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K.A. Abasheva
Central district hospital, Shalkar, Aktobe region, Kazakhstan
DEFINITION OF EFFICIENCY OF TREATMENT OF BACTERIAL vAGINOSIS OF PREGNANT WOMEN AT PREPARATION FOR CAESAREAN SECTION
Objective of the research was to define efficiency of application of metronidazole under the program of preparation of pregnant women with bacterial vaginosis to childbearing. From January 2010 to July 2012, Shalkar district hospital RSE researched 109 pregnant women. Cohort research was conducted. This research was focused on detection of interrelation between presence of BV at pregnant women and development of complication in puerperal period.
Key words: caesarean section, bacterial vaginosis, post-operative complications, Metronidazole
Introduction. Bacterial vaginosis (BV) is a clinical syndrome stipulated by pathologic change of a vaginal medium represented by high concentration of anaerobic opportunistic pathogenic bacteria and harsh decrease of quantity and absence of lactic acid bacteria. Bacterial vaginosis is one of three infectious diseases of the lower part of a reproductive system reaching 30%-35% among them, along with vaginal candidosis (20%-25%), and trychomonad vaginitis (5% - 25%) [1,2]).
Bacterial vaginosis is 21%-64% among women of reproductive age. Its frequency is from 10% to 25% [4,5] among pregnant women. Sour-milk bacteria have a leading position at healthy women of the reproductive age among all microorganisms (over 90% from all bacteria). Peptococcus, bacteroides, epidermal staphylococcus, corynebacteria, eubacteria, streptococci, peptostreptococci, and bifidus bacteria can be among other microorganisms in vaginal fluid [6].
In many cases, infection of urinary system occurs due to bacterial vaginosis that results in development of recurrent inflammatory diseases [7].
Bacterial vaginosis with a frequency of 25% among pregnant women is a serious risk factor of development of infectious complications. There is a significant interrelation of bacteria vaginosis with premature miscarriage and untimely breaking of amniotic layers. Development risk of these complications of pregnant women increases in 2.6 times in comparison with healthy women [8,9].
Moreover, there is an interrelation between bacterial vaginosis and development of puerperal endometritis and after caesarean section. Probability of endometritis at bacterial vaginosis is 10 times higher than at healthy women [10-12].
Treatment of this pathology causes many questions at researchers, and their solution is an actual challenge, thus, we decided to analyze influence of metronidazole on the course of bacterial
vaginosis at pregnant women.
Objective of the research was to define efficiency of application of metronidazole under the program of preparation of pregnant women with bacterial vaginosis to childbearing.
Material and methods. From January 2010 to July 2012, Shalkar district hospital RSE researched 109 pregnant women. Cohort research was conducted. This research was focused on detection of interrelation between presence of BV at pregnant women and development of complication in puerperal period.
Criteria for inclusion into the research were availability of single pregnancy, examination of a pregnant woman for BV, term birth (37-41 weeks), and delivery by caesarean section. Criteria for exclusion were untimely discharge of amniotic fluid and untimely development of pregnancy. 15 women were excluded from the research due to non-conformance with the above-mentioned criteria, thus, total quantity was 94 women.
Women were studied during the whole period of pregnancy, during childbearing and puerperal period in order to analyze further prospective data.
Among 94 women within the period 1630 weeks of pregnancy, 23.7% (n=22) received treatment concerning mycoplasmosis, 19.8 (n=19)
- ureaplasmosis, 20.7 (n=19) - clamidiosis. Metronidazole was a drug of choice in the dose 500 mg x 2 times per day within 10 days. Recombinant human alpha 2-interferons (Genferon 500000, Kipferone - 1 suppository 2 times per day within 7-10 days into vagina) were applied at detection of cytomegaloviral infection 4.9% (n=5), herpetic
- 20.7% (n=19), papillomaviral infection - 11.9% (n=11). In case of trichomoniasis - 2.5% (n=2), treatment was represented by suppositories Klion D-100 (metronidazole 100 mg, miconazole 100 mg).
Treatment in post-operation period was estimated with usage of such indices as temperature of the body, quantity of leucocytes in
CBC at the 5th day of the post-operation period and data of ultrasound scanning. USI of uterine was conducted at the 5th day of the post-operation period by the Aloka 3500 instrument (Hitachi Aloka Medical, Ltd., Japan). All maternity patients had transabdominal scanning by convex sensor 3.5 MHz. At transabdominal echography, they measured length (A), width (b) and A-P diameter of uterine (C), studied size of the cavity, presence of pathologic inclusions, and condition of stitch on the uterine. Volume of the uterine was calculated by the
following formula: V=0.5236*A*B*C.
3 groups were formed in order to analyze data. Group I (n=48) - pregnant women with the BV who received treatment by metronidazole in the dose 500 mg x 2 times per day within 5 days, group II (n=24) - women with the BV who did not receive treatment or refused from the treatment, group III (n=22) - healthy women.
Examined women did not have any significant differences by age (p>0.05) or by parity (p>0.05) (Table 1).
Table 1. Age of Pregnant Women of Different Groups
Group Age I (n=48) II(n=24) III (n=22)
To 25 years 14 (29.4%) 8 (30%) 6 (28%)
From 26 to 30 years 11(22.5%) 7 (28%) 7 (30%)
From 31 to 35 years 14 (29.4%) 5 (22%) 4 (20%)
Over 35 years 9 (18.7%) 4(20%) 5 (22%)
Note: Age characteristics of pregnant women are divided into two categories: to 25 years, 26-30 years, 31-35 years, and over 35 years.
Repeatedly pregnant women in group I amounted to 68.6% (n=33), in II - 64% (n=15) in III - 60% (n=13), repeatedly childbearers in group I amounted to 60.8% (n=29), in II - 60% (n=14), in III - 60% (n=13) (p>0.05).
All groups with practically equal frequency had cardio-vascular diseases, kidney diseases, and endocrinopathy (p>0.05).
Indications to operative childbearing were the following: uterine scar 28.4% (n=14) in group I, and 30% (n=7, n=6), in groups II and III; pelvic presentation of big fetus (18.7% (n=9), 16% (n=4) and 18% (n=4), correspondingly), associated indications (21.6% (n=10), 20% (n=5) and 18% (n=4), correspondingly), chronic intrauterine hypoxia and chronic placental insufficiency (14.7% (n=7), 16% (n=4) and 16% (n=4), correspondingly), etc.
Research materials were processed by the
methods of mathematical statistics [3] with the usage of Statistica 7.0 software (StatSoft, Inc., USA), MSExcel (Microsoft, USA).
Results. Ratio of healthy women (n=22) to pregnant women with bacterial vaginosis, received treatment (n=48) and hadn't received treatment (n=24) by Metronidazole, made 1:2:1, correspondently.
The proportion of women with body temperature rise was >37 °C made 14.7% (7/48) in the group I, 36% (9/24) - in the group II and 16% (4/22) - in the group III. Significant differences (p<0.05) were revealed between I and II, II and III groups, i.e. the group of women who received treatment of BV, has shown similar results with healthy maternity patients, and women with BV have demonstrated body temperature rise >37 °C more frequently (picture 1).
I I II
Picture 1. Survey maternity patients' fever.
Note: Percentage ratio of fever development in each group.
Absolute risk (AR) fever development at bacterial vaginosis amounts 36%, but only 15% under the treatment of BV by Metronidazole. The treatment of BV reduces body temperature rise by 21,3% (Absolute risk decrease). The risk of fever development at BV treatment is 59% from the risk at expectant management, i.e. Relative risk (RR) body temperature rise by 41% less at the treatment than at its absence. Chance relation (CR) temperature rise in the treatment of BV to the chance of fever in the absence of treatment of 0.31, 95% CI = [0.14, 0.68]. About 7 women will need treatment of BV in each case to prevent the development of fever in the postoperative period (the number of patients requiring treatment). The percentage of women with leucocytes quantity >9.0x109/l made 19.6% (10/48) in the group I, 28% (7/24) - in the group II and 22% (5/22) - in the group III, correspondently. Significant differences (p<0.05) were revealed between group I and II, and group II and III, i.e. the group of women
who received treatment of BV, has shown similar results with healthy maternity patients, and women with BV have demonstrated increasing of leucocytes quantity >9.0x109/l more frequently (picture 3). AR leucocytosis development at BV makes 28%, at the treatment of BV by Metronidazole - 19.6%. The treatment of BV reduces risk of leucocytes increasing by 8.4% (Absolute risk decrease). RR leucocytes increasing at the treatment of BV makes 70% from the risk of expectant management, i.e. RR of leucocytosis is by 30% less at the treatment performance than its absence. CR of leucocytes increasing >9.0x109/l at the treatment of BV to the leucocytosis chance at absence is 0.44 at 95% Confidence interval (CI) = [0.21; 0.92]. About 12 women will need BV treatment on each case of in each case to prevent the development of increasing the number of leukocytes in the postoperative period (the number of patients requiring treatment).
Picture 2. Leucocytosis at investigated maternity patients.
Note: Percentage ratio of leucocytosis development in each group.
According to the results if US investigation in post-operation period, pathological inclusions or
blood clots in the uterus were revealed in 8.8% (4/48) of cases in the group I, in 16% (4/24) - in
the group II and in 8% (2/22) - in the group III. CR complications from the uterus at BV treatment to the chance of complications at therapy absence is 0.51 at 95% CI = [0.19; 1.37]. The following changes were revealed in the group II: infiltration of the cicatrix and hematoma - in 14% (3/24) of follow-up. Healthy women and those who haven't received BV treatment didn't have such pathologies. Significant differences (p<0,05) were revealed between group I and II, II and III, i.e. the group of women who received BV treatment showed similar results with healthy maternity patients, and women with BV had pathologies of uterine wore frequently. The estimation of the size of the uterus was carried out; the results are presented in the Table 3. Significant
differences (p<0,05) were revealed between group I and II, II and III, i.e. the group of women who received BV treatment showed similar results with healthy maternity patients, and uterine sizes of women with BV were out of the norms (slit-like cavity was within the norm). Moreover, the combination of study indices (hyperthermia, leucocytosis, changes by US investigation) was revealed in the group II in 4 follow-ups (16.6%). Such dynamics required adjuvant therapy in postoperative period, and in follow-ups (8.3%) - uterine curettage, all of which led to an increase of length of maternity patients' staying in hospital.
Table 2. The sizes of maternity patients' uterine cavity.
Size of uterine cavity I group (n=48) II group (n=24) III group (n=22)
Slit-like cavity 29 (60.8%) 10 (40%) 13 (60%)
Cavity size up to 10 mm 14 (29,4%) 10 (40%) 6 (28%)
Cavity size 10 mm and more 5 (9.8%) 4 (20%) 3 (12%)
Note: The size of the uterus of maternity patients in the postpartum period. Normal ultrasound picture in the postpartum period is a slit-like cavity of the uterus.
Discussion. Currently, BV issue is widely discussed as one of preterm birth and pyoinflammatory complications risk factor. [2; 4]. A variety of approaches of the BV treatment are presented: probiotics, antibiotics, dietary intervention and compliance with nutrition prescription [1; 2; 5]. However, the studies that would justify the use of Metronidazole for women with BV to prepare them for a planned caesarean section were not found in the literature. We have found that the use of Metronidazole by women with BV before caesarean section reduces the risk of postoperative fever by
21.3%, leukocytosis - by 8.4% leads to a significant decrease of pathological changes in the uterus on ultrasound.
Conclusions. The proposed scheme of the treatment of bacterial vaginosis at gravidas, using Metronidazole at a dosage of 500 mg two times a day for 5 days, significantly facilitates the postoperative period.
Our suggestions: The investigation of bacterial vaginosis should be included in the standard of gravidas' check-up at preparation for operative delivery.
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Определение эффективности лечения бактериального вагиноза у беременных при подготовке к кесареву сечению
Бактериальный вагиноз является серьез- послеоперационном периоде зарегистрировано
ным фактором риска развития инфекционных значительно меньшее количество случаев раз-
осложнений в послеродовом периоде. Установ- вития лихорадки, лейкоцитоза и патологических
лено, что у женщин с бактериальным вагинозом, изменений в матке. которые получали лечение метронидазолом в дозе 500 мг 2 раза в день в течение 5 дней, в
Material Received by the Editors 08.08.2012
