Background. No larger population‐based study of bacterial vaginosis in pregnancy has previously been available. The objective of this study was to examine risk factors for bacterial vaginosis in pregnancy. Design. From a prospective population‐based cohort of 3,596 eligible pregnant women, 2,927 (81.4%) completed the study. Methods. Women were asked to participate in this study at their first prenatal visit at 17 gestational weeks (range 7 + 3–24 + 0). Samples from the genital tract were taken at enrolment. Bacterial vaginosis was determined by Amsel's clinical criteria (3 out of 4: pH > 4.5, homogenous discharge, clue cells, and positive amine test). Data were collected from three questionnaires completed during the second and third trimesters and correlated with the diagnosis of bacterial vaginosis. Crude and adjusted relative risks (reproductive, medical, behavioral, sexual, and sociodemographic factors) were computed. Results. At enrolment, bacterial vaginosis was diagnosed in 13.7% of Danish pregnant women. Significant risk factors for bacterial vaginosis were: daily coitus (adjusted relative risk 2.09 [1.43–3.04]), being single (1.76 [1.21–2.56]), smoking more than 10 cigarettes daily at conception (1.59 [1.29–1.93]), previous genital infection with Chlamydia trachomatis or Neisseria gonorrhoeae (1.39 [1.07–1.79]), and consuming 2 or more drinks per week (1.33 [1.02–1.74]) after control for confounding factors. Conclusion. In pregnancy, women who have daily coitus, are single, smokers, with a previous sexually transmitted disease, or with high alcohol consumption in pregnancy are at increased risk for bacterial vaginosis. Information on these risk factors may be important when planning preventive and treatment strategies of bacterial vaginosis in pregnancy.

OBJECTIVES:the aim was to examine factors associated with acquisition and elimination of bacterial vaginosis in pregnancy.METHODS:a group of 229 pregnant women were randomly selected from a population-based prospective cohort study of 2927. They were examined at enrollment (mean gestational weeks 16w+0d) and again in mid-third trimester (mean gestational age 32w+3d).MEASURES:BV (Amsel's clinical criteria), microbiological cultures of the genital tract and questionnaire data.RESULTS:BV prevalence decreased from 17% in early second trimester to 14% in mid-third trimester due to a tenfold higher elimination rate (39%) than incidence rate (4%). Heavy smokers (>10/d) in early pregnancy were at increased risk (5.3[1.1-25]) for the acquisition of BV during pregnancy, as were women receiving public benefits (4.8[1.0-22]), having a vaginal pH above 4.5(6.3[1.4-29]) or vaginal anaerobe bacteria (18[2.7-122]) at enrollment. A previous use of combined oral contraceptives was preventive for the acquisition of BV (0.2[0.03-0.96]). Elimination of BV in pregnancy tended to be associated with a heavy growth of Lactobacillus(3.2[0.8-13]) at enrollment.CONCLUSIONS:acquisition of BV during pregnancy is rare and is associated with smoking, while the presence of anaerobe bacteria and a vaginal pH >4.5 are interpreted as steps on a gradual change towards BV. In the same way heavy growth of Lactobacillus spp in early pregnancy may be an indicator of women on the way to eliminate BV.

Background. No larger population-based study of bacterial vaginosis in pregnancy has previously been available. The objective of this study was to examine risk factors for bacterial vaginosis in pregnancy. Design. From a prospective population-based cohort of 3,596 eligible pregnant women, 2,927 (81.4%) completed the study. Methods. Women were asked to participate in this study at their first prenatal visit at 17 gestational weeks (range 7 + 3–24 + 0). Samples from the genital tract were taken at enrolment. Bacterial vaginosis was determined by Amsel's clinical criteria (3 out of 4: pH > 4.5, homogenous discharge, clue cells, and positive amine test). Data were collected from three questionnaires completed during the second and third trimesters and correlated with the diagnosis of bacterial vaginosis. Crude and adjusted relative risks (reproductive, medical, behavioral, sexual, and sociodemographic factors) were computed. Results. At enrolment, bacterial vaginosis was diagnosed in 13.7% of Danish pregnant women. Significant risk factors for bacterial vaginosis were: daily coitus (adjusted relative risk 2.09 [1.43–3.04]), being single (1.76 [1.21–2.56]), smoking more than 10 cigarettes daily at conception (1.59 [1.29–1.93]), previous genital infection with Chlamydia trachomatis or Neisseria gonorrhoeae (1.39 [1.07–1.79]), and consuming 2 or more drinks per week (1.33 [1.02–1.74]) after control for confounding factors. Conclusion. In pregnancy, women who have daily coitus, are single, smokers, with a previous sexually transmitted disease, or with high alcohol consumption in pregnancy are at increased risk for bacterial vaginosis. Information on these risk factors may be important when planning preventive and treatment strategies of bacterial vaginosis in pregnancy.

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

Female genital mutilation has been practised in different cultures through centuries primarily in Africa but also in parts of Asia and America. Traditionally people without any medical training perform the mutilation with no respect for basic hygienic principles. The procedure has not changed during the years and the complication rate remains high with significant mortality related to the mutilation. A great variety of complications have been reported. We report an unusual complication: a cystic structure containing stones isolated from the area of the clitoris. The patient has suffered from these foreign bodies for almost 25 years. (excerpt)

Objectives To estimate the incidence of human parvovirus B19 among pregnant women before and during an epidemic, to elucidate possible sociodemographic and medical risk factors during pregnancy and to estimate the association between parvovirus B19 infection and negative pregnancy outcome.Design Prospective study among pregnant women followed from their first antenatal visit before 24 full weeks of gestation until delivery.Setting Department of Obstetrics and Gynaecology, Odense University Hospital, Denmark, November 1992 to February 1994.Methods 3596 pregnant women were invited to participate. The women were examined at first antenatal visit in the period from November 1992 to February 1994 and at delivery. The last delivery was in August 1994 and samples were thus collected before and during a large parvovirus B19 epidemic in Denmark January to September 1994. A blood sample for parvovirus B19 serology was taken at enrolment and from the umbilical cord at delivery. Three questionnaires were completed during 2nd and 3rd trimesters and a registration form at delivery. In total, 3174 (87.6%) were enrolled and 79.5% completed the study.Results The prevalence of B19 IgG seropositivity at the first antenatal visit before 24 full weeks of gestation was 66%. The cumulative prevalence proportion of acute parvovirus B19 infection during pregnancy among IgG negative women was found to be 10.3% (IgM seropositivity and/or IgG sero‐conversion). The IgG seroconversion incidence increased significantly from 1.0% to 13.5% among 932 seronegative pregnant women before and during the epidemic, respectively (P < 0.001). Independent risk factors related to increased risk of B19 infection during pregnancy, adjusted for other sociodemographic and medical factors, were: children at home (adjusted OR 2.1, 95% CI 1.3–3.2); serious medical disease (adjusted OR 3.0, 95% CI 1.0–8.5); and a stressful job (adjusted OR 1.8, 95% CI 1.0–3.3). Parvovirus B19 IgM seropositivity was associated with events of late spontaneous abortions and stillbirths (crude OR 9.9; 95% CI 3.3–29.4).Conclusion Before and during an epidemic of acute B19 infection incidences were measured among pregnant women to be 1.0% and 13.5%, respectively. Three factors, significantly increasing the risk of acute B19, were identified as: having children at home; suffering from serious medical diseases; and having a stressful job. IgM positivity for parvovirus B19 was associated with negative outcome of pregnancy.

OBJECTIVE: To evaluate the association between various microorganisms isolated from the genital tract in pregnant women with bacterial vaginosis.STUDY DESIGN: A cross-sectional population-based study among pregnant women addressed at their first antenatal visit before 24 full gestational weeks from the referring area of the Department of Obstetrics and Gynecology at Odense University Hospital, Denmark, from November 1992 to February 1994. The main outcome measures were prevalence of various microorganisms and statistical estimates of interactions (crude, adjusted, and relative odds ratios) between the microorganisms isolated from the lower genital tract in pregnant women with and without clinical diagnosis of bacterial vaginosis.RESULTS: Three thousand five hundred ninety-six (3596) pregnant women were asked to participate. Of the 3596 pregnant women 3174 (88.4%) agreed to participate before 24 full gestational weeks. After controlling for the presence of other microorganisms, strong associations between Gardnerella vaginalis, anaerobic bacteria, Mycoplasma hominis, and present bacterial vaginosis were found. Similarly Lactobacillus spp. were found to be associated with the absence of bacterial vaginosis. The combination of G. vaginalis and anaerobic bacteria and/or M. hominis was found in 59.6% of the cases with bacterial vaginosis and in 3.9% of the cases without bacterial vaginosis (odds ratio 36.4, 95% confidence interval 27.8 to 47.8). The crude odds ratio was found to be as high as 74.8 (95% confidence interval 32.3 to 174.1) when the combination of G. vaginalis, M. hominis, anaerobic bacteria, and no Lactobacillus spp. was associated with bacterial vaginosis,CONCLUSION: There is a microbial foundation for bacterial vaginosis, and it is possibly due to an intermicrobial interaction in which the microorganisms G. vaginalis, anaerobic bacteria, and M. hominis are dominating, indicating that these constitute the pathologic core of bacterial vaginosis.

Authors' reply Sir—We are surprised by Muldoon's comments. Ours was a collaborative study with Abbott Laboratories and they were offered coauthorship of the paper but never replied. We found that the LCR assay applied to urine samples from pregnant women did not work as well as an enzyme immunoassay on cervical swabs. The result was clear-cut and we saw no scientific reason for expanding the scope of the project by, for example, comparing findings in non-pregnant women. When this study began there were no transport instructions for urine samples; the 18–24 h uncooled transport used was well known to the project collaborators. In a recent study1Østergaard L Møller JK Andersen B Olesen F Diagnosis of urogenital Chlamydia trachomatis infection in women based on mailed samples obtained at home: multipractice comparative study.BMJ. 1996; 313: 1186-1189Crossref PubMed Scopus (94) Google Scholar LCR worked excellently on mailed urine samples (in Denmark that means uncooled transport for 18–24 h) from non-pregnant women, so specimen decomposition as the cause of the low sensitivity we found is not as plausible as Muldoon suggests. We do not know whether the low sensitivity was caused by inhibitors found only in “pregnant urine” and suggest further studies. In Denmark the LCx Chlamydia trachomatis Assay would be far more useful if it could be shown that uncooled transportation of urine from pregnant women did not influence sensitivity. An internal inhibitor control in the LCR assay should be an option. Testing for Chlamydia trachomatis in urineJensen and colleagues (Feb 1, p 832)1 report on the utility of the ligase chain reaction (LCR) assay in screening for Chlamydia trachomatis in urine specimens from pregnant women. We dispute the validity of their conclusions. Jensen et al present no control data from matched non-pregnant women. Their conclusion that urine from pregnant women contained LCR inhibitors is unsupported for they present no evidence that inhibitors were present. The specimens investigated were transported uncooled for 18–24 h. Full-Text PDF Testing for Chlamydia trachomatis in urineJensen and colleagues1 raise concerns about the diagnostic sensitivity of the ligase chain reaction (LCR) assay for the detection of Chlamydia trachomatis in urine samples from pregnant women. Enzyme immunoassay on cervical swabs, confirmed by direct fluorescence, proved to be more sensitive. This finding is important because it is generally accepted that nucleic acid amplification techniques such as LCR are more sensitive than antigen detection, and a first void urine sample is easier to obtain than urethral or cervical swabs for screening of C trachomatis infection in men and women. Full-Text PDF

It is accepted that ligase chain reaction (LCR) on a urine sample from men as well as from non-pregnant women is suitable for screening for symptom-free Chlamydia trachomatis infection.1–5 C trachomatis infection of the genital tract in pregnant women may cause preterm birth, postpartum endometritis, neonatal conjunctivitis, and neonatal pneumonia. Diagnosis from a urine sample would be useful because it is difficult to obtain an adequate cervical swab due to the increased amount of vaginal discharge during pregnancy. It is also difficult to collect a urine sample without contamination from the vagina.

The purpose of the investigation was 1) to determine the prevalence of C. trachomatis among young men and women enrolled in military service, 2) to compare enzyme-immunoassay (EIA) of a urethral swab with a sample of first voided morning urine, 3) to determine frequency of earlier venereal diseases (VD) and actual symptoms of urethritis and cervicitis. EIA positive specimens were confirmed by immunofluorescent microscopy. The investigation comprised 831 men and 80 women (17-26 years). The prevalence was 5.7% (95% confidence limits 4.2-7.4%) and 15% (8-25%) for men and women, respectively (p < 0.005, chi 2). The agreement between the results of the urethral swab and the urine sample was low. Sensitivity and positive predictive value for urethral swab was better than for urine. The handling of urine specimens was more laborious and confirmation more difficult. The percentage of actual symptoms among Chlamydia positive men was 6. The frequency of earlier VD was 7.5% and 10% among men and women, respectively. Treatment with tetracycline was effective, which makes control of eradication unnecessary. We conclude that genital chlamydial infection among young asymptomatic people is common and screening would be desirable. We still recommend urethral swabbing as the routine method until simpler and/or more reliable assays for urine specimens are developed.

The effectiveness of transcervical resection of the uterine endometrium was assessed in 106 consecutive women admitted for surgical treatment for menstrual disorders, suitable for treatment with endometrial resection. No hormonal pretreatment was given. Amenorrhoea occurred in about 25%; 80% were satisfied after the initial treatment and 86% were satisfied if the procedure was repeated after at least one year postoperatively. The results were the same in 34 (32%) who had fibroids or polyps in the uterine cavity. No serious operative or postoperative complications appeared. Seven patients (6.6%) required temporary tamponade to control bleeding. It is concluded that endometrial resection is an advance in the management of menstrual disorders. The satisfaction in the patients is high and the complication rate low.

In a prospective open study the sterility of the uterine cavity was evaluated in 99 women admitted for hysterectomy. The indications for hysterectomy were in most cases persistent irregular vaginal bleeding and fibromyomas of the uterus. Samples for both aerobic and anaerobic bacteria, Chlamydia trachomatis, yeasts and viruses were taken preoperatively from the apex of the vagina and cervical os. Immediately after hysterectomy the uterus was opened under sterile conditions and samples obtained from the isthmus and fundus of the uterine cavity for microbiological examination. Wet smears were taken from the same sites. Nearly a quarter of all the patients harbored one or more microorganisms in the uterus, mostly Gardnerella vaginalis, Enterobacter and Streptococcus agalactiae. We found that in a significant number of cases, the uterine cavity is colonized with potentially pathogenic organisms which may play a causative role in endometritis. The results indicate that inflammation of the uterine cavity should be evaluated by hysteroscopic examination before hysterectomy is undertaken in patients with persistent irregular vaginal bleeding.

In a prospective open study the sterility of the uterine cavity was evaluated in 99 women admitted for hysterectomy. The indications for hysterectomy were in most cases persistent irregular vaginal bleeding and fibromyomas of the uterus. Samples for both aerobic and anaerobic bacteria, Chlamydia trachomatis , yeasts and viruses were taken preoperatively from the apex of the vagina and cervical of. Immediately after hysterectomy the uterus was opened under sterile conditions and samples obtained from the isthmus and fundus of the uterine cavity for microbiological examination. Wet smears were taken from the same sites. Nearly a quarter of all the patients harbored one or more microorganisms in the uterus, mostly Gardnerella vaginalis, Enterobacter and Streptococcus agalactiae . We found that in a significant number of cases, the uterine cavity is colonized with potentially pathogenic organisms which may play a causative role in endometritis. The results indicate that inflammation of the uterine cavity should be evaluated by hysteroscopic examination before hysterectomy is undertaken in patients with persistent irregular vaginal bleeding.

OBJECTIVE:To investigate the incidence of post-operative infection after first trimester abortion in women treated with a long-acting cephalosporin (ceftriaxone) compared with low risk patients receiving no treatment and with high risk patients receiving our standard treatment of ampicillin/pivampicillin and metronidazole. DESIGN:A prospective, randomised controlled trial. SETTING:Department of Obstetrics and Gynaecology, Rigshospitalet, University of Copenhagen, Denmark. SUBJECTS:Nine hundred and ninety-six women, admitted on an outpatient basis for legal termination of pregnancy at 12 weeks or less of gestation, were included in the study after giving informed consent. The women were divided into high risk and low risk categories and allocated either to treatment with ceftriaxone or to standard treatment. For high risk patients the standard treatment was initiated by a peroperative injection of ampicillin and metronidazole, followed by oral doses of metronidazole and pivampicillin three times daily for four days. No prophylactic antibiotics were given to the women randomised to standard treatment in the low risk group. INTERVENTIONS:All women were kept under observation, and, between six and 14 days postoperatively, underwent pelvic examination. Clinical endpoints were noted. MAIN OUTCOME MEASURES:Post-operative pelvic inflammatory disease in women applying for legal first trimester abortion. RESULTS:Seven hundred and eighty-six women fulfilled the criteria for evaluation. A tendency toward a prophylactic effect of ceftriaxone was observed in most clinical findings. A significant prophylactic effect of ceftriaxone was found in the low risk group. CONCLUSIONS:This study demonstrated a significant reduction in post-operative pelvic inflammatory disease in low risk patients, who were applying for legal first trimester abortion, treated peroperatively with ceftriaxone. No significant difference was demonstrated between high risk patients treated with ceftriaxone or ampicillin/pivampicillin and metronidazole.

A 50-year-old woman was admitted for hysterectomy due to persistent vaginal bleeding and enlargement of the uterus. Before operation a significant increased beta-HCG was measured. Histologic examination of uterine contents obtained by aspiration showed trophoblastic disease. An decrease in beta-HCG was registered postoperatively. However, two weeks later it rose again and the patient started treatment with methotrexate. It is recommended that the treatment of patients with invasive gestational trophoblastic disease is centralized.

The incidence of genital herpes infection is increasing. About 50% of infections in women are asymptomatic. Neonatal infection is the most serious complication of genital HSV-infection, the mortality being 70% if untreated. The incidence of asymptomatic HSV-infection in pregnant women at the time of giving birth is 0.2%. These women cannot be identified on the basis of clinical symptoms and medical history, and the diagnostic methods currently in use are not sufficiently sensitive for the screening of low risk groups. Pregnant women with primary HSV-infection shed larger quantities of virus than women with recurrent infection, furthermore the foetus has not received passive immunisation by maternal antibody transfer. There is an increased risk of miscarriage, intrauterine infection and premature birth in connection with primary HSV-infection in pregnancy. Almost 50% of children born to mothers with primary HSV-infection at the time of birth become infected neonatally, compared with only 2-5% of children born to mothers with active recurrent HSV-infection. Recommendations are given for monitoring primary HSV-infection in the third trimester with viral cultures, monitoring recurrent HSV-infections clinically and indications for when delivery should be by caesarean section. Children born to women with active primary HSV-infection should be treated with antiviral agents. Children born to women with recurrent infection should have their secretions cultured for HSV.