Per-Göran Larsson

Incidence of pelvic inflammatory disease after first-trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: A double-blind, randomized study

OBJECTIVE The purpose of this study was to evaluate the effect of metronidazole treatment on the incidence of postoperative pelvic inflammatory disease after first-trimester abortion in women with bacterial vaginosis. STUDY DESIGN A double-blind, randomized, multicenter study was conducted on 231 women undergoing first-trimester legal abortion and fulfilling the criteria for bacterial vaginosis. The women were randomized to either metronidazole 500 mg three times daily for 10 days or placebo. Treatment was started at the outpatient visit the week before the operation. RESULTS Among the 174 women who could be evaluated, pelvic inflammatory disease developed in 14 after the abortion. In the treatment group there were three infections (3.8%) compared with 11 (12.2%) in the placebo group (p less than 0.05). CONCLUSION These data suggest that patients with bacterial vaginosis should be treated in conjunction with first-trimester abortion because treatment with metronidazole reduces the postoperative infection rate more than three times.

Bacterial vaginosis - a microbiological and immunological enigma

The development of bacterial vaginosis (BV) among women of childbearing age and the resulting quantitative and qualitative shift from normally occurring lactobacilli in the vagina to a mixture of mainly anaerobic bacteria is a microbiological and immunological enigma that so far has precluded the formulation of a unifying generally accepted theory on the aetiology and clinical course of BV. This critical review highlights some of the more important aspects of BV research that could help in formulating new basic ideas respecting the biology of BV, not least the importance of the interleukin mediators of local inflammatory responses and the bacterial shift from the normally occurring lactobacilli species: L. crispatus, L. gasseri, L. jensenii, and L. iners to a mixed flora dominated by anaerobic bacteria.

Bacterial vaginosis and cervical intraepithelial neoplasia

Methods. In an attempt to investigate an association between the finding of clue cells in Papanicolaou‐stained (PAP) smears and cervical intraepithelial neoplasia (CIN), a total of 6I50 smears from 1976 were re‐investigated.

Bacterial vaginosis - Transmission, role in genital tract infection and pregnancy outcome: An enigma

Whether bacterial vaginosis (BV) is acquired from an endogenous or an exogenous source is subject to controversy. Despite findings of an association between sexual behaviour and BV, some data indicate that BV is not a sexually transmitted infection in the traditional sense, while other data indicate that BV is an exogenous infection. A third aspect of BV is its tendency to go unnoticed by affected women. All of this will have a strong impact on how physicians view the risks of asymptomatic BV. This review focuses on whether or not BV should be regarded as a sexually transmitted infection (STI), its role in postoperative infections and pelvic inflammatory disease (PID), and on whether or not treatment of BV during pregnancy to reduce preterm delivery should be recommended. The reviewed studies do not lend unequivocal support to an endogenous or exogenous transmission of the bacteria present in BV. For women undergoing gynaecological surgery such as therapeutic abortion, the relative risk of postoperative infection is clearly elevated (approx. 2.3–2.8). A weaker association exists between BV and pelvic inflammatory disease. Data on treatment of BV as a way of reducing preterm delivery are inconclusive and do not support recommendations for general treatment of BV during pregnancy. The discrepant associations between BV and preterm birth found in recent studies may be explained by variations in immunological response to BV. Genetic polymorphism in the cytokine response – both regarding the TNF alleles and in interleukin production – could make women more or less susceptible to BV, causing different risks of preterm birth. Thus, studies on the vaginal inflammatory response to microbial colonization should be given priority.

GUILT AND EMPTINESS: WOMEN'S EXPERIENCES OF MISCARRIAGE

Women who lose an early pregnancy are shocked when they are first given the information that they have miscarried. Later they feel guilt and emptiness. Heideggerian interpretive phenomenology has been used with 13 women from southwest Sweden to uncover their lived experience of miscarriage. Women plan their future with a child during early pregnancy. When miscarriage occurs it is not a gore, an embryo, or a fetus they lose, it is their child. They feel that they are the cause of the miscarriage through something they have done, eaten, or thought. They feel abandonment and they grieve for their profound loss; they are actually in bereavement.

Bacterial vaginosis--a disturbed bacterial flora and treatment enigma.

The syndrome bacterial vaginosis (BV) is characterized by a disturbed vaginal microflora in which the normally occurring lactobacilli yield quantitatively to an overgrowth of mainly anaerobic bacteria. As BV is a possible cause of obstetrics complications and gynaecological disease – as well as a nuisance to the affected women – there is a strong impetus to find a cure. In BV treatment studies, the diagnosis criteria for diagnosis of BV vary considerably and different methods are used for cure evaluation. The design of study protocols varies and there is no consensus respecting a suitable time for follow‐up visits. For the purpose of this review, available data were recalculated for 4‐week post treatment cure rates. For oral metronidazole the 4‐week cure rate was found not to exceed 60–70%. Treatment regimens with topical clindamycin or topical metronidazole have the same cure rates. It can thus be said that no sound scientific basis exists for recommending any particular treatment. There is no evidence of beneficial effects on BV engendered by partner treatment, or by addition of probiotics or buffered gel. Long‐term follow‐up (longer than 4 weeks) shows a relapse rate of 70%. With a primary cure rate of 60–70%, and a similar relapse rate documented in the reviewed literature, clinicians simply do not have adequate data for determining treatment or designing clinical studies. This is unfortunate since – apart from the obvious patient benefits – clinical studies can often serve as a guide for more basic studies in the quest for underlying disease mechanisms. In the case of BV there is still a need for continued basic studies on the vaginal flora, local immunity to the flora and host‐parasite interactions as an aid when designing informative clinical studies.

Advantage or Disadvantage of Episiotomy Compared with Spontaneous Perineal Laceration

In a prospective clinical investigation of 2,144 deliveries, we elucidate the indications for episiotomy and how different methods of anesthesia affect the frequency of episiotomy and the perineal problems after episiotomy compared with those after spontaneous perineal laceration. We found a significantly higher infection rate (p less than 0.001) and a longer healing period in the episiotomy group. These differences remain even if only primigravida or the indication, imminent perineal laceration, is studied. The results indicate that many women will unnecessarily suffer after an episiotomy. The patients subjective problems are significantly increased, both immediately and at the 3-month postoperative follow-up.

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).

Analysis of bacterial vaginosis-related amines in vaginal fluid by gas chromatography and mass spectrometry

ABSTRACT The presence of various amines in vaginal fluid from women with malodorous vaginal discharge has been reported before. The investigations have used several techniques to identify the amines. However, an optimized quantification, together with a sensitive analysis method in connection with a diagnostic procedure for vaginal discharge, including the syndrome of bacterial vaginosis, as defined by the accepted “gold standard,” has not been done before. We now report a sensitive gas chromatographic and mass spectrometric method for identifying the amines isobutylamine, phenethylamine, putrescine, cadaverine, and tyramine in vaginal fluid. We used weighted samples of vaginal fluid to obtain a correct quantification. In addition, a proper diagnosis was obtained using Gram-stained smears of the vaginal fluid that were Nugent scored according to the method of Nugent et al. (R. P. Nugent et al., J. Clin. Microbiol., 29:297–301, 1991). We found that putrescine, cadaverine, and tyramine occurred in high concentrations in vaginal fluid from 24 women with Nugent scores between 7 and 10. These amines either were not found or were found only in very low concentrations in vaginal fluid from women with Nugent scores of 0 to 3. There is a strong correlation between bacterial vaginosis and the presence of putrescine, cadaverine, and tyramine in high concentrations in vaginal fluid.

An international study of the interobserver variation between interpretations of vaginal smear criteria of bacterial vaginosis

An international workshop on vaginal smear‐based diagnosis of bacterial vaginosis was organized where 13 investigators scoring 258 slides with smears from vaginal fluid. Interobserver reproducibility of interpretations of Nugent scores, Hay/Ison scores and wet smear scores for the diagnosis of bacterial vaginosis was shown to be high. Detailed analysis of individual scoring results however indicated that basic standards of quality control to ensure robust individual readings of slides must be adhered to.