with the screen and treat strategy compared with usual care. The rate of preterm birth was 3.8% (127 of 3333) in the screen and treat group and 4.6% (153 of 3338) in the control group (risk ratio [RR], 0.83; 95% CI, 0.66-1.05; P = .12). On average, the cost of the intervention was €203.6 (US $218.0) per participant, and the total average cost was €3344.3 (US $3580.5) in the screen and treat group vs €3272.9 (US $3504.1) in the control group, with no significant differences being observed. In the subgroup of nulliparous women (n = 3438), screen and treat was significantly more effective than usual care (RR, 0.62; 95% CI, 0.45-0.84; P for interaction = .003), whereas no statistical difference was found in multiparous (RR, 1.30; 95% CI, 0.90-1.87).

Conclusion and Relevance

In this clinical trial of pregnant women at low risk of preterm birth, molecular screening and treatment for BV based on A vaginae (F vaginae) and/or G vaginalis quantification did not significantly reduce preterm birth rates. Post hoc analysis suggests a benefit of screen and treat in low-risk nulliparous women, warranting further evaluation in this group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02288832.

The Effect of Sexual Intercourse during Pregnancy on Preterm Birth: Prospective Single-Center Cohort Study in Japan

Several studies in Europe and the United States have shown that sexual intercourse (SI) during pregnancy is not associated with preterm birth. However, it is unclear whether these findings apply to pregnant Japanese women. The aim of this prospective cohort study was to elucidate the influence of SI during pregnancy on preterm birth in Japan. A total of 182 women who underwent antenatal care and delivery were included in this study. The frequency of SI was assessed using a questionnaire, and its association with preterm birth was analyzed. The results showed that SI during pregnancy was associated with a significantly higher cumulative preterm birth rate (p = 0.018), which was more pronounced for SI more than once a week (p < 0.0001). Multivariate analysis showed that SI, bacterial vaginosis in the second trimester, previous preterm birth, and smoking during pregnancy were independent risk factors for preterm birth. The combination of SI and second trimester bacterial vaginosis was associated with a 60% preterm birth rate, whereas either factor alone was associated with a lower rate, suggesting a synergistic effect (p < 0.0001). Future studies are needed to investigate the effect of prohibiting SI in pregnant women with bacterial vaginosis on preterm birth.

Bacterial Vaginosis and Post-Operative Pelvic Infections

Bacterial vaginosis (BV) represents a condition in which the normal protective Lactobacilli, especially those that produce H₂O₂, are replaced by high quantities of facultative anaerobes, leading to gynecologic and obstetric post-operative complications. BV is an important cause of obstetric and gynecological adverse sequelae and it could lead to an increased risk of contracting sexually transmitted infections such as gonorrhea, genital herpes, Chlamydia, Trichomonas, and human immunodeficiency virus. Herein, we reviewed bacterial vaginosis and its association with post-operative pelvic infections. In Obstetrics, BV has been associated with increased risk of preterm delivery, first-trimester miscarriage in women undergoing in vitro fertilization, preterm premature rupture of membranes, chorioamnionitis, amniotic fluid infections, postpartum and postabortal endomyometritis as well as postabortal pelvic inflammatory disease (PID). In gynecology, BV increases the risk of post-hysterectomy infections such as vaginal cuff cellulitis, pelvic cellulitis, pelvic abscess, and PID. BV is often asymptomatic, can resolve spontaneously, and often relapses with or without treatment. The American College of Obstetricians and Gynecologists recommends testing for BV in women having an increased risk for preterm delivery. Women with symptoms should be evaluated and treated. Women with BV undergoing gynecological surgeries must be treated to reduce the frequency of post-operative pelvic infections. Metronidazole and clindamycin are the mainstays of therapy. Currently, there is no consensus on pre-surgery screening for BV; decisions are made on a case-by-case basis.

Safety, tolerability, and acceptability of Lactobacillus crispatus CTV-05 (LACTIN-V) in pregnant women at high-risk of preterm birth

The vaginal microbiota is a determinant for the risk of preterm birth (PTB). Dominance of the vaginal niche by Lactobacillus crispatus associates with term delivery. This is the first observational clinical study of live vaginal biotherapeutics (Lactobacillus crispatus CTV-05 (LACTIN-V)) in pregnant women at high-risk of PTB. The primary aim was to explore safety, tolerability and acceptability of LACTIN-V in pregnancy. Women were offered a course of LACTIN-V at 14 weeks gestation for five consecutive days followed by weekly administration for six weeks. Participants were followed up at 15, 18-, 20-, 28- and 36-weeks' gestation and at delivery for assessment of adverse events, compliance and tolerability. Participants completed a questionnaire to gauge experience and acceptability. In total, 73 women were recruited, of whom eight withdrew, leaving a final cohort size of 61. Self-reported compliance to the course was high (56/60, 93%). Solicited adverse events were reported in 13 women (19%) including changes in vaginal discharge, odour, colour or consistency of urine, itching and vaginal bleeding. One unsolicited adverse event was reported as haematuria at 38 weeks gestation, but was judged to be unrelated to LACTIN-V. No serious adverse events occurred. One mild adverse event led to study withdrawal. Thirty-one women completed an experience and acceptability questionnaire. Women found LACTIN-V easy and comfortable to use and the majority (30/31, 97%) would use LACTIN-V in future pregnancies. Eight women (8/31, 26%) found the schedule of use difficult to remember. The rate of PTB <34 weeks in this cohort was 3.3% compared to 7% in a historical cohort of 2,190 women at similar background PTB risk. With satisfactory uptake and good compliance, we demonstrate that LACTIN-V is safe and accepted in pregnancy, with high tolerability. Further studies are needed to assess colonisation of Lactobacillus crispatus CTV-05 and clinical efficacy.

Maternal and fetal outcomes of pregnant women with bacterial vaginosis

Background

Bacterial vaginosis (BV) is a common infection in women of reproductive age group because of vaginal dysbiosis. The impact of BV during pregnancy is still not well defined. The objective of this study is to assess the maternal-fetal outcome in women with BV.

Materials and Methods

A prospective cohort study over one-year duration was conducted from December, 2014 until December, 2015, involving 237 women who presented with abnormal vaginal discharge, preterm labour or preterm prelabour rupture of membrane between 22- and 34-weeks period of gestation. Vaginal swabs were sent for culture and sensitivity, BV® Blue testing and PCR for Gardnerella vaginalis (GV).

Results

BV was diagnosed in 24/237 (10.1%) cases. The median gestational age was 31.6 weeks. GV was isolated from 16 out of 24 (66.7%) in the BV positive group. There was a significantly higher preterm birth rate, below 34 weeks (22.7% vs. 6.2%, p = 0.019) in women with BV. There was no statistically significant difference in maternal outcome such as clinical chorioamnionitis or endometritis. However, placental pathology revealed more than half (55.6%) of women with BV had histologic chorioamnionitis. Neonatal morbidity was significantly higher with exposure to BV, with a lower median birth weight, higher rate of neonatal intensive care unit admission (41.7% vs. 19.0%, p = 0.010), increased intubation for respiratory support (29.2% vs. 7.6%, p = 0.004) and respiratory distress syndrome (33.3% vs. 9.0%, p = 0.002).

Conclusion

More research is needed to formulate guidelines for prevention, early detection and treatment of BV during pregnancy to reduce intrauterine inflammation and the associated adverse fetal outcomes.

Screening and diagnosis of women for chorioamnionitis: An integrative literature review

OBJECTIVE

This integrative literature review provides an overview of current best research evidence on the screening and diagnosis of women for chorioamnionitis, as no current review has been conducted. An overview of best practices on screening and diagnosis of women for chorioamnionitis can assist midwives with an accurate diagnosis, allowing for early referral and adequate management of this infection.

DESIGN

An integrative literature review was conducted using a systematic electronic literature search through EBSCOhost (CINAHL with Full Text, e-Book Collection, Health Source: Nursing/Academic Edition, MEDLINE, Open Dissertations and PsycINFO), Cochrane Online, PubMed, Scopus, followed by a manual search for grey literature using Google and a citation search. Guidelines, research studies, and reports in English related to chorioamnionitis from 2008 up until 2020 were included in the study.

FINDINGS

After critical appraisal, using the Joanna Briggs Institution's checklists, Evaluation Tool for Quantitative Research Studies' tool and the Appraisal of Guidelines for Research & Evaluation instrument, 31 articles were included. More than half (64%) of the literature included ranked on the three highest levels of evidence (Level I, II and III). Data extracted regarding screening and diagnosis of women for chorioamnionitis was synthesised into four themes, namely: screening by clinical signs and symptoms, screening by causative factors of chorioamnionitis, screening of obstetric history, and essential biomarkers to diagnose chorioamnionitis.

KEY CONCLUSIONS

Screening and recording of any risk factors will assist midwives in providing tailored health education to possibly prevent causative factors that could lead to chorioamnionitis. Although matrix-metalloproteinase-8 (MMP-8) seems the most suitable test to use for screening, an accurate diagnosis of chorioamnionitis requires a combination of screening methods and tests, such as clinical signs and symptoms, maternal biomarkers, amniotic fluid testing and histology. Screening for chorioamnionitis, particularly the parameters for maternal fever as a clinical symptom of chorioamnionitis, contributing factors and microbes responsible for chorioamnionitis, the usability of MMP-8 and the development of rapid, inexpensive, easy-to-use techniques for screening and diagnosis of chorioamnionitis, warrants further research.

IMPLICATIONS FOR PRACTICE

Findings can be used by midwives in the screening and diagnosis of women for chorioamnionitis which allows for early referral and adequate management before maternal and neonatal complications arise.

Myrtle-Functionalized Nanofibers Modulate Vaginal Cell Population Behavior While Counteracting Microbial Proliferation

Vaginal infections affect millions of women annually worldwide. Therapeutic options are limited, moreover drug-resistance increases the need to find novel antimicrobials for health promotion. Recently phytochemicals were re-discovered for medical treatment. Myrtle (Myrtus communis L.) plant extracts showed in vitro antioxidant, antiseptic and anti-inflammatory properties thanks to their bioactive compounds. The aim of the present study was to create novel nanodevices to deliver three natural extracts from leaves, seeds and fruit of myrtle, in vaginal milieu. We explored their effect on human cells (HeLa, Human Foreskin Fibroblast-1 line, and stem cells isolated from skin), resident microflora (Lactobacillus acidophilus) and on several vaginal pathogens (Trichomonas vaginalis, Escherichia coli, Staphylococcus aureus, Candida albicans, Candida kefyr, Candida glabrata, Candida parapsilosis, Candida krusei). Polycaprolactone-Gelatin nanofibers encapsulated with leaves extract and soaked with seed extracts exhibited a different capability in regard to counteracting microbial proliferation. Moreover, these nanodevices do not affect human cells and resident microflora viability. Results reveal that some of the tested nanofibers are interesting candidates for future vaginal infection treatments.

Pattern of Antibiotic Use in the Perinatal Period in a Public University Hospital in Romania

Background and Objectives: Antibiotics are the most frequently prescribed drugs in hospitals and their prescription is increased during pregnancy and labor. There are limited data about this issue, and the safe use of antibiotics in pregnancy and antibiotic resistance remains a concern. The aim of the study is to evaluate the use of antibiotics among pregnant women attending hospital for five years. Materials and Methods: Antibiotic consumption and treatment information of patients were retrospectively collected from a hospital software program and expressed as defined daily dose (DDD) according to the World Health Organization (WHO) methodology for inpatients between 2017 and 2021. We evaluated antibiotic prescription by name, classes, and Food and Drug Administration (FDA) categories. Results: Antibiotic consumption shows a decreasing trend between 2017 and 2019, but an increasing one between 2020 and 2021. Ceftriaxone was the most prescribed antibiotic in each year, followed by cefixime, amoxicillin, metronidazole, cefuroxime, ampicillin, and ciprofloxacin. We noticed that first- and fourth-generation cephalosporins were not prescribed to these patients. A very small percentage of women in this study received antibiotics such as aminoglycosides; fluoroquinolones were generally contraindicated in the perinatal period. A large percentage of prescriptions were antibiotics classified as category B by the FDA. The most common infections that occurred in the perinatal period were those of the kidney and urinary tract in a higher number than in other studies. Conclusions: Our study shows that many classes of antibiotics used in perinatal women belong to category B antibiotics, the most prescribed being cephalosporins. Because of insufficient safety evidence and the potential for teratogenic effects on the fetus, restricted use among the category C and D antibiotic classes was seen and anticipated. Improving maternal health requires the involvement of healthcare experts in risk assessment and evaluation of existing data for appropriate antibiotic selection, dose, duration of medication, and monitoring.

Influence of Maternal Microbiome and Inflammatory Response in Preterm Birth: Recent Aspects of the Prevention of Preterm Birth

Preterm birth (PTB) is a global health issue and one of the most challenging problems affecting 12.9 million births worldwide. PTB is a multi-etiological disease and remains incompletely understood. The major cause of PTB is infection or inflammation and disruption of the vaginal microbiome, which affects the maternal immunologic response leading to PTB. The vaginal microbiome composition changes by a shift in the community are typically dominated by Lactobacillus during pregnancy. There are complex interactions between the maternal microbiome in pregnancy and the development of PTB, therefore, researchers have struggled to connect the maternal microbiome with the dysregulation of the maternal immune response in cases of PTB. The host microbiome affects alterations of the microorganisms with external stimuli such as disease, nutrition, immunity, and behavior. In this review, we discuss the complex association between the maternal microbiome and the risk of PTB and also focus on recent aspects of the prevention of PTB.

Screening for Vaginal and Endocervical Infections in the First Trimester of Pregnancy? A Study That Ignites an Old Debate

Objectives: Vaginal and endocervical infections are considered a global health problem, especially after recent evidence of their association with preterm delivery and other adverse obstetric outcomes. Still, there is no consensus on the efficacy of a screening strategy for these infections in the first trimester of pregnancy. This study evaluated their prevalence and whether screening and treatment resulted as effective in reducing pregnancy and perinatal complications. Methods: A single-center prospective observational study was designed; a sample size of 400 first-trimester pregnant women was established and they were recruited between March 2016–October 2019 at the Puerta de Hierro University Hospital (Spain). They were screened for vaginal and endocervical infections and treated in case of abnormal flora. Pregnancy and delivery outcomes were compared between abnormal and normal flora groups by univariate analysis. Results: 109 patients had an abnormal flora result (27.2%). The most frequently detected infection was Ureaplasma urealyticum (12.3%), followed by Candida spp. (11.8%), bacterial vaginosis (5%), Mycoplasma hominis (1.2%) and Trichomonas vaginalis (0.8%). Patients with abnormal flora had a 5-fold increased risk of preterm premature rupture of membranes (5.3% vs. 1.1% of patients with normal flora, Odds Ratio 5.11, 95% Confidence Interval 1.20–21.71, p = 0.028). No significant differences were observed regarding preterm delivery or neonatal morbidity. Conclusions: Considering the morbimortality related to prematurity and that the results of our study suggest that the early treatment of abnormal flora could improve perinatal outcomes, the implementation of a screening program during the first trimester should be considered.

Quality of life and long-term clinical outcome following robot-assisted radical trachelectomy

Quality of Life and long-term clinical outcome following robot-assisted radical trachelectomy.

OBJECTIVES

To evaluate quality of life (QoL) and long-term clinical outcome following robot-assisted radical trachelectomy (RRT).

STUDY DESIGN

Prospectively retrieved clinical data were rereviewed on all women planned for a fertility sparing RRT for early stage cervical cancer at Skåne University Hospital, Sweden between 2007 and 2020. QoL was assessed using the validated questionnaires EORTC QLQ-C30, QLQ-CX24 and the Swedish LYMQOL.

RESULTS

Data was analyzed from 49 women, 42 with a finalised RRT and seven with an aborted RRT due to nodal metastases (n = 3) or insufficient margins (n = 4). At a median follow-up time of 54 months one recurrence (2%) occurred (aborted RRT). According to QLQ-C30 the median global health status score was 75. The disease specific QLQ-C24 showed an impact on symptoms related to sexual function where sexual/vaginal functioning had a median score of 25 and 48% of patients reported worry that sex would cause physical pain. Despite this the functional items sexual activity and sexual enjoyment both had a median score of 66.7. Lymphoedema was reported in 45%, where 9% reported severe symptom with an impact on their QoL. No intraoperative complications and no postoperative complications ≥ Clavien Dindo grade III were observed. Twenty-two of 28 (79%) women who attempted to conceive were successful. A metronidazole/no intercourse regimen was applied between GW 15 + 0-21 + 6 in 26 of 28 pregnancies beyond first trimester resulting in a 92% term (≥GW 36 + 0) delivery rate.

CONCLUSIONS

Although robot-assisted radical trachelectomy in this cohort was associated with a low recurrence rate, a high fertility rate and an exceptionally high term delivery rate, women's quality of life was affected postoperatively, particularly with regards to their sexual well-being and lymphatic side-effects.

Midwives' knowledge and practices regarding the screening for and management of chorioamnionitis: A qualitative study

BACKGROUND

Screening for chorioamnionitis, or the risk thereof, by midwives is largely lacking during antenatal care and no best practice guidelines for chorioamnionitis in South Africa was noted.

AIM

To explore and describe midwives' knowledge and practices related to the screening and management of women who are at risk of or diagnosed with chorioamnionitis.

SETTING

Public healthcare institutions in a health district in the Eastern Cape province of South Africa.

METHODS

A qualitative, exploratory, descriptive and contextual research design was used. Ten midwives were purposively included in this study, and semi-structured interviews were conducted with them. The data were analysed using an adapted version of Tesch's eight steps for data analysis.

RESULTS

The main theme revealed that midwives lack knowledge regarding chorioamnionitis, resulting in incorrect practices including a lack of screening, misdiagnosis and mismanagement of the infectious condition.

CONCLUSIONS

Findings of this research showed that midwives lacked knowledge regarding the screening and management of women with chorioamnionitis resulting in incorrect practices in this regard. There is thus a need for midwives to update their knowledge regarding the screening and management of chorioamnionitis and training (e.g. through a short learning programme).

CONTRIBUTION

Findings of this study could be used by midwives to update their knowledge regarding screening and managing women with chorioamnionitis, which is expected to translate to better practices. Moreover, study findings were synthesised with the results of a literature review study to form the basis for the development of a best practice guideline for screening and managing women with chorioamnionitis.

Vaginal pH Value for Clinical Diagnosis and Treatment of Common Vaginitis

In modern society, 75% of all women worldwide have had vaginitis at least once in their lives. The vagina has a dynamic microbial ecosystem with varying vaginal pH levels. An imbalance in that ecosystem can alter the vaginal pH and tip the scale to the point of causing issues, such as vaginitis, that require medical attention. Although vaginitis is not an incurable disease, it causes discomfort and pain that disrupt women's daily lives. The most common causes of vaginitis include bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. In this review, we discuss the causes, diagnostic methods, and symptoms of different types of vaginitis, the relationship of vaginitis to the prevalence of other diseases, issues associated with recurrent vaginitis and the immune system, and a variety of effective available treatments. In our article, we summarize the relationship of pH with the vaginal ecosystem, discuss the associated factors of vaginal pH, and finally introduce the different available vaginal pH self-test products.

The reproductive tract microbiota in pregnancy

The reproductive tract microbiota plays a crucial role in maintenance of normal pregnancy and influences reproductive outcomes. Microbe–host interactions in pregnancy remain poorly understood and their role in shaping immune modulation is still being uncovered. In this review, we describe the composition of vaginal microbial communities in the reproductive tract and their association with reproductive outcomes. We also consider strategies for manipulating microbiota composition by using live biotherapeutics, selective eradication of pathogenic bacteria with antibiotics and vaginal microbiota transplantation. Finally, future developments in this field and the need for mechanistic studies to explore the functional significance of reproductive tract microbial communities are highlighted.

The Prevalence, Antibiotic Resistance Pattern, and Associated Factors of Bacterial Vaginosis Among Women of the Reproductive Age Group from Felege Hiwot Referral Hospital, Ethiopia

BACKGROUND

Bacterial vaginosis is an infection of the vagina, which results due to change in the normal balance of vaginal bacteria. The aim of this study was to assess the magnitude and determinants of bacterial vaginosis among women of reproductive age group from Felege Hiwot Referral Hospital.

MATERIALS AND METHODS

A cross-sectional study was conducted among women during the reproductive period at Felege Hiwot Referral Hospital from September 1, 2019 to October 2020. About 413 vaginal swab samples were collected and examined using the Nugent scoring system and culture. Data were analyzed by SPSS version 25. The odds ratio (OR) was used as a measure of the strength of association and reported with 95% confidence intervals. P-value ≤ 0.05 was considered to be statistically significant. Bivariate and multivariate logistic regression models were used to identify possible associated factors with bacteria causing bacterial vaginosis.

RESULTS

The overall prevalence of bacteria causing bacterial vaginosis was 39.5%. The predominant bacteria were S. aureus (25.4%), G. vaginalis (22.7%), S. agalactiae (14.1%), and E. coli (13.5%). S. aureus was resistant to erythromycin (69.8%) and trimethoprim/sulfamethoxazole (53.5%); despite this, it was susceptible to ciprofloxacillin (93%), gentamycin (93%), and cefoxitin (90.7%). On the other hand, E. coli was resistant to trimethoprim/sulfamethoxazole (91.3%) and ceftriaxone (63.6%), but was susceptible to ciprofloxacillin (95.5%) and gentamycin (93%).

CONCLUSION

The high prevalence of bacterial vaginosis was significantly associated with the pH level of the vagina (≥4.5), participant age ≤20, pregnancy, and history of HIV infection. Therefore, early identification of factors leading to bacterial overgrowth on the vagina is very important to protect maternal and child morbidity and mortality.

Brazilian Protocol for Sexually Transmitted Infections, 2020: infections causing vaginal discharge

The topic of vaginal discharge is one of the chapters of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Health Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. The chapter has been developed based on scientific evidence and validated in discussions with specialists. This article presents epidemiological and clinical aspects associated with vaginal discharge conditions, as well as guidance to health service managers and health professionals. Screening, diagnosing, and treating these conditions, the main complaints among women seeking health services, caused by infectious or non-infectious factors, also are presented. Besides, information is presented on surveillance, prevention, and control actions to promote knowledge of the problem and provide quality care and effective treatment.

In healthcare servicing cases of sexually transmitted infections, vaginal discharge is the main referred symptom, common among pregnant women.

Bioinformatics Analysis of Oral, Vaginal, and Rectal Microbial Profiles during Pregnancy: A Pilot Study on the Bacterial Co-Residence in Pregnant Women

Preterm birth (PTB) and threatened preterm labor (TPL), an important pre-PTB state, are major obstetric complications during pregnancy. However, their triggers have not been fully elucidated. The vagina is dominated by Lactobacillus species (categorized as community state types; CSTs I, II, III, and V) or by mixed anaerobes (CST IV). An abundance of the latter is associated with bacterial vaginosis (BV) and BV-triggered PTB/TPL. To identify factors that influence the diversity of vaginal microbiota associated with BV and CST IV (BV-type) bacterial profile, we performed a bioinformatic analysis of the microbial taxa using 16S rRNA amplicon sequencing data of bacterial genome in oral, vaginal, and rectal samples collected from 58 pregnant Japanese women. Interestingly, common residence of BV-associated bacteria in the vagina and rectum was individually detected in the CST IV (non-Lactobacillus dominated) group by species-level Spearman correlation coefficient analysis, suggesting that the rectum acts as a reservoir of BV-associated bacterial species in the CST IV group. The current study provides evidence of bacterial co-residence in vagina and rectum in the non-Lactobacillus dominated group, which could be targeted to reduce the risk of preterm incidence in pregnancy.

The Female Vaginal Microbiome in Health and Bacterial Vaginosis

The vaginal microbiome is an intricate and dynamic microecosystem that constantly undergoes fluctuations during the female menstrual cycle and the woman's entire life. A healthy vaginal microbiome is dominated by Lactobacillus which produce various antimicrobial compounds. Bacterial vaginosis (BV) is characterized by the loss or sharp decline in the total number of Lactobacillus and a corresponding marked increase in the concentration of anaerobic microbes. BV is a highly prevalent disorder of the vaginal microbiota among women of reproductive age globally. BV is confirmed to be associated with adverse gynecologic and obstetric outcomes, such as sexually transmitted infections, pelvic inflammatory disease, and preterm birth. Gardnerella vaginalis is the most common microorganism identified from BV. It is the predominant microbe in polymicrobial biofilms that could shelter G. vaginalis and other BV-associated microbes from adverse host environments. Many efforts have been made to increase our understanding of the vaginal microbiome in health and BV. Thus, improved novel and accurate diagnosis and therapeutic strategies for BV have been developed. This review covers the features of vaginal microbiome, BV, BV-associated diseases, and various strategies of diagnosis and treatment of BV, with an emphasis on recent research progresses.

Vaginal Microbiota and Cytokine Levels Predict Preterm Delivery in Asian Women

Preterm birth (PTB) is the most common cause of neonatal morbidity and mortality worldwide. Approximately half of PTBs is linked with microbial etiologies, including pathologic changes to the vaginal microbiota, which vary according to ethnicity. Globally more than 50% of PTBs occur in Asia, but studies of the vaginal microbiome and its association with pregnancy outcomes in Asian women are lacking. This study aimed to longitudinally analyzed the vaginal microbiome and cytokine environment of 18 Karen and Burman pregnant women who delivered preterm and 36 matched controls delivering at full term. Using 16S ribosomal RNA gene sequencing we identified a predictive vaginal microbiota signature for PTB that was detectable as early as the first trimester of pregnancy, characterized by higher levels of Prevotella buccalis, and lower levels of Lactobacillus crispatus and Finegoldia, accompanied by decreased levels of cytokines including IFNγ, IL-4, and TNFα. Differences in the vaginal microbial diversity and local vaginal immune environment were associated with greater risk of preterm birth. Our findings highlight new opportunities to predict PTB in Asian women in low-resource settings who are at highest risk of adverse outcomes from unexpected PTB, as well as in Burman/Karen ethnic minority groups in high-resource regions.

When a Neonate Is Born, So Is a Microbiota

In recent years, the role of human microbiota as a short- and long-term health promoter and modulator has been affirmed and progressively strengthened. In the course of one’s life, each subject is colonized by a great number of bacteria, which constitute its specific and individual microbiota. Human bacterial colonization starts during fetal life, in opposition to the previous paradigm of the “sterile womb”. Placenta, amniotic fluid, cord blood and fetal tissues each have their own specific microbiota, influenced by maternal health and habits and having a decisive influence on pregnancy outcome and offspring outcome. The maternal microbiota, especially that colonizing the genital system, starts to influence the outcome of pregnancy already before conception, modulating fertility and the success rate of fertilization, even in the case of assisted reproduction techniques. During the perinatal period, neonatal microbiota seems influenced by delivery mode, drug administration and many other conditions. Special attention must be reserved for early neonatal nutrition, because breastfeeding allows the transmission of a specific and unique lactobiome able to modulate and positively affect the neonatal gut microbiota. Our narrative review aims to investigate the currently identified pre- and peri-natal factors influencing neonatal microbiota, before conception, during pregnancy, pre- and post-delivery, since the early microbiota influences the whole life of each subject.

Skewed logit model for analyzing correlated infant morbidity data

BACKGROUND

Infant morbidity is a topic of interest because it is used globally as an indicator of the status of health care in a country. A large body of evidence supports an association between bacterial vaginosis (BV) and infant morbidity. When estimating the relationship between the predictors and the estimated variable of morbidity severity, the latter exhibits imbalanced data, which means that violation of symmetry is expected. Two competing methods of analysis, that is, (1) probit and (2) logit techniques, can be considered in this context and have been applied to model such outcomes. However, these models may yield inconsistent results. While non-normal modeling approaches have been embraced in the recent past, the skewed logit model has been given little attention. In this study, we exemplify its usefulness in analyzing imbalanced longitudinal responses data.

METHODOLOGY

While numerous non-normal methods for modeling binomial responses are well established, there is a need for comparison studies to assess their usefulness in different scenarios, especially under a longitudinal setting. This is addressed in this study. We use a dataset from Kenya about infants born to human immunodeficiency virus (HIV) positive mothers, who are also screened for BV. We aimed to investigate the effect of BV on infant morbidity across time. We derived a score for morbidity incidences depending on illnesses reported during the month of reference. By adjusting for the mother's BV status, the child's HIV status, sex, feeding status, and weight for age, we estimated the standard binary logit and skewed logit models, both using Generalized Estimating Equations.

RESULTS

Results show that accounting for skewness in imbalanced binary data can show associations between variables in line with expectations documented by the literature. In addition, an in-depth analysis accounting for skewness has shown that, over time, maternal BV is associated with multiple health conditions in infants.

INTERPRETATION

Maternal BV status was positively associated with infant morbidity incidences, which highlights the need for early intervention in cases of HIV-infected pregnant women.

Case report : Actinomyces naeslundii complicating preterm labour in a trisomy-21 pregnancy

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Actinomyces naeslundii causing preterm birth.

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Inappropriate antibiotics usage postpartum.

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Treatment of intrapartum Actinomyces naeslundii to prevent preterm birth.

Preterm birth is a global concern with considerable morbidity and mortality. Intrapartum infection is a known cause of preterm birth and Actinomyces infection is one of the infections contributing to preterm birth. We report a case of preterm birth of a trisomy-21 neonate to a mother with positive Actinomyces naeslundii from an intra-operative placental swab sample and discussed the relationship of this bacteria and preterm delivery, and the role of postpartum antibiotics use in this case.

Association of genitourinary infections and cervical length with preterm childbirth

A prospective cohort study was conducted on a convenience sample of 1370 pregnant women with a gestational age of 20 to 25 weeks in the city of Ribeirão Preto. Data on obstetrical history, maternal age, parity, smoking habit, and a history of preterm delivery was collected with the application of a sociodemographic questionnaire. Cervical length was determined by endovaginal ultrasound, and urine and vaginal content samples were obtained to determine urinary tract infection (UTI) and bacterial vaginosis (BV), respectively. The aim of this study was to verify the association of cervical length and genitourinary infections with preterm birth (PTB). Ultrasound showed no association of UTI or BV with short cervical length. PTB rate was 9.63%. Among the women with PTB, 15 showed UTI (RR: 1.55, 95%CI: 0.93–2.58), 19 had BV (RR: 1.22, 95%CI: 0.77–1.94), and one had both UTI and BV (RR: 0.85, 95%CI: 0.13–5.62). Nineteen (14.4%) PTB occurred in women with a cervical length ≤2.5 cm (RR: 2.89, 95%CI: 1.89–4.43). Among the 75 patients with PTB stratified as spontaneous, 10 showed UTI (RR: 2.02, 95%CI: 1.05–3.86) and 14 had a diagnosis of BV (RR: 1.72, 95%CI: 0.97–3.04). A short cervical length between 20 and 25 weeks of pregnancy was associated with PTB, whereas UTI and BV determined at this age were not associated with short cervical length or with PTB, although UTI, even if asymptomatic, was related to spontaneous PTB.

Maternal Microbiome and Infections in Pregnancy

Pregnancy induces unique changes in maternal immune responses and metabolism. Drastic physiologic adaptations, in an intricately coordinated fashion, allow the maternal body to support the healthy growth of the fetus. The gut microbiome plays a central role in the regulation of the immune system, metabolism, and resistance to infections. Studies have reported changes in the maternal microbiome in the gut, vagina, and oral cavity during pregnancy; it remains unclear whether/how these changes might be related to maternal immune responses, metabolism, and susceptibility to infections during pregnancy. Our understanding of the concerted adaption of these different aspects of the human physiology to promote a successful pregnant remains limited. Here, we provide a comprehensive documentation and discussion of changes in the maternal microbiome in the gut, oral cavity, and vagina during pregnancy, metabolic changes and complications in the mother and newborn that may be, in part, driven by maternal gut dysbiosis, and, lastly, common infections in pregnancy. This review aims to shed light on how dysregulation of the maternal microbiome may underlie obstetrical metabolic complications and infections.

Community State Types of Vaginal Microbiota and Four Types of Abnormal Vaginal Microbiota in Pregnant Korean Women

Abnormal vaginal microbiota (AVM), including bacterial vaginosis (BV), is caused by a microbiota imbalance. Nugent scoring is the gold standard for the laboratory diagnosis of BV; however, it is somewhat subjective to interpret, and challenging to distinguish bacteria. Hence, there is a need for improved technologies for the accurate diagnosis of AVM. To this end, next-generation sequencing (NGS) technology has been shown to yield comprehensive information on the pathophysiology of AVM. Hence, to evaluate the relationship between microbiota composition and the pathophysiology of AVM and its clinical significance, we characterized vaginal swab samples from 212 pregnant Korean women using both Nugent scoring and NGS analysis. Of these, the Nugent scoring identified 175 subjects (82.5%; 175/212) with normal flora (NF), 20 (9.4%; 20/212) with intermediate flora (IF), and 17 (8.0%; 17/212) with BV. NGS analysis followed by the characterization of vaginal microbiota composition, as represented by alpha and beta diversity, revealed the relative abundance of specific bacterial taxa at the genus and species level. Moreover, we identified all five predominant community state types (CSTs) along with three smaller CSTs. Analysis of the vaginal microbiota revealed the dominance of one or two Lactobacillus spp. in the NF group. Meanwhile, the IF and BV groups were dominated by the genera Gardnerella, Prevotella, and Atopobium. These two groups also showed higher alpha diversity than the NF group (p < 0.05). Principal coordinate analysis (PCoA) indicated that the NF group was significantly different from the AVM groups (p < 0.05), whereas no significant difference was observed between IF and BV groups (p = 0.25). Lastly, to investigate the characteristics of vaginal microbiota based on taxonomic composition, the IF and BV groups (AVM groups) were reclassified using the unweighted pair group method with arithmetic mean (UPGMA) clustering. Consequently, they were reclassified into BV1 (Lactobacillus iners-dominated), BV2-1 (Bifidobacterium breve-dominated), BV2-2 (Gardnerella vaginalis s1 or s2 and Atopobium vaginae-dominated), and BV3 [mixed population of G. vaginalis, L. iners, and other bacteria (p < 0.05)]. Collectively, these findings could serve to advance the current understanding regarding AVM pathophysiology.

Probiotics and the envisaged role in treating human infertility

Background

Considerable attention is being directed nowadays towards using probiotics as an alternative therapy in treating several human diseases including gastrointestinal tract diseases especially colorectal cancers, cardiovascular diseases, hyperlipidemia, and blood pressure cases. However, infertility as affected by the microbiome and the probable role of probiotics in alleviating infertility problems did not receive the deserved attention, especially in IVF patients with male or female factors.

Main body

In this review, we tried to draw the attention of researchers in the medical settings to the importance of the forthcoming role of probiotics use in elucidating the role of the microbiome in infertile patients. The hope is to attain the best performance of both male and female reproductive systems and to shed some light on infertility problems.

Conclusion

More in vivo experiments are still needed to address many aspects of probiotics like proper administration, exact functional strains, required dose, application method, duration of treatment, and combination with antibiotics before considering probiotics as an alternative treatment.

The pregnancy microbiome and preterm birth

Preterm birth is a global health concern and continues to contribute to substantial neonatal morbidity and mortality despite advances in obstetric and neonatal care. The underlying aetiology is multi-factorial and remains incompletely understood. In this review, the complex interplay between the vaginal microbiome in pregnancy and its association with preterm birth is discussed in depth. Advances in the study of bacteriology and an improved understanding of the human microbiome have seen an improved awareness of the vaginal microbiota in both health and in disease.

Volatile organic compound analysis, a new tool in the quest for preterm birth prediction-an observational cohort study

Preterm birth is the leading cause of death worldwide in children under five years. Due to its complex multifactorial nature, prediction is a challenge. Current research is aiming to develop accurate predictive models using patient history, ultrasound and biochemical markers. Volatile organic compound (VOC) analysis is an approach, which has good diagnostic potential to predict many disease states. Analysis of VOCs can reflect both the microbiome and host response to a condition. We aimed to ascertain if VOC analysis of vaginal swabs, taken throughout pregnancy, could predict which women go on to deliver preterm. Our prospective observational cohort study demonstrates that VOC analysis of vaginal swabs, taken in the midtrimester, is a fair test (AUC 0.79) for preterm prediction, with a sensitivity of 0.66 (95%CI 0.56–0.75) and specificity 0.89 (95%CI 0.82–0.94). Using vaginal swabs taken closest to delivery, VOC analysis is a good test (AUC 0.84) for the prediction of preterm birth with a sensitivity of 0.73 (95%CI 0.64–0.81) and specificity of 0.90 (95%CI 0.82–0.95). Consequently, VOC analysis of vaginal swabs has potential to be used as a predictive tool. With further work it could be considered as an additional component in models for predicting preterm birth.

[Use (and abuse) of antibiotics in perinatal medicine]

INTRODUCTION

The rational use of antibiotics (ATB) implies that patients receive those adequate for their clinical needs, in correct doses according to their individual conditions, during an adequate period of time, and at the lowest cost for them and their community. The highest rate of ATB abuse occurs during the perinatal period, despite the fact that there is evidence of multiple short- and long-term negative effects. Furthermore, this abuse is associated with increased costs of medical care.

OBJECTIVE

To update and report the evidence on the use, abuse, and adverse effects of ATB in perinatal medicine, and possible measures to prevent them, and thus improve health care outcomes and costs.

METHODS

A review and analysis was performed from the literature related to the use of ATB in perinatal medicine up to February 2020.

RESULTS

ATB abuse in perinatal medicine ranges from 50% to 70%, with even higher rates in some neonatal centres. Adverse effects include death, increased microbial resistance, along with microbiome abnormalities and dysbiosis that lead to serious life-long complications such as infections, allergies, autoimmune disorders, gastrointestinal disorders, arthritis, asthma, obesity, and perhaps cancer. Preventing and reducing the abuse of ATB would lead to better health and to significant savings in the health sector. In only 4neonatal intensive care units, with 1000 admissions per year, savings are estimated at US$230,000 per year.

CONCLUSION

The need to optimise the use of ATB in perinatal medicine has never been more urgent.

Genital Micro-Organisms in Pregnancy

The microbiome of the female genital tract may undergo changes in pregnancy due to metabolic, endocrinological, and immunological alterations. These dysbiotic states may cause infections which may ascend upwards to the feto-placental unit or may be seeded hematogenously. These low grade and often low virulent infectious states lead to chronic inflammatory states and maybe associated with adverse maternal and neonatal outcome. Organisms have been isolated from amniotic fluid and placentae from women delivering pre-term; however the possibility of contamination cannot be conclusively ruled out. Common vaginal dysbiotic states often cause symptoms that are overlooked and often untreated. Vulvovaginal Candidiasis (VVC), Bacterial Vaginosis (BV), and Trichomonas Vaginitis (TV) are the commonly occurring dysbiotic states leading to vaginal infective states in pregnancy. With the advent of novel technologies like Next Generation sequencing (NGS), it will soon be possible to comprehensively map the vaginal microbiome and assess the interplay of each microbial state with their effects in pregnancy. This may open new avenues for antibiotic recommendations, probiotics and potential alternate therapies for dysbiotic states leading to pregnancy complications.

Impact of preconception vaginal microbiota on women's risk of spontaneous preterm birth: protocol for a prospective case-cohort study

INTRODUCTION

Bacterial vaginosis (BV) and vaginal microbiota disruption during pregnancy are associated with increased risk of spontaneous preterm birth (SPTB), but clinical trials of BV treatment during pregnancy have shown little or no benefit. An alternative hypothesis is that vaginal bacteria present around conception may lead to SPTB by compromising the protective effects of cervical mucus, colonising the endometrial surface before fetal membrane development, and causing low-level inflammation in the decidua, placenta and fetal membranes. This protocol describes a prospective case-cohort study addressing this hypothesis.

METHODS AND ANALYSIS

HIV-seronegative Kenyan women with fertility intent are followed from preconception through pregnancy, delivery and early postpartum. Participants provide monthly vaginal specimens during the preconception period for vaginal microbiota assessment. Estimated date of delivery is determined by last menstrual period and first trimester obstetrical ultrasound. After delivery, a swab is collected from between the fetal membranes. Placenta and umbilical cord samples are collected for histopathology. Broad-range 16S rRNA gene PCR and deep sequencing of preconception vaginal specimens will assess species richness and diversity in women with SPTB versus term delivery. Concentrations of key bacterial species will be compared using quantitative PCR (qPCR). Taxon-directed qPCR will also be used to quantify bacteria from fetal membrane samples and evaluate the association between bacterial concentrations and histopathological evidence of inflammation in the fetal membranes, placenta and umbilical cord.

ETHICS AND DISSEMINATION

This study was approved by ethics committees at Kenyatta National Hospital and the University of Washington. Results will be disseminated to clinicians at study sites and partner institutions, presented at conferences and published in peer-reviewed journals. The findings of this study could shift the paradigm for thinking about the mechanisms linking vaginal microbiota and prematurity by focusing attention on the preconception vaginal microbiota as a mediator of SPTB.

Vaginal microbiome diversity and preterm birth: results of a nested case-control study in Peru

PURPOSE

Preterm birth (PTB) is a major cause of neonatal mortality. The vaginal microbiome is associated with PTB, but results vary across racial/ethnic populations. Some evidence suggests gestational age affects this association. We investigated these associations in a novel population, conducting a post hoc analysis assessing if associations differed between women swabbed at different gestational ages.

METHODS

We compared vaginal microbiomes from women with PTB (n = 25) to a random sample of women with term births (n = 100) among participants in the Pregnancy Outcomes, Maternal and Infant Study, conducted in Lima, Peru. Using DADA2, we identified taxa from 16S DNA sequencing and used Dirichlet multinomial mixture models to group into community state types (CSTs).

RESULTS

If gestational age at sampling was not considered, no CST (diverse, Lactobacillus-dominated or Lactobacillus iners-dominated), was associated with PTB. Among women sampled before 12 weeks' gestation, women with Lactobacillus-dominated CSTs were less likely to have a PTB than those with a diverse CST. Among those swabbed between 12 and 16 weeks' gestation, the reverse was true.

CONCLUSIONS

Our study supports previous literature suggesting that what constitutes a healthy vaginal microbiome varies by race/ethnicity. Longitudinal studies are necessary to disentangle effects of vaginal microbiome differences over gestation.

Reducing the Risk of Preterm Birth by Ambulatory Risk Factor Management

BACKGROUND

The preterm birth rate in Germany has remained unchanged at 8-9% since 2009. Preterm birth is the most common cause of neonatal morbidity and mortality. In the absence of a causal treatment, it is important to lower the risk of preterm birth by preventive measures in prenatal outpatient care.

METHODS

This review is based on pertinent publications from the years 2000-2019 that were retrieved by a selective search in PubMed.

RESULTS

The clinical risk factors for preterm birth-known mainly from retrospective cohort studies-include previous preterm birth (adjusted odds ratio [aOR]: 3.6), multiple pregnancy (relative risk [RR]: 7.7), nicotine consumption (aOR: 1.7), and a short uterine cervix, i.e., <25 mm in the second trimester (aOR: 6.9). In women with a short cervix, vaginally administered progesterone significantly lowers the preterm birth rate (22.5% vs. 14.1% for birth before 33 weeks of gestation, RR: 0.62; 95% confidence interval [0.47; 0.81]). Nicotine abstinence is associated with a lower pre- term birth rate as well (aOR: 0.91; [0.88; 0,.94]), while working more than 40 hours per week (aOR: 1.25; [1,.01; 1,.54]) and heavy lifting during pregnancy (hazard ratio [HR]: 1.43; [1.13; 1.80]) are associated with a higher preterm birth rate. Avoidance of physical exertion, or bed rest, in the face of impending preterm birth does not lower the preterm birth rate, but it does increase the risk of complications, such as thromboembolism.

CONCLUSION

The meticulous assessment and elimination of treatable risk factors at the outset of ambulatory prenatal care can help lower the preterm birth rate. Further velopment of causally directed treat- ments (e.g., changes of relevant environmental and epigenetic factors).

Periodontopathogenic microbiota, infectious mechanisms and preterm birth: analysis with structural equations (cohort-BRISA)

PURPOSE

The association between periodontopathogenic microbiota and preterm birth (PTB) has been overly studied. However, the biological mechanisms involved are little known. The objective is to evaluate the effect of periodontopathogenic bacteria burden (PBB), periodontal disease and other infections during pregnancy on preterm birth (PTB), through Structural Equation Modeling.

METHODS

This was a case-control study nested in a prospective cohort called BRISA, including 330 pregnant women, 110 cases and 220 controls. This study included the following variables: cytokines interleukin-10 (IL-10) and transforming growth factor beta (TGF-β), periodontal disease, PBB, age, socioeconomic status (SES), systemic infections and PTB. The correlations between variables were analyzed using Standardized Coefficient (SC).

RESULTS

Greater PBB interfered positively with the occurrence of periodontal disease (SC: 0.027; p: 0.011), but these were not associated with the cytokines studied, nor with PTB. The lower serum levels of IL-10 (SC - 0.330; p 0.022) and TGF-β (SC - 0.612; p  < 0.001), and the presence of other systemic infections during pregnancy (SC 0.159; 0.049) explained the higher occurrence of PTB.

CONCLUSION

It is possible that only the more severe periodontal disease and other systemic infections are capable of altering the cascade of cytokines regulating the inflammatory process and have an effect on the occurrence of PTB.

Cytokine profiles of umbilical cord blood mononuclear cells upon in vitro stimulation with lipopolysaccharides of different vaginal gram-negative bacteria

Inflammatory immune responses induced by lipopolysaccharides (LPS) of gram-negative bacteria play an important role in the pathogenesis of preterm labor and delivery, and in neonatal disorders. To better characterize LPS-induced inflammatory response, we determined the cytokine profile of umbilical cord blood mononuclear cells (UBMC) stimulated with LPS of seven vaginal gram-negative bacteria commonly found in pregnant women with preterm labor and preterm rupture of membrane. UBMC from ten newborns of healthy volunteer mothers were stimulated with purified LPS of Escherichia coli, Enterobacter aerogenes, Klebsiella pneumoniae, Proteus mirabilis, Acinetobacter calcoaceticus, Citrobacter freundii, and Pseudomonas aeruginosa. UBMC supernatants were tested for the presence of secreted pro-inflammatory cytokines (IL-6, IL-1β, TNF), anti-inflammatory cytokine (IL-10), TH₁-type cytokines (IL-12, IFN-γ), and chemokines (IL-8, MIP-1α, MIP-1β, MCP-1) by Luminex technology. The ten cytokines were differentially induced by the LPS variants. LPS of E. coli and E. aerogenes showed the strongest stimulatory activity and P. aeruginosa the lowest. Interestingly, the ability of UBMC to respond to LPS varied greatly among donors, suggesting a strong individual heterogeneity in LPS-triggered inflammatory response.

Preterm Birth: A Narrative Review of the Current Evidence on Nutritional and Bioactive Solutions for Risk Reduction

Preterm birth (PTB) (<37 weeks of gestation) is the leading cause of newborn death and a risk factor for short and long-term adverse health outcomes. Most cases are of unknown cause. Although the mechanisms triggering PTB remain unclear, an inappropriate increase in net inflammatory load seems to be key. To date, interventions that reduce the risk of PTB are effective only in specific groups of women, probably due to the heterogeneity of its etiopathogenesis. Use of progesterone is the most effective, but only in singleton pregnancies with history of PTB. Thus, primary prevention is greatly needed and nutritional and bioactive solutions are a promising alternative. Among these, docosahexaenoic acid (DHA) is the most promising to reduce the risk for early PTB. Other potential nutrient interventions include the administration of zinc (possibly limited to populations with low nutritional status or poor zinc status) and vitamin D; additional preliminary evidence exists for vitamin A, calcium, iron, folic acid, combined iron-folate, magnesium, multiple micronutrients, and probiotics. Considering the public health relevance of PTB, promising interventions should be studied in large and well-designed clinical trials. The objective of this review is to describe, summarize, and discuss the existing evidence on nutritional and bioactive solutions for reducing the risk of PTB.

Early adversity and the regulation of gene expression: Implications for prenatal health

Early life, including prenatal development and childhood, is a period of sensitivity, with potential for developmental programming under conditions of adversity. The intergenerational effects of early adversity have received attention, most often studied in relation to fetal development according to maternal exposures. Less often considered but critically important is the effect of early adversity on future prenatal risk (e.g., risk for preeclampsia, preterm birth), which threatens the health of mother and infant. The body's ability to turn collections of genes "on" or "off" across a range of tissues via receptor-driven transcription factors and epigenetic mechanisms (i.e., chemical modifications to the genome) in response to the perceived environment may help to explain such associations. This review aims to summarize discoveries surrounding the effects of early adversity on gene expression, emphasizing prenatal populations. First, we review findings from gene expression studies examining the effects of early adversity on various tissues known to contribute to prenatal health in adulthood. Next, we review several gene regulatory mechanisms thought to underlie differences in gene expression. Finally, we discuss potential implications for prenatal risk among early adversity-exposed mothers according to our current understanding of the biology that contributes to the development of prenatal syndromes.

Berberine exhibits antioxidative effects and reduces apoptosis of the vaginal epithelium in bacterial vaginosis

Bacterial vaginosis (BV) is a common type of vaginitis. Berberine is a natural alkaline product that reduces oxidative stress and apoptosis in cells. The aim of the present study was to investigate the effects of berberine on oxidative stress and apoptotic rates of BV. Vaginal epithelial and discharge samples were obtained from 60 healthy individuals and 180 patients with BV before and after one month of berberine treatment. Clinical observation was documented for all patients before and after treatment for comparison. Additionally, an in vitro study was performed; the samples were divided into groups the following groups: Control, model (H₂O₂-treated), LT (low-dose berberine), MT (medium-dose berberine) and HT (high-dose berberine). Expression levels of the oxidative stress related proteins were detected by western blotting. Clinical symptoms of patients with BV significantly improved following berberine treatment. Oxidative stress in vaginal discharge was significantly lower following treatment, indicated by the increased activity of superoxide dismutase (SOD) and catalase, as well as the reduced levels of malondialdehyde and H₂O₂. Apoptosis of the vaginal epithelial cells was also reduced, which was indicated by the reduced expression of apoptosis proteins caspase-3, cytochrome C, capase-12 and Bax, and increased expression of Bcl-2. The results of the in vitro experiments demonstrated a dose-dependent decrease in apoptosis with berberine treatment compared with levels before treatment. Oxidative stress relief was demonstrated by the reduced reactive oxygen species level and increased SOD and endothelial nitric oxide synthase levels, whereas suppression of apoptosis was further supported by the reduction in apoptotic proteins, as well as a decreased Bax/Bcl-2 ratio. Berberine exhibited effects on lowering oxidative stress in vaginal discharge and reducing oxidative damage, as well as apoptosis of the vaginal epithelium, which are beneficial to patients with bacterial vaginosis.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.

OBJECTIVES

The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.

Effects of oral probiotic supplements on vaginal microbiota during pregnancy: a randomised, double-blind, placebo-controlled trial with microbiome analysis

Objective

To determine the effects on the vaginal microbiota of an oral probiotic preparation administered from early pregnancy.

Design

Randomised, double blind, placebo‐controlled trial.

Setting

Four maternity units in the UK.

Population

Women aged 16 years or older recruited at 9–14 weeks' gestation.

Methods

Participants were randomly allocated to receive oral capsules of probiotic containing Lactobacillus rhamnosus GR‐1 and Lactobacillus reuteri RC‐14 each at 2.5 × 10⁹ colony‐forming units (CFUs) or placebo once daily from recruitment until the end of pregnancy.

Main outcome measure

Rates of bacterial vaginosis (BV, defined as Nugent score ≥7) at 18–20 weeks' gestation compared by logistic regression adjusted for possible confounders.

Results

The primary analysis included 78% (238/304) of participants who initially consented (probiotic group 123, placebo group 115). Of these participants, 95% (227/238) reported an intake of 93% or more of the required number of capsules. The rates of BV did not differ between groups at 18–20 weeks' gestation (15% (19/123) in the probiotic group vs. 9% (10/115) in the placebo group, adjusted odds ratio 1.82, 95% confidence interval 0.64–5.19). There were also no differences between the groups in the proportion of women colonised with the probiotic strains, Escherichia coli, group B streptococci or other vaginal microbiota. There were no differences in the alpha diversity or composition of the bacterial communities between or within the probiotic and placebo groups at 9–14 and 18–20 weeks’ gestation.

Conclusions

Oral probiotics taken from early pregnancy did not modify the vaginal microbiota.

Tweetable abstract

The oral probiotic preparation used in this study does not prevent BV in pregnant women.

The oral probiotic preparation used in this study does not prevent BV in pregnant women.

Prevalence of and risk factors for abnormal vaginal flora and its association with adverse pregnancy outcomes in a rural district in north-east Bangladesh

INTRODUCTION

The role of screening and treatment for abnormal vaginal flora (AVF) on adverse pregnancy outcomes remains unclear. Using data from women who participated in a population-based cluster randomized trial who were screened and treated for AVF, we report risk factors for AVF and association of persistent AVF with adverse perinatal outcomes.

MATERIAL AND METHODS

Pregnant women (n = 4221) <19 weeks of gestation provided self-administered mid-vaginal swabs; smears were Nugent-scored. AVF was treated with oral clindamycin; if AVF was present 3 weeks after treatment, persistent AVF was re-treated. We examined risk factors for AVF and the association of persistent AVF with adverse pregnancy outcomes.

RESULTS

The prevalence of AVF was 16.5%: 9.8% of women had bacterial vaginosis and 6.8% had intermediate flora. Lower economic and educational status of women were associated with increased risk of AVF. One-third of women with AVF had persistent abnormal flora; these women had a higher risk of a composite measure of adverse pregnancy outcomes from 20 to <37 weeks (preterm live birth, preterm still birth, late miscarriage) (relative risk [RR] 1.33, 95% confidence interval [CI] 1.07-1.65) and of late miscarriage alone (RR 4.15, 95% CI 2.12-8.12) compared to women without AVF.

CONCLUSIONS

In this study in Sylhet District, Bangladesh, rates of AVF and persistent AVF were high and persistent AVF was associated with adverse pregnancy outcomes, with an especially high associated risk for late miscarriage. Further characterization of the microbiome and relative bacterial species density associated with persistent AVF is needed.

Association between increased antenatal vaginal pH and preterm birth rate: a systematic review

Background Worldwide, 14.9 million infants (11%) are born preterm each year. Up to 40% of preterm births (PTBs) are associated with genital tract infections. The vaginal pH can reflect changes in the vaginal milieu and, if elevated, indicates an abnormal flora or infection. Objective The aim of the study was to investigate whether an increased antenatal vaginal pH >4.5 in pre-labour pregnant women is associated with an increased PTB rate <37 completed weeks gestation. Search strategy Key databases included SCOPUS, EMBASE, MEDLINE, PsycInfo and the Cochrane Central Register of Controlled Trials, complemented by hand search, up to January 2017. Selection criteria Primary research reporting vaginal pH assessment in pre-labour pregnant women and PTB rate. Data collection and analysis Data extraction and appraisal were carried out in a pre-defined standardised manner, applying the Newcastle-Ottawa scale (NOS) and Cochrane risk of bias tool. Analysis included calculation of risk difference (RD) and narrative synthesis. It was decided to abstain from pooling of the studies due to missing information in important moderators. Main results Of 986 identified records, 30 were included in the systematic review. The risk of bias was considered mostly high (40%) or moderate (37%). Fifteen studies permitted a calculation of RD. Of these, 14 (93%) indicated a positive association between increased antenatal vaginal pH and PTB (RD range: 0.02-0.75). Conclusion An increased antenatal vaginal pH >4.5 may be associated with a higher risk for PTB. It is recommended to conduct a randomised controlled trial (RCT) to investigate the effectiveness of antenatal pH screening to prevent PTB. Tweetable abstract Pregnant women with an increased vaginal pH >4.5 may be at higher risk to experience preterm birth.

Association between preterm delivery and bacterial vaginosis with or without treatment

The relationship between bacterial vaginosis (BV) and preterm delivery has become well known in recent years, although there are few studies on: (i) the differences in test results during the early gestational (EGP) and middle gestational (MGP) periods; (ii) the significance of the intermediate (I) group that does not develop overt BV; or (iii) the therapeutic effects of metronidazole. We performed a retrospective study to analyze the relationship between the vaginal bacterial status and the preterm delivery rate. Without treatment, the preterm delivery rate was higher in the BV subgroup than in the I and normal (N) subgroups (p = 0.021) in the EGP, whereas the rates in the BV and I subgroups were higher than in the N subgroup in the MGP (p = 0.0003). Although treatment of BV by metronidazole vaginal tablets significantly increased the N subgroup in the MGP (p = 0.020), there was no significant improvement in the preterm delivery rate. Decreasing the rate of preterm delivery requires development of treatment methods that will further increase the percentage of patients who test N during the MGP after BV during the EGP.