R. F. Lamont

A longitudinal study of bacterial vaginosis during pregnancy

Objective To determine the longitudinal changes in the incidence of bacterial vaginosis in pregnancy.

Use of C‐reactive protein as a predictor of chorioamnionitis in preterm prelabour rupture of membranes: a systematic review

Background  Studies examining the use of C‐reactive protein (CRP) as a predictor of chorioamnionitis in preterm prelabour rupture of membranes (PPROM) report highly conflicting results. Despite this, CRP is commonly used for the early diagnosis of chorioamnionitis.

Diagnosis of bacterial vaginosis in a gynaecology clinic

Objective To estimate the prevalence of bacterial vaginosis in women referred to a gynaecology clinic, and to compare two methods of diagnosing bacterial vaginosis.

Can antibiotics prevent preterm birth—the pro and con debate

Studies using different diagnostic methods and outcome parameters have used different antibiotics and dose/administration regimes to women of differing risk of preterm birth with, not surprisingly, different results. Studies which have shown benefit have been criticised for having either poor methodology, low sample size or having only showed benefit after a non‐prespecified subgroup analysis. Studies which have failed to show any benefit have been criticised for unacceptable methods of diagnosing abnormal genital tract flora or having excluded a large percentage of patients eligible for the study, for having permitted a long period to elapse from diagnosis of abnormal genital tract flora to administration of treatment and for having employed treatment too late in pregnancy. A Cochrane Systematic Review of these studies failed to provide a definitive answer because this was published one month before two randomised double‐blind placebo‐controlled trials were published, in which clindamycin used either systemically or intravaginally in low risk, unselected women resulted in a 60% reduction in the incidence of preterm birth. This would have influenced the inconclusive results of the Cochrane review, with respect to general population studies. Very early spontaneous preterm labour and preterm birth is more likely to be of infectious aetiology than preterm birth just before term. The earlier in pregnancy at which abnormal genital tract flora is detected, the greater is the risk of an adverse outcome. Women with abnormal flora in early pregnancy, who subsequently revert to normal, continue to have a high risk of adverse outcome of pregnancy, at a degree similar to women with abnormal genital tract flora in early pregnancy who were treated with placebo. This suggests that whatever damage abnormal flora induces, this is at an early gestation, even if the flora subsequently reverts to normal. It follows therefore that if antibiotics are to be of help in preventing spontaneous preterm labour and preterm birth of infectious aetiology, these must be administered early in pregnancy. Antibiotics used prophylactically for the prevention of preterm birth are more likely to be successful if: they are used in women with abnormal genital tract flora (rather than other risk factors for preterm birth, e.g. low BMI, twins, generic previous preterm birth); they are used early in pregnancy prior to infection (tissue penetration/inflammation and tissue damage); they are used in women with the greatest degree of abnormal genital tract flora; and if they are used in women with a predisposition to mount a damaging inflammatory response to infection.

Prevalence of bacterial vaginosis in women attending one of three general practices for routine cervical cytology.

A prospective observational study of asymptomatic women from three different general practices was set up to establish the incidence of bacterial vaginosis (BV). The study group comprised 287 women recalled to their general practitioners surgery for routine cervical smears. The prevalence of an abnormal vaginal flora was about the same in women attending the 3 practices. Nearly 14% of women had abnormal vaginal flora and about 9% had BV on Gram stain examination of vaginal secretions. This was 2-3 times more common than findings consistent with vaginal candidiasis (3.8%). Significant numbers of women with BV had received antifungal therapy suggesting a misdiagnosis. Because of its potential complications, women should be offered screening for BV in a well-women setting and, if found, should be treated if symptomatic or at risk of adverse obstetric or gynaecological sequelae.

A comparison of the use of Papanicolaou-stained cervical cytological smears with Gram-stained vaginal smears for the diagnosis of bacterial vaginosis in early pregnancy

Our objective is to compare the efficacy of using Papanicolaou (PAP)-stained cervical cytology smears with a standardized method of interpreting Gram-stained vaginal smears for the diagnosis of bacterial vaginosis (BV) in pregnancy. High vaginal smears were Gram-stained and examined by a single observer to characterize 3 grades of vaginal flora and diagnose BV. Cervical smears were PAP-stained and examined for characteristic patterns of vaginal flora including evidence of BV by either a number of cytotechnicians or a single cytopathologist. The results of the 2 methods were compared. Seven hundred and forty-seven women attending an antenatal clinic in a district general hospital who consented to have a smear of vaginal secretions and cervical cytology in early pregnancy. The main outcome measure is the diagnosis of BV by different methods in a pregnant population. Compared with the Gram-stain method for the diagnosis of BV, there was good agreement between PAP-stain interpretation by a single observer but the agreement was not as good with PAP-stain interpretation by multiple cytotechnicians. When the grades were consolidated to normal (grade I) and abnormal flora (grades II and III), compared to Gram-stained smears, PAP cytology undertaken by several cytotechnicians had a sensitivity of 80.7% and a specificity of 90.7%. The sensitivity and specificity increased to 87% and 97%, respectively, when the PAP-stained smears were read by a single cytopathologist. Using kappa scores, only those readings made by a single cytopathologist were reliable. The setting in a cytopathology laboratory comprises multiple cytotechnicians, so that PAP-stain analysis of vaginal smears for the diagnosis of BV is likely to provide results which are less reliable than those obtained by Gram staining. The latter should be the first choice and every effort should be made to set up this service.

The contemporary use of beta-agonists.

The available evidence, therefore, suggests that sweeping of the membranes is an effective method of induction of labour in women with prolonged pregnancy because approximately two-thirds will achieve labour within three days, avoiding potentially more hazardous and more uncomfortable methods of induction of labour, such as vaginal prostaglandins or intravenous oxytocin. The trials have been too small to comment on the effect of sweeping of the membranes on mode of delivery and perinatal outcome. Furthermore, there has been no assessment of the discomfort experienced by the women who underwent sweeping compared with simple vaginal examination, and there has been no formal comparison of the financial cost of a policy of sweeping of the membranes compared with controls. Finally, it should be emphasised that these results apply to sweeping of the membranes in prolonged pregnancy; there is no information about the effect of sweeping of the membranes before term as a method of induction of labour in complicated pregnancies. These should be the focus of future investigations. J. M. Grant Consultant Bellshill Hospital Lanarkshire References

New approaches in the management of preterm labour of infective aetiology

12 Proceedings of the Joint Royal College of Physicians of Edinburgh and the Royal College of Obstetricians and Gynaecologists Consensus Conference on Anti-D Prophylaxis; Edinburgh; 8-9 Apr 1997. BrJObstet Gynaecoll998; 105 Suppl 17. In press. 13 Bowman JM. The prevention of Rh immunisation. TransfMed Rev 1988;Z: 129-150. 14 Zipurski A, Israels LG. The pathogenesis and prevention of Rh irmnunisation. Can MedAssoc J 1967; 91: 1254-1257. 15 Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study of general practice. BMJ 1997; 315:

Bacterial vaginosis in climacteric and menopausal women

The objective was to determine how frequently an abnormal vaginal flora occurred in women attending a menopause clinic and whether any abnormality might be related to a particular risk factor. Women completed a questionnaire on their gynaecological, sexual and medical history. Whether they were perimenopausal or postmenopausal was determined on the basis of symptomatology, duration of amenorrhoea and on a follicle-stimulating hormone (FSH) assay when clinically indicated. A speculum examination of the vagina was undertaken, at which time a smear of vaginal secretion was Gram stained and the bacterial flora graded as follows: grade 1, normal; grade 2, intermediate, and grade 3, bacterial vaginosis (BV). Of 100 women examined, 44 had grade 1 flora, 17 had grade 2 flora and 18 had BV. An apparent absence of, or very scanty, vaginal bacteria in which grading was not possible was found in 21 women. Women with BV had had more sexual partners than the others, but otherwise there were no discernible factors associated with the occurrence of BV. Women with vaginal atrophy were more likely to have an apparent absence of vaginal bacteria, but a few had BV.

Infection and preterm labour

quality and quantity of information they were given and, despite having continuing pain, most did not receive further medical care. Many felt they were not believed and were given no help in the management of their chronic condition. These women require understanding and time from the doctors involved in their care, and our work suggests potential benefits in the joint gynaecological and psychological support of such women.