Year : 2010 | Volume
: 35 | Issue : 2 | Page : 285--289
Estimation of the incidence of bacterial vaginosis and other vaginal infections and its consequences on maternal/fetal outcome in pregnant women attending an antenatal clinic in a tertiary care hospital in North India
Indu Lata1, Yashodhara Pradeep2, Sujata2, Amita Jain3,
1 Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India
2 Department of Obstetric & Gynaecology, K. G. Medical University, Lucknow, UP, India
3 Department of Microbiology, K. G. Medical University, Lucknow, UP, India
Assistant Professor, Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP
Aims: This study was undertaken to estimate the incidence of bacterial vaginosis (BV) and other vaginal infections during pregnancy and its association with urinary tract infections (UTI) and its consequences on pregnancy outcome, maternal and fetal morbidity and mortality. Settings and Design: Prospective cohort study. Materials and Methods: The present prospective cohort study was conducted on 200 women attending the antenatal clinic (ANC) of a tertiary hospital. All pertinent obstetric and neonatal data covering antenatal events during the course of pregnancy, delivery, puerperium and condition of each newborn at the time of birth were collected. BV was detected by both Gram stain and gold standard clinical criteria (Amsel«SQ»s composite criteria). Statistical analysis used: Data were analyzed using SPSS version 9. Fischer«SQ»s exact test, chi square tests and Student«SQ»s«SQ» test has been used for analysis. The probability of 5% was considered as significant for continuous variables such as age, period of gestation and birth weight. Odds ratio (OR) and confidence interval (CI) with 95% probability were determined. Results: The incidence of bacterial vaginosis was 41 in 200 patients. Adverse outcomes such as preterm labor, PROM and fetal complications were found more in pregnant women who had bacterial vaginosis (N=41), bacterial vaginosis with UTI (N=14) as compared to those without bacterial vaginosis (N=118). Conclusions: The incidence of poor pregnancy outcome was higher in bacterial vaginosis with UTI. Prevention of BV and UTI is cost effective to minimize the pregnancy-related complications and preterm labor to decrease in perinatal and maternal mortality and morbidity. We recommend all antenatal patients should be screened for the presence of bacterial vaginosis, other infections and UTI.
|How to cite this article:|
Lata I, Pradeep Y, Sujata, Jain A. Estimation of the incidence of bacterial vaginosis and other vaginal infections and its consequences on maternal/fetal outcome in pregnant women attending an antenatal clinic in a tertiary care hospital in North India.Indian J Community Med 2010;35:285-289
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Lata I, Pradeep Y, Sujata, Jain A. Estimation of the incidence of bacterial vaginosis and other vaginal infections and its consequences on maternal/fetal outcome in pregnant women attending an antenatal clinic in a tertiary care hospital in North India. Indian J Community Med [serial online] 2010 [cited 2020 Oct 23 ];35:285-289
Available from: https://www.ijcm.org.in/text.asp?2010/35/2/285/66855
Bacterial vaginosis (BV) is a condition in which the normal, lactobacillus-predominant vaginal flora is replaced with anaerobic bacteria, gardnerella vaginalis, and mycoplasma hominis.  Bacterial vaginosis has been associated with premature rupture of membranes, , preterm delivery, ,,,,, , infection of the chorion and amnion,  histologic chorioamnionitis,  infection of amniotic fluid, intrauterine death. ,, In other reports, the microflora associated with bacterial vaginosis, including anaerobic Gram-negative rods, G. vaginalis, and M. hominis, has been linked to preterm delivery. ,,
This suggests that it may be possible to prevent a proposition of preterm births by screening women for bacterial vaginosis and eradicating it early in pregnancy. BV is detected by Gram stain (Spiegel criteria,  Nugent criteria  ) and accepted Gold standard criteria (Amsel's composite criteria).  In 2000, for the first time, there was a report that women suffering from (BV) are at greatest risk of UTI than others with increased risk of HIV and STD. ,
Materials and Methods
The present double blind, prospective study was conducted on 200 pregnant women attending the antenatal clinic, after taking approval from institutional ethical committee and informed written consent from the patients. All pertinent obstetric and neonatal data covering the course of pregnancy, delivery and the puerperium, as well as condition of each new-born were collected, under the following headings: abortion, premature rupture of membrane(PROM) and preterm premature rupture of membrane (PPROM), spontaneous/induced labor, period of gestation at the time of delivery, birth weight of the baby, maturity, high risk factor for mother, obstetrical complications and any other relevant information. All questionnaires were administered and all examinations and microbiologic procedures were performed according to a standardized protocol. Women were enrolled in the study during routine prenatal visits of gestation 10 weeks to term; for each woman, a medical, obstetrical, sexual, and social history was taken and cultures of the vagina was obtained.
Collection of specimens
After assurance of patient, clean unlubricated speculum was passed into the vagina to see the condition of the vaginal wall, cervix and nature of the discharge. 'Whiff' test was done for 'Fishy odor' with collected discharge on speculum. First swab sample was taken from the posterior vaginal fornix aseptically tested for pH and then made slide for Gram staining. The second swab was put into a sterile test tube for culture. The urine sample was collected by midstream and clean catches method in a sterile container for analysis and culture.  The methods used to detect microbiologic organisms have been described elsewhere. 
Evaluation of vaginal smears
BV was detected by both Gram stain (Spiegel criteria, Nugent score)  and accepted Gold standard criteria (Amsel's composite criteria), defines bacterial vaginosis as being present if three of the following criterion are found.  (1) homogenous vaginal, discharge, (2) vaginal pH greater than 4.5, (3) positive 'Whiff' test and (4) the presence of clue cells on wet microscopy of vaginal fluid. 
Diagnosis of bacterial vaginosis
Patients, who fulfilled 3 out of 4 clinical criteria (Amsel et al), were diagnosed as bacterial vaginosis (BV). On evaluation of Gram stain, women could be diagnosed as BV (S) or Non BV (Non-Bacterial Vaginosis), and based on criteria suggested by Spiegel et al., women could be diagnosed as BV (N) intermediate BV (N) or Non BV on the basis of criteria put forward by Nugent et al.
Observations and results are shown in [Table 1],[Table 2],[Table 3],[Table 4] and (Graph 1) [SUPPORTING:1] ,(Graph 2). [SUPPORTING:2]
Out of 200 patients enrolled, 164 patients could be followed during ANC to delivery at our institute, and the remaining 36 patients who were having no vaginal infection on investigation either not turned back or delivered elsewhere. The incidence of types of infection in 200 patients is comparable with Govender et al and Levett et al [Table 1].
The incidence of bacterial vaginosis was most common in the age group of 18-27 years and in primipara between the gestational ages 11-20 weeks comparable with Cristiano.  The incidence of bacterial vaginosis was most common in lower socio-economic status (P=0.0477) [Table 2].
The condition of cervix on per speculum examination was evaluated. The incidence of bacterial vaginosis with unhealthy cervix was in 8 patients (66.7%) in comparison to bacterial vaginosis with healthy cervix in 33 patients (17.6%), statistically significant (P=0.016) [Table 2].
In this study, the criteria (Amsel's, Spiegel, Nugent et al) followed for the diagnosis of bacterial vaginosis in which Amsel's clinical criteria [38/46 (82.6%)] was statistically highly significant compared to two other ones [Graph 1]. The reason may be as mentioned above by Hay et al,, that the incidence of bacterial vaginosis decreases with the increase in gestational age and may remit spontaneously. In this study, the lower incidence of bacterial vaginosis by Spiegel's and Nugent's criteria can be explained as most of women fell in the gestational age group from 21 to 30 weeks or they might had chronic infection in which clue cells were absent due to local immune response to IgA antibodies.
We found highly significant correlation of bacterial vaginosis with adverse incidences of poor pregnancy outcome. Out of 164 women who followed till the final outcome of delivery, 65 were having adverse outcome and the rest 99 were delivered without any complications [Graph 2]. Adverse outcomes such as preterm labor, PROM and fetal complications (prematurity, low birth weight) were found more in pregnant women with bacterial vaginosis(N=41), bacterial vaginosis with UTI (N=14) as compared to those without bacterial vaginosis (N=118) [Table 3]. The mechanism by which bacterial vaginosis causes the preterm birth of an infant with low birth weight is not known, but there is evidence that it causes infection of the upper genital tract, which in turn causes premature birth.  Pregnant women with bacterial vaginosis have elevated vaginal or cervical levels of endotoxin,  mucinase, sialidase,  and interleukin-1b, suggesting that microorganisms that cause bacterial vaginosis stimulate the production of cytokines. A relative reduction in the number of vaginal lactobacilli is one characteristic of this syndrome,  further supporting the biologic plausibility of the hypothesis that bacterial vaginosis causes an increase in the preterm delivery of infants with low birth weight , in the present study out of 41 BV positive mothers, 25 having infants with low birth weight (LBW, <2.5 Kg) compared to 118 BV negative (18 infants) and only 4 infants LBW in BV with UTI [Table 3].
In the present study, the pregnancy outcome in pregnant women of bacterial vaginosis without UTI vs bacterial vaginosis with UTI were abortion(3 vs 1), PROM(11 vs 3), preterm labor (22 vs 9), puerperal pyrexia(2 vs 1) and low birth weight(25 vs 4 ) [Table 3]. It has been found that incidence of poor pregnancy outcome is higher in pregnant women having bacterial vaginosis without UTI than with UTI as the reason mentioned above that the diagnosis of UTI was made with mid-day sample of urine in OPD, because to avoid false results as patients were coming to our tertiary centre OPD so morning sample either get spoiled or some patients lost to follow-up.
Urinary tract infection and bacterial vaginosis are common coexisting conditions. ,, The incidence of UTI with bacterial vaginosis was also found higher by Harmauli et al., In our study, the incidence of UTI were in 51/200 patients (found significant, P=0.000), incidence of UTI with bacterial vaginosis 14/41 and the incidence of UTI without bacterial vaginosis 37/159 .The incidence of UTI with bacterial vaginosis is higher (34.1%) than without bacterial vaginosis (23.3%) (not significant, P=0.42) [Table 4].
The incidence of poor pregnancy outcome was higher in bacterial vaginosis with UTI. Prevention of BV and UTI is cost effective to minimize the pregnancy outcome complication such as abortion, PROM, PPROM and preterm labor to decrease perinatal and maternal mortality and morbidity.
|1||Hillier SL, Krohn MA, Rabe LK, Klebanoff SJ, Eschenbach DA. The normal vaginal flora, H 2 O 2 -producing lactobacilli, and bacterial vaginosis in pregnant women. Clin Infect Dis 1993;16:S273-81. |
|2||Gravett MG, Nelson HP, DeRouen T, Critchlow CW, Eschenbach DA, Holmes KK. Independent associations of bacterial vaginosis and Chlamydia trachomatis infection with adverse pregnancy outcome. JAMA 1986;256:1899-903.|
|3||Martius J, Krohn MA, Hillier SL, Stamm WE, Holmes KK, Eschenbach DA. Relationship of vaginal Lactobacillus species, cervical Chlamydia trachomatis, and bacterial vaginosis to preterm birth. Obstet Gynecol 1988;71:89-95.|
|4||Kurki T, Sivonen A, Renkonen OV, Savia E, Ylikorkala O. Bacterial vaginosis in early pregnancy and pregnancy outcome. Obstet Gynecol 1992;80:173-7. |
|5||Riduan JM, Hillier SL, Utomo B, Wiknjosastro G, Linnan M, Kandun N. Bacterial vaginosis and prematurity in Indonesia: Association in early and late pregnancy. Am J Obstet Gynecol 1993;169:175-8. |
|6||Hay PE, Lamont RF, Taylor-Robinson D, Morgan DJ, Ison C, Pearson J. Abnormal bacterial colonisation of the genital tract and subsequent preterm delivery and late miscarriage. BMJ 1994;308:295-8. |
|7||Holst E, Goffeng AR, Andersch B. Bacterial vaginosis and vaginal microorganisms in idiopathic premature labor and association with pregnancy outcome. J Clin Microbiol 1994;32:176-86. |
|8||Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK, Eschenbach DA. A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988;319:972-8.|
|9||Silver HM, Sperling RS, St Clair PJ, Gibbs RS. Evidence relating bacterial vaginosis to intraamniotic infection. Am J Obstet Gynecol 1989;161:808-12.|
|10||Gravett MG, Hummel D, Eschenbach DA, Holmes KK. Preterm labor associated with subclinical amniotic fluid infection and with bacterial vaginosis. Obstet Gynecol 1986;67:229-37.|
|11||Hillier SL, Krohn MA, Cassen E, Easterling TR, Rabe LK, Eschenbach DA. The role of bacterial vaginosis and vaginal bacteria in amniotic fluid infection in women in preterm labor with intact fetal membranes. Clin Infect Dis 1995;20:S276-8.|
|12||Krohn MA, Hillier SL, Lee ML, Rabe LK, Eschenbach DA. Vaginal Bacteroides species are associated with an increased rate of preterm delivery among women in preterm labor. J Infect Dis 1991;164:88-93.|
|13||Minkoff H, Grunebaum AN, Schwarz RH, Feldman J, Cummings M, Crombleholme W, et al. Risk factors for prematurity and premature rupture of membranes: A prospective study of the vaginal flora in pregnancy. Am J Obstet Gynecol 1984;150:965-72.|
|14||McDonald HM, O'Loughlin JA, Jolley P, Vigneswaran R, McDonald PJ. Vaginal infection and preterm labour. Br J Obstet Gynaecol 1991;98:427-35.|
|15||Spiegel CA, Amsel R, Holmes KK. Diagnosis of Bacterial vaginosis by direct gram stain of vaginal fluid. J Clin Microbiol 1983;18:170-7.|
|16||Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991;29:297-301.|
|17||Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis: Diagnostic criteria and microbial and epidemiological associations. Am J Med 1983;74:14-22.|
|18||Hillier SL. The vaginal microbial ecosystem and resistance to HIV. AIDS Res Hum Retroviruses 1998;14:S17-21.|
|19||Hillier SL, Krohn MA, Nugent RP, Gibbs RS. Characteristics of three vaginal flora patterns assessed by gram stain among pregnant women: Vaginal Infections and Prematurity Study Group. Am J Obstet Gynecol 1992;166:938-44.|
|20||Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991;29:297-301.|
|21||Govender L, Hoosen AA, Moodley J, Moodley P, Sturm AW. Bacterial vaginosis and associated infections in pregnancy. Int J Gynaecol Obstet 1996;55:23-8.|
|22||Levett PN. Aetiology of vaginal infections in pregnant and non-pregnant women in Barbados. West Indian Med J 1995;44:96-8.|
|23||Cristiano L, Rampello S, Noris C, Valota V. Bacterial vaginosis: Prevalence in an Italian population of asymptomatic pregnant women and diagnostic aspects. Eur J Epidemiol 1996;12:383-90.|
|24||Hay PE, Morgan DJ, Ison CA, Bhide SA, Romney M, McKenzie P, et al. A longitudinal study of bacterial vaginosis during pregnancy. Br J Obstet Gynaecol 1994;101:1048-53.|
|25||Hay PE, Lamont RF, Taylor-Robinson D, Morgan DJ, Ison C, Pearson J. Abnormal bacterial colonisation of the genital tract and subsequent preterm delivery and late miscarriage. BMJ 1994;308:295-8.|
|26||Watts DH, Krohn MA, Hillier SL, Eschenbach DA. The association of occult amniotic fluid infection with gestational age and neonatal outcome among women in preterm labor. Obstet Gynecol 1992;79:351-7.|
|27||Platz-Christensen JJ, Mattsby-Baltzer I, Thomsen P, Wiqvist N. Endotoxin and interleukin-1 alpha in the cervical mucus and vaginal fluid of pregnant women with bacterial vaginosis. Am J Obstet Gynecol 1993;169:1161-6.|
|28||McGregor JA, French JI, Jones W, Milligan K, McKinney PJ, Patterson E, et al. Bacterial vaginosis is associated with prematurity and vaginal fluid mucinase and sialidase: Results of a controlled trial of topical clindamycin cream. Am J Obstet Gynecol 1994;170:1048-59; discussion 1059-60.|
|29||Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK, Eschenbach DA. A case controlled study of chorioamniotic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988;319:972-8.|
|30||Holst E, Brandberg A. Treatment of bacterial vaginosis in pregnancy with a lactate gel. Scand J Infect Dis 1990;22:625-6.|
|31||Hooton TM, Fihn SD, Johnson C, Roberts PL, Stamm WE. Association between bacterial vaginosis and acute cystitis in women using diaphragms. Arch Intern Med 1989;149:1932-6.|
|32||Reid G, Burton J. Use of Lactobacillus to prevent infection by pathogenic bacteria. Microbes Infect 2002;4:319-24. |
|33||Hillebrand L, Harmanli OH, Whiteman V, Khandelwal M. Urinary tract infections in pregnant women with bacterial vaginosis. Am J Obstet Gynecol 2002;186:916-7.|
|34||Harmanli OH, Cheng GY, Nyirjesy P, Chatwani A, Gaughan JP. Urinary tract infections in women with bacterial vaginosis. Obstet Gynecol 2000;95:710-2.|
|35||Franklin TL, Monif GR. Trichomonas vaginalis and bacterial vaginosis: Coexistence in vaginal wet mount preparations from pregnant women. J Reprod Med 2000;45:131-4.|