Q. What
specific changes do occur in Bact vaginosis ?? Ans:BV is mainly an increased prevalence of anaerobic bacteria
including Gardnerella vaginalis,
Mycoplasma hominis, Prevotella,
and Peptostreptococcus
Q.2: What is
the prevalence ? Ans:Bacterial
vaginosis is the most common urogenital disease affecting about 19-24% of the women
during the reproductive age, and
occurs as a result of imbalance in
the vaginal microbiota, disruption
of the normal lactobacillus and subsequently
increase in predominantly anaerobic
bacteria including Gardnerella vaginalis, Mycoplasma hominis,
Prevotella, and
Peptostreptococcus have led to its
occurrence.
Q.3: Vaginal ecobiogy :--Lactobacillus is
associated with supporting full term birth and healthy pregnancy, and is the dominant microbe in the vagina ,
Q.4: What
harm can occur in preg period if BV overrules Lactobacilli ?? Disruption of L bacilli
population increases the risk of potentially severe gynecological and obstetric complications. Bacterial vaginosis
is associated with an elevation of
cervico- vaginal pro inflammatory cytokines including interleukin- 1 beta
and lL -8, which initiates the cascade
of inflammatory events
involved in prelabour. ,
late miscarriage, chorioamnionitis,
premature rupture of membranes, preterm
birth and postpartum endometritis.
Q.5: What
gynae harm it can do?? Bacterial
vaginosis is associated with increased risk of pelvic inflammatory disease, tubal factor infertility . Antibiotic therapy is the current treatment for bacterial vaginosis , but its
uncertainty in preventing preterm
birth in women has been
reported. Also, antibiotics are unable to fully eradicate bacterial
vaginosis vaginal biofilms
associated bacteria , which
can explain its high
recurrence rates. Therefore ,
probiotics have been suggested as an add an to antibiotic
therapy in restoring vaginal lactobacilli
and reversing bacterial
vaginosis.
NORMAL VAGINAL
FLORA
Over
50 microbial species have been recovered from the vaginal tract
and lactobacillus is the
predominant species .
BACTERIAL
VAGINOSIS – DYSBIOSIS
It is
abnormal vaginal discharge
characterized by an
overgrowth of predominantly
anaerobic organisms in the vagina leading
to a replacement of lactobacilli
and an increase in vaginal pH.
It often
remits spontaneously , but may
present as chronic or recurrent
disease.
Often seen
in women of childbearing age and
sometimes even menopausal women .
Depletion of
lactobacilli population and the presence of
Gram – negative anaerobes, or an some cases Gram- positive cocci, and aerobic pathogens.
BACTERIAL VAGINOSIS
Depletion
of lactobacilli population
Presence of Gram – negative anaerobes, Gram – positive cocci, and aerobic pathogens
SYMPTOMS
Offensive fishy
smelling vaginal discharge
Not associated
with soreness, itching or irritation
Approximately
50% women are asymptomatic.
SIGNS
Thin
white , homogenous discharge coating
the walls of the vagina
No
evidence of inflammation
Unpleasant fishy
odour of discharge
BACTERIAL VAGINOSIS
DIAGNOSIS
CLINICAL
DIAGNOSIS
AMSEL’S
Criteria : At least three of the four criteria
are present for the
diagnosis to be confirmed.
Fishy smell
Clue cells
on wet mount microscopy
Full blown
> 20 %
Partial >
0and < 20 %
Vaginal pH
> 4.5
LABORATORY DIAGNOSIS
Gram stained
vaginal smear
Hay/ Ison
criteria :
Grade 1 : Lactobacillus morphotypes
are predominate
Grade 2 : Mixed flora
with some Lactobacilli is present. Gardnerella or Mobiluncus
morphotypes are also present
Grade 3 :
Predominantly Gardnerella and / or
Mobiluncus morpho types and few or
absent Lactobacilli,
Grade 4 :
Predominantly Gram – positive cocci
The Nugent score :
Normal <4
Intermediate
4-6
Bacterial
vaginosis >6
WHOM TO
SCREEN ?
AMSEL’S Criteria : At least three of the four
criteria are present for the diagnosis to be confirmed.
All
symptomatic patients
Asymptomatic with high risk
SCREENING
TEST
Amsel’s
criteria
COMPLICATION
Bacterial vaginosis is not a sexually transmitted but it may be associated with sexually transmitted infections
and other genital infections.
Increased
risk of acquiring human immunodeficiency virus in pregnant women.
Decrease
incidence of chlamydia have been
reported in women treated for
asymptomatic bacterial vaginosis
Its prevalence
is high in women with pelvic
inflammatory disease.
It is common in women undergoing
elective termination of
pregnancy and is associated with post –
TOP endometritis and PID.
In pregnancy
bacterial vaginosis is
associated with late miscarriage ,
preterm birth , preterm premature rupture of membranes
, and postpartum endometritis
It is associated with an increased incidence
of vaginal cuff cellulitis and
abscess formation following
transvaginal hysterectomy
It is associated with non gonococcal urethritis in male partners.
MANAGEMENT
General
advice :
To avoid vaginal
douching
Avoid use of
shower gel
Avoid use of
antiseptic agent or shampoo
Treatment
of recurrence : Co – treatment with antibiotics and probiotics but probiotics is preferred.
Treatment
for SCREEN POSITIVE –Symptomatic pregnant
/ non pregnant , Asymptomatic with high risk pregnancy ,
women undergoing some surgical procedure
Co-
treatment with antibiotic and probiotic
Metronidazole 400 mg
twice daily for 5-7 days .
Or Metronidazole 2 g single dose
Or Intravaginal metronidazole gel once daily for 5 days
Or
Intravaginal clindamycin cream
once daily for 7 days
Probiotics :
Lactobacilli species like acidophilus,
rhamnosus, reuterii , fermentum etc for
15 days,
DIAGNOSTIC AND DIFFERENTIAL DIAGNOSIS ALGORITHM
Vaginal
discharge – Gray thin, watery or yellowish – green
White cottage- cheese appearing , homogenously
thick – check pH -1) >pH 4.5 2) <
pH 4.5
>pH 4.5
–Saline microscopy -1) Trichomonads- Trichomonads vaginalis 2) Clue
cells with positive whiff test-
Bacterial vaginosis 3) No Trichomonads No clue cells - Cervicitis obtains GC/ Chlamydia DNA probe,
NAAT on probe or urine – Positive –PID. Negative – No diagnosis
<pH 4.5 –
Hyphae seen –Candida Vulvovaglnitis
No Hyphae
seen – Obtain a yeast culture . Negative – Normal physiological
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