Introduction Abnormal vaginal flora (AVF) before 14 gestational weeks is a risk factor for preterm birth (PTB). The presence of aerobic microorganisms and an inflammatory response in the vagina may also be important risk factors.Aim The primary aim of the study was to investigate the differential influences of AVF, full and partial bacterial vaginosis, and aerobic vaginitis in the first trimester on PTB rate. The secondary aim was to elucidate why treatment with metronidazole has not been found to be beneficial in previous studies.Setting Unselected women with low-risk pregnancies attending the prenatal unit of the Heilig Hart General Hospital in Tienen, Belgium, were included in the study.Materials and methods At the first prenatal visit, 1026 women were invited to undergo sampling of the vaginal fluid for wet mount microscopy and culture, of whom 759 were fully evaluable. Abnormal vaginal flora (AVF; disappearance of lactobacilli), bacterial vaginosis (BV), aerobic vaginitis (AV), increased inflammation (more than ten leucocytes per epithelial cell) and vaginal colonisation with Candida (CV) were scored according to standardised definitions. Partial BV was defined as patchy streaks of BV flora or sporadic clue cells mixed with other flora, and full BV as a granular anaerobic-type flora or more than 20% clue cells. Vaginal fluid was cultured for aerobic bacteria, Mycoplasma hominis and Ureaplasma urealyticum. Outcome was recorded as miscarriage £13 weeks + 6 days [early miscarriage (EM), n = 8 (1.1%)], between 14 + 0 and 24 weeks + 6 days [late miscarriage (LM), n = 7 (0.9%)], delivery or miscarriage £34 weeks + 6 days n = 29 (3.8%)], £36 weeks + 6 days n = 70 (9.2%)]. PTB between 25 + 0 and 36 weeks + 6 days was further divided in severe PTB (SPTB, 25 + 0 to 34 weeks + 6 days) and mild PTB (MPTB, 35 + 0 to 36 weeks + 6 days).Results Women without abnormalities of the vaginal flora in the first trimester had a 75% lower risk of delivery before 35 weeks compared with women with AVF [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.12-0.56]. The absence of lactobacilli (AVF) was associated with increased risks of PTB (OR 2.4; 95% CI 1.2-4.8), EPTB (OR 6.2; 95% CI 2.7-14) and miscarriage (OR 4.9; 95% CI 1.4-17). BV was associated with increased risks of PTB (OR 2.4; 95% CI 1.1-4.7), EPTB (OR 5.3; 95% CI 2.1-12.9) and miscarriage (OR 6.6; 95% CI 2.1-20.9) and coccoid AV was associated with increased risks of EPTB (OR 3.2; 95% CI 1.2-9.1) and miscarriage (OR 5.2; 95% CI 1.5-17). In women with BV, partial BV had a detrimental effect on the risk of PTB for all gestational ages, but full BV did not. Preterm deliveries later than 24 weeks+ 6 days were more frequent when M. hominis was present (EPTB OR 13.3; 95% CI 3.2-55).Discussion Bacterial vaginosis, AV and AVF are associated with PTB, especially LM and severe PTB between 25 and 35 weeks. The absence of lactobacilli (AVF), partial BV and M. hominis, but not full BV, were associated with an increased risk of preterm delivery after 24 weeks+ 6 days. As metronidazol...

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Aerobic vaginitis (AV) is an alteration in vaginal bacterial flora that differs from bacterial vaginosis (BV). AV is characterised by an abnormal vaginal microflora accompanied by an increased localised inflammatory reaction and immune response, as opposed to the suppressed immune response that is characteristic of BV. Given the increased local production of interleukin (IL)-1, IL-6 and IL-8 associated with AV during pregnancy, not surprisingly AV is associated with an increased risk of preterm delivery, chorioamnionitis and funisitis of the fetus. There is no consensus on the optimal treatment for AV in pregnant or non-pregnant women, but a broader spectrum drug such as clindamycin is preferred above metronidazole to prevent infection-related preterm birth. The exact role of AV in pregnancy, the potential benefit of screening, and the use of newer local antibiotics, disinfectants, probiotics and immune modulators need further study.Keywords Abnormal vaginal flora, aerobic vaginitis, bacterial vaginosis, chorioamnionitis, intrauterine infection, intrauterine inflammatory syndrome, preterm birth, vaginitis. IntroductionThe prevention of preterm birth remains a major challenge in obstetrics. Whereas over the years much attention has been given to structural deficiencies, such as uterine abnormalities, or a 'weak' or 'insufficient' cervix, during the last decades the importance of ascending infection as a possible cause of preterm birth, preterm rupture of the membranes and intrauterine infection has become increasingly evident. 1The earlier in gestation that preterm labour starts, the higher the likelihood that underlying chorioamnionitis is present. Although the risk of chorioamnionitis in term deliveries is around 1%, this risk increases to more than 45% in preterm deliveries.2 The consequences of intrauterine infection for the fetus is not limited to the complications and sequelae of preterm birth, but is also related to inflammation-induced neurologic injury resulting in intra-or periventricular haemorrhage and cerebral palsy.3 Ascending infection during gestation may also result in maternal complications such as sepsis, septic arthritis and maternal respiratory distress. 4 Definition of aerobic vaginitisAerobic vaginitis (AV) is defined as a disruption of the lactobacillary flora, accompanied by signs of inflammation and the presence of a rather scarce, predominantly aerobic microflora, composed of enteric commensals or pathogens. The concerted and exclusive emphasis on the recognition and diagnosis of bacterial vaginosis (BV) has minimised efforts to describe other abnormal flora types that may cause vaginal disease. By systematically analysing fresh smears of vaginal fluid of symptomatic and asymptomatic women with phase contrast microscopy, another important type of abnormal bacterial flora, in addition to BV, needs to be considered as a potential contributing factor in the pathogenesis of preterm labour. Diagnosis of aerobic vaginitisThe criteria for the microscopic diagnosis of AV are provided in Table...

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Mycoplasmata have been linked to pregnancy complications and neonatal risk. While formerly a limited number of species could be discovered by cultures, molecular biology nowadays discovers both lower quantities and more diverse species, making us realize that mycoplasmata are ubiquitous in the vaginal milieu and do not always pose a danger for pregnant women. As the meaning of mycoplasmata in pregnancy is not clear to many clinicians, we summarized the current knowledge about the meaning of different kinds of mycoplasmata in pregnancy and discuss the potential benefits and disadvantages of treatment. Currently, there is no general rule to screen and treat for mycoplasmata in pregnancy. New techniques seem to indicate that Ureaplasma parvum (Up), which now can be distinguished from U. urealyticum (Uu), may pose an increased risk for preterm birth and bronchopulmonary disease in the preterm neonate. Mycoplasma hominis (Mh) is related to early miscarriages and midtrimester abortions, especially in the presence of abnormal vaginal flora. Mycoplasma genitalium (Mg) is now recognized as a sexually transmitted infection (STI) that is involved in the causation of cervicitis, pelvic inflammatory disease (PID) in non-pregnant, and preterm birth and miscarriages in pregnant women, irrespective of the presence of concurrent other STIs, like Chlamydia or gonorrhoea. Proper studies to test for efficacy and improved pregnancy outcome are scarce and inconclusive. Azythromycin is the standard treatment now, although, for Mg, this may not be sufficient. The role of clarithromycin in clinical practice still has to be established. There is a stringent need for new studies based on molecular diagnostic techniques and randomized treatment protocols with promising and safe antimicrobials.