1. Bacterial vaginosis is a common cause of vaginal discharge in women of reproductive age, caused by a shift in vaginal bacteria from predominantly lactobacillus to other bacteria like Gardnerella vaginalis and anaerobes. 2. It is diagnosed based on clinical criteria like increased vaginal pH, presence of clue cells on microscopy, or a positive amine test. Treatment involves oral or topical antibiotics like metronidazole or clindamycin. 3. Bacterial vaginosis in pregnancy is associated with risks like preterm labor, so pregnant women are often screened and treated, especially those at high risk of preterm labor. Oral metronidazole is the

1. Bacterial vaginosis Prof. Aboubakr Elnashar Benha University Hospital, Egypt E-mail: elnashar53@hotmail.com

2. Non-specific vaginitis: Haemophilus vaginalis Gardnerella vaginitis: Gardnerella vaginalis Anaerobic vaginosis: Gardnerella vaginalis & anaerobic bacteria Bacterial vaginosis: polymicrobial alteration in vaginal flora causing an increase in vaginal pH, sometimes associated with an homogenous discharge, but in the absence of a demonstrable inflammatory response (Eschenbach et al, 1988 ) History

6. Gram stain b= bacteroids, c= mobilincus, g= gardenerlla, p=peptostreptococci

7. Electron micrograph of Mobiluncus

8. 1. Increase vaginal pH: Semen, after menstruation when estradiol levels increase. 2. Decrease lactobacilli: Douching, change of sexual partner (change of vaginal environment), episodes of candida . Predisposing factors

11. Up to half the women diagnosed with BV are asymptomatic . . Discharge: thin, homogenous, whitish-grey, frothy & fishy. Absence of discharge does not imply the absence of BV. It is not accepted as a reliable indicator on its own as it is neither sensitive nor specific to BV.(Deborah et al,2003) . Seldom associated with mucosal inflammation or irritation of the vagina or vulval itch. Clinical picture

12. 1. pH of discharge: 5.7 A low pH virtually excludes BV. An elevated pH is the most sensitive but least specific as an increase can also associated with menstruation, recent sexual intercourse, or infection with T. vaginalis Diagnosis

13. 2. Whiff test (amine test). Addition of 10% KOH to a sample of vaginal discharge produces fishy odor. It has a positive predictive value of 90% & specificity of 70%

14. 3. Wet film (drop of vaginal secretion & drop of saline): clue cells (epithelial cells covered by coccobacilli, borders are indistinct), No WBC. It is the single most sensitive & specific criterion for BV. , but it is operator dependent. Debris & degenerated cells may be mistaken for clue cells & lactobacilli may adhere to epithelial cells in low numbers. .

15. 4. Gram stain: 90% sensitivity, highly sensitive & specific (Gr. Variable c.bacilli, no WBC, no lactobacilli). Scoring systems which weight numbers of lactobacilli & numbers of G vaginalis & Mobiluncus. It is simple & objective method. However the cost & need for microscopist. .

16. 5. Rapid tests: . Diamine test: rapid, sensitive & specific . Proline aminopeptidase test (Pip Activity test Card) . A card test for detection of elevated pH & trimethylamine (FemExam test card) . DNA probe based test for high concentration of G. vaginalis (Affirm VP III) may have clinical utility.

17. . Pap. smear: clue cells. Limited clinical utility because of low sensitivity . Culture: It is not recommended as a diagnostic tools because it is not specific.

20. 4. Post-hysterectomy vaginal cuff infection. 5. Uretheral syndrome. 6. HIV susceptibility infection . The presence of BV increases susceptibility to HIV infection BV is not associated with CIN

22. 3. Preterm labour. The earlier in pregnancy that BV is detected the greater the risk of PTL. Treatment of high risk, BV positive pregnant women has resulted in reduction of PTL by 40-50%. 4. Bactraemia after instrumental delivery 6. Chorioamnionitis. 7. Postpartum endometritis, post cesarean wound infection

24. Recommended regimens (CDC,2002) Metronidazole 500 mg orally twice a day for 7 days, OR Metronidazole gel 0.75%, one full applicator (5g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5g) intravaginally at bed time for 7 days.

25. Alternative regimens (CDC,2002) Metronidazole 2 g orally in a single dose, OR Clindamycin 300 mg orally twice a day for 7 days, OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days.

28. .Follow up Follow-up visits are unnecessary if symptoms resolve. Another recommended treatment regimen may be used to treat recurrent disease. Management of husband is not recommended

30. Recommended regimen Metronidazole 250 mg orally three times a day for 7 days, OR Clindamycin 300 mg orally twice a day for 7 days

33. Indications 1. All symptomatic pregnant women should be tested & treated. 2. Asymptomatic pregnant women at high risk for PTL ( previous history), should be screened early in pregnancy & treated (Cochrane library,2002)

34. 3. Asymptomatic pregnant females at low risk for PTL: Data are conflicting whether treatment reduces adverse outcomes of pregnancy. One trial, using oral clindamycin demonstrated a reduction in PTL & postpartum infectious complications (Hay et al, 2001). Oral clindamycin early in the second trimester significantly reduced the rate of late miscarriage & PTL in general obstetric population (Ugwumadu et al, 2003).

35. How to screen for BV ? (Gierdingen et al, 2000) Ask about symptoms & pH of the vagina is determined frequently during pregnancy. If pH > 4.5 ( BV or TV in 84%), do wet mount. Follow-up of pregnant women One month after treatment to evaluate whether therapy was effective is recommended.

37. Thank you Prof. Aboubakr Elnashar Benha University Hospital, Egypt E-mail: elnashar53@hotmail.com