Treatment of bacterial vaginosis in pregnant women. Bacterial vaginosis during pregnancy treatment

Every year, every fifth expectant mother is diagnosed with a rather unpredictable diagnosis: bacterial vaginosis. Women complain of pathological discharge and are very surprised when gynecologists find this infection in them. Even more striking is the fact that bacterial vaginosis is the most common disease among pregnant women.

The fact is that under the influence of all those changes that occur in the female body during pregnancy, the bacterial balance in the vagina can be disturbed. Usually, lactic acid bacteria maintain the "balance" of microflora, but in pregnant women their number decreases. Immunity decreases, and harmful pathogenic microbes develop in the vagina, which cause bacterial vaginosis.

The risk is that this infection can be asymptomatic for years and only appear during pregnancy. And if you do not pay attention to the warning signs and do not take action, the disease can lead to diseases of the pelvic organs and even to or to miscarriage. However, until now, the connection between such complications and vaginosis has not been fully confirmed by scientists. There have been cases when in women with vaginosis, pregnancy proceeded absolutely normally, and the disease eventually disappeared on its own.

Causes of bacterial vaginosis during pregnancy

Normally, the vagina is inhabited by 98% of lactobacilli. They control the balance of microflora and produce lactic acid, which maintains an acidic environment that is destructive for most pathogenic infectious agents. Under the influence of some factors, the number of lactobacilli may decrease. In this case, the acidity of the microecological system of the vagina is disturbed. A decrease in lactobacilli causes an uncontrolled growth of a "minority" of harmful bacteria: gardnerella, bacteroids, mobilinkus, peptococci, streptococci. This is how bacterial vaginosis occurs.

It is difficult to determine exactly what exactly affects the microflora. The decrease in the number of lactobacilli can be influenced by both internal and external factors:

• taking strong antibiotics, antimicrobial drugs, antifungal and hormonal agents;
• hormonal disruptions after abortion, childbirth, puberty and irregularities in the menstrual cycle;
• the use of antimicrobial agents for intimate hygiene with triclosan, vaginal douching, as well as antiseptic solutions, soda;
• the use of combined oral contraception and spirals;
• the use of spermicides (they are part of vaginal suppositories and tablets);
• allergic and endocrine diseases;
• abrupt climate changes, stress;
• violation of the microbial balance of the intestine;
• wearing synthetic tight underwear;
• pregnancy, especially complicated;
• neglect of basic hygiene rules.

What is the danger of vaginosis during pregnancy

During pregnancy, harmful microorganisms from the vagina can enter the genital area and infect the membranes and placenta. This "migration" leads to the development of severe complications: chorioamnionitis, inflammation and purulent fusion of the membranes, rupture and early rupture of amniotic fluid. This provokes premature birth.

The infection can "spread" to the child, can cause prolonged hypoxia, disruption of the normal functioning of the placenta and its vessels. Then the child is born weakened, with low body weight, with pneumonia, diseases of the nervous system. In some cases, vaginosis causes a miscarriage.

After childbirth, especially a cesarean section, problems may arise for the mother herself. Bacterial vaginosis gives a whole "bouquet" of complications: inflammation of the inner lining of the uterus, purulent infections of the mammary gland, poor healing of the suture, prolonged lochia. This is why vaginosis is very dangerous during pregnancy.

Bacterial vaginosis. Symptoms

According to statistics, in about half of women, bacterial vaginosis is asymptomatic. This makes it difficult to detect the infection and treat it in a timely manner. You should be concerned if you notice any of the following symptoms:

1. sticky and viscous abundant discharge of white, sometimes gray. If the disease continues for more than one month, the discharge may acquire a yellow and green tint;
2. sour, fishy-like odor of discharge, which intensifies after intercourse, in particular after contact with sperm;
3. itching, mainly in the evening and at night, aggravated after intercourse or after taking a hot bath;
4. pain when urinating;
5. pain during intercourse;
6. pain in the lower abdomen in the absence of any other inflammatory processes in the pelvic organs and hypertonicity of the uterus.

If you have these symptoms, see your doctor immediately! Your gynecologist will take a swab to check for bacterial vaginosis or other infection and then prescribe appropriate treatment.

In some cases, pregnant women who have been diagnosed with vaginosis still give birth to a healthy baby. It happens that the disease in expectant mothers goes away on its own. But there is another side to the coin: vaginosis makes you more susceptible to sexually transmitted infections. You can catch immunodeficiency virus, chlamydia, or gonorrhea.

How to treat bacterial vaginosis in a pregnant woman?

If your gynecologist diagnosed you with bacterial vaginosis during pregnancy, don't panic. You will most likely be prescribed a course of antibiotics that are safe to take while you are expecting a baby. It is important that you take the problem seriously and take medication even if some of the symptoms go away. See your gynecologist every 3-4 months. Vaginosis is treated, but the infection can recur at any time. The fact is that drugs kill harmful microorganisms, but do not affect the increase in the number of lactobacilli.

Treatment of vaginosis in most cases begins from 20-22 weeks of pregnancy. More often, expectant mothers are recommended to use the drugs Metronidazole, Trichopolum, Klion, Metrogyl, Clindamycin, Tiberal or Ornidazole. According to doctors, these drugs do not affect the development of the fetus, but it is prohibited to use them in the first half of pregnancy. If the symptoms have resumed, and the tests did not show candidiasis or the presence of gardnerella, drugs are prescribed to restore microflora: "Acylact", "Bifidin" or "Lactobacterin".

Treatment of the spouse or partner is not required - it does not affect the recovery of the expectant mother in any way. Watch your diet: your diet should be enriched with fermented milk products and coarse fiber.

To prevent vaginosis, follow a few simple rules. First, have protected sex if you or your partner has sex with other people. Second, stop smoking as it increases your risk of infection. Thirdly, do not use perfumed intimate hygiene products - they can imbalance the vaginal microflora. Regularly undergo gynecological examinations and take tests to determine the state of the vaginal microflora. If you are planning a pregnancy, then be sure to cure all sexually transmitted diseases.

Specially for Nadezhda Zaitseva

Bacterial vaginosis is a violation of the vaginal microecosystem with a sharp decrease or complete disappearance of lactic acid bacteria and a pronounced increase (hundreds and thousands of times) in the amount of opportunistic microflora. Inflammation is rare. One of the most common diseases among women of reproductive age. It is accidentally diagnosed in 17-37% of cases, in women with profuse and prolonged leucorrhoea - in 95% of cases, and in pregnant women in 15-37% of cases.

What bacteria normally colonize the vagina?

95-98% are lactobacilli. The overwhelming majority are lactobacilli or Dederlein's bacilli, but besides them, there are about 40 species of acidophilic bacteria that also perform the function of protection.

2-5%2, 3 is conditionally pathogenic flora, which normally does absolutely no harm to the female body. The number of species related to conditionally pathogenic microflora is huge, and each woman has her own "set", but there are about a dozen microorganisms present in each, and they necessarily manifest themselves in dysbiosis. The main bacterium is Gardnerella vaginalis - it necessarily appears with all vaginosis in all women. It is considered a kind of marker and it is on it that many laboratory analyzes are based.

How should it be normal?

Normally, lactobacilli break down glycogen from the cells of the squamous epithelium lining the vagina to lactic acid and hydrogen peroxide, creating an acidic environment with a pH of up to 3.8 - 4.5. An acidic environment is optimal for the growth of lactic acid bacteria and destructive for opportunistic flora. A constant pH level is the key to a clean vagina.

Colonies of lactobacilli, together with their waste products, form a biofilm - glycocalyx, which lines the vagina from the inside and protects it.

How the ratio of good to bad bacteria changes during pregnancy

As mentioned above, lactobacilli break down glycogen from the cells of the squamous epithelium of the vagina, which performs a barrier function. But these cells have a certain lifespan associated with hormonal changes in the woman's body.

During pregnancy, under the influence of corpus luteum hormones, squamous epithelial cells become especially abundant. An almost endless supply of glycogen, the number of lactobacilli is growing, the amount of opportunistic microflora decreases, and the pH level becomes even lower. The body is trying to do everything possible so that by the time the child is born, the birth canal is as clean as possible, and he gets acquainted with a healthy lactic acid flora, which will settle in his intestines.

It would seem that everything should be fine, but in fact, a strongly acidic environment, in 30% of cases, stimulates the growth of some forms of transient infections (opportunistic), such as yeast-like fungi candida, mycoplasma, ureaplasma, etc.4, 5.

What Happens With Bacterial Vaginosis?

When exposed to one of the triggers, the number of lactobacilli decreases in the vagina. The level of lactic acid drops rapidly, the pH rises, conditionally pathogenic microflora begins to multiply, primarily gardnerella, which further inhibits the vital activity of lactic acid bacteria. It turns out a "vicious circle", the result of which is either the complete death of lactobacilli, or their presence is no more than 30%. The rapid development of Gardnerella vaginalis creates favorable conditions for the growth of the mass of other pathogenic microorganisms, each of which gives some of its own specific symptoms.

Thus, bacterial vaginosis is a disease caused by many forms of microbes, not just gardnerella, as was thought until recently. Although Gardnerella vaginalis is the dominant infectious agent. By itself, bacterial vaginosis does not pose a threat to women's health, but over the years, accumulating in large quantities opportunistic microflora, creates conditions for the development of inflammatory processes in the pelvic organs. Women with vaginosis are more likely to become infected with sexually transmitted diseases, including HIV infection, they are difficult to bear pregnancy and often.

Symptoms of bacterial vaginosis in pregnant women

· Profuse leucorrhoea, sometimes gray. If the disease lasts for years, it may turn greenish-yellow. Foamy, sticky and stringy.

· A characteristic fishy odor that intensifies after intercourse, in particular after contact with sperm.

· Dyspareunia is pain during intercourse.

· Pain in the lower abdomen, in the absence of any other inflammatory processes in the pelvic organs and hypertonicity of the uterus.

· Itching, burning, urinary disorders are extremely rare, so the disease is diagnosed late and has time to deliver a number of unpleasant moments.

What leads to the development of bacterial vaginosis

· Decreased immunity

· Systemic and local antibiotic therapy

· Endocrine diseases, most often diabetes mellitus

· Treatment with hormonal and cytostatic drugs

· Genital malformations

· Anemias of various origins

· Disregard for basic hygiene rules

· The hypothesis of transmission of bacterial vaginosis by sexual partners has not been clinically confirmed and is unproven.

Features of the course of bacterial vaginosis in pregnant women

Bacterial vaginosis during pregnancy is very insidious and fraught with many pitfalls. In a smear of vaginal discharge, pathogenic microorganisms that exceed the permissible level can be detected, but at the same time, a woman may not present absolutely any complaints characteristic of vaginosis. Recently, it is generally accepted that it is not worth treating such women, but simply observing the dynamics of development. It is likely that the vaginal microecosystem with the help of pregnancy hormones will recover on its own without medical intervention. But such women temporarily belong to a high-risk group because of the possible.They should more often come to an appointment with a gynecologist and have a home

The second category of women - with profuse vaginal discharge. The most difficult in terms of diagnosis. Primarily because during pregnancy, physiological secretions increase, which can cause unnecessary anxiety and treatment. With profuse leucorrhoea during pregnancy, a differential diagnosis should be made between bacterial vaginosis, candidiasis and Since leakage in the vast majority of cases is the result of bacterial vaginosis, women at risk should have a test system at home to monitor the integrity of the amniotic membranes in order to exclude this pathology first - as the most dangerous. The only home system recommended by the European Association of Obstetricians and Gynecologists today is 99.8% accurate and surpasses many laboratory diagnostic methods.

If it is excluded, and this was not the reason for the sudden increase in discharge, you should contact your gynecologist and conduct an amine test to identify gardnerella, confirming bacterial vaginosis and take a smear to identify candida causing thrush. When confirming the diagnosis, it is imperative to treat, since there is a huge risk of complications.

Complications of pregnancy with bacterial vaginosis

Bacterial vaginosis treatment

Treatment is individual. Should be prescribed only by a doctor after all diagnostic measures have been carried out. You cannot use medications for the treatment of bacterial vaginosis on your own, as this can only aggravate the situation, prolong treatment in the future and increase the number of complications.

Bacterial vaginosis is a non-inflammatory disease of the vagina associated with changes in its microflora. This condition is extremely widespread among women of fertile age (20-45 years old), its occurrence in this group reaches 80%. That is, out of ten women, 8 suffer bacterial vaginosis at least once in their lives. The disease does not pose a danger to the patient herself, but it can negatively affect her reproductive function. Bacvaginosis often causes miscarriages, intrauterine infection of the fetus, complications after childbirth, abortion and invasive interventions on the genitals. How the disease is transmitted and how to get rid of it, read on.

How does bacterial vaginosis develop?

Human existence is inseparable from the activities of various microorganisms. Those of them that, in the process of evolution, have adapted to productive cooperation with people, are called normal microflora / biocenosis. Its composition is permanent: some microorganisms are found only on the skin, others in the oral cavity, in the intestines. In their habitat, they perform the most important functions: they protect the host's body from pathogenic bacteria, produce vitamins, and stimulate the immune response.

Normally, the vagina is inhabited by lactobacilli - short thick sticks. They break down glycogen, which is rich in cells of the vaginal epithelium with the formation of lactic acid. Thus, an acidic environment is constantly maintained in the lower genital tract of a woman, which prevents the fixation and growth of pathogenic microflora. To maintain normal conditions and the protective function of the vagina, a large number of lactobacilli are needed, therefore their share in its biocenosis is 95-98%.

For various reasons listed below, lactic acid sticks are displaced and replaced by other microorganisms. This situation facilitates the colonization of the vagina with pathogenic microorganisms - the causative agents of sexually transmitted infections, but in most cases there is a change to a nonspecific microflora. It includes bacteria that live on the skin of the perineum, perianal folds, in the lower part of the urethra. They freely occupy a new habitat, multiply intensively, but cannot perform the functions of a normal microflora. Their enzyme system differs from that of lactobacilli and does not break down glycogen to form lactic acid.

Nonspecific microflora causes a number of disorders in the metabolic and immune processes of the vagina as a whole. The level of production of protective immunoglobulin A decreases, which prevents pathogenic agents from fixing on the vaginal epithelium. Epithelial cells partially adsorb opportunistic bacteria on their surface and slough off intensively, which is associated with the appearance of secretions in bacterial vaginosis. Lactobacilli are replaced mainly by anaerobes - bacteria that function without oxygen. Some of their metabolic products - volatile fatty acids and amino acids - are broken down in the vagina into volatile amines, which have a characteristic fishy odor.

The described changes lead to a shift in vaginal pH from acidic to alkaline. This entails progressive changes in protein, carbohydrate, mineral and lipid metabolism of epithelial cells. Their production and mucus production is enhanced, which is clinically manifested as abundant discharge - the main symptom of bacterial vaginosis. It should be noted that there is no inflammatory reaction in the walls of the vagina and all changes are only functional in nature.

What causes the disease?

Bacterial vaginosis does not belong to genital infections and does not have a single pathogen, therefore it is otherwise called nonspecific vaginosis. The root cause is a change in the vaginal environment, which entails disturbances in the microbiocenosis. The microflora that replaces lactobacilli can be very different and is most often represented by associations of opportunistic bacteria. Among them there are:

• bacteroids;
• peptococci;
• peptostreptococci;
• megaspheres;
• leptotrichs;
• atopobium;
• gardnerella;

Their growth, as a rule, is excessive and the number of bacteria in the vaginal secretion reaches 10 10 per 1 ml. However, comfortable conditions for their reproduction arise only after the influence of certain factors of the external or internal environment of the organism.

The main causes of bacterial vaginosis are divided into 2 large groups:

Internal (endogenous):

1. hormonal imbalance with a predominance of progesterone;
2. atrophy of the vaginal mucosa;
3. intestinal dysbiosis;
4. immune disorders in the body.

External (exogenous):

1. long-term antibiotic treatment;
2. drug immunosuppression - taking cytostatics, glucocorticoids;
3. radiation therapy for tumors;
4. foreign objects in the vagina (hygiene tampons, pessary, contraceptive diaphragm, ring);
5. the use of spermicides, frequent douching;
6. non-observance of the rules of personal hygiene.

All of these factors in one way or another disrupt the normal functioning of the vaginal mucosa or cause the death of a large number of lactobacilli. Thus, a niche is freed up for opportunistic microflora and it immediately occupies it.

Among the main causes of bacterial vaginosis during pregnancy is a change in the hormonal status of a woman: for the normal bearing of a child, high doses of progesterone are required, which reduces the glycogen content in epithelial cells. Lack of a nutrient substrate for lactobacilli leads to alkalization of the vaginal environment and the reproduction of nonspecific microflora. In addition, progesterone reduces the activity of the immune defense, which facilitates the growth of bacterial colonies.

How does bacvaginosis manifest?

Despite the fact that the disease does not belong to genital infections, its occurrence is often associated with sexual intercourse, especially when changing a partner. Signs of bacterial vaginosis in women develop on average one day after intercourse, if it took place without a condom. If the cause of the disease was the intake of antibiotics and other drugs, a change in hormonal levels (menopause), then the symptoms of bacterial vaginosis develop regardless of sexual activity.

Acute vaginosis manifests itself:

• secretions from the genital tract: they have a grayish-white color, a uniform consistency, an unpleasant "fishy smell". Their number can be different, as a rule, they become more abundant after menstruation, intercourse, the use of irritating detergents;
• soreness during intercourse;
• discomfort, itching and burning in the genitals. These signs are usually weak or absent;
• rarely, a woman has pain, pain during urination, a stomach ache in the suprapubic region.

Chronic bacterial vaginosis is a continuous course of the disease for more than 2 months, despite the ongoing treatment. As a rule, it is combined with hormonal imbalance and atrophy of the vaginal mucosa.

Diagnostics

The diagnosis is established by the gynecologist after taking the patient's history, studying her complaints, examining her on the gynecological chair and obtaining laboratory data. In favor of bacterial vaginosis, they say:

• age - sexually active women of reproductive age are most often affected;
• relationship with a change of partner, treatment of other diseases, surgery;
• moderate or mild severity of clinical signs of the disease.

During the examination, the doctor assesses the condition of the vagina, cervix, and external genitalia. With nonspecific changes, the mucous membrane is pink, not inflamed, unevenly covered with secretions. In acute bacvaginosis, they are white-gray, with an unpleasant odor. If the disease has passed into a chronic stage and lasts for several years, then the discharge changes its color to yellowish-green, becomes thicker, viscous, resembles cottage cheese or has a foamy appearance. During the examination, the gynecologist measures the pH of the vagina with an indicator strip: with bacterial vaginosis, its value is higher than 6.

There is a simple but informative test for express diagnostics of bacvaginosis. The doctor places a small amount of secretions on a glass slide and mixes it with a 10% solution of caustic potassium. With a positive reaction, the unpleasant odor intensifies and resembles rotten fish.

Laboratory diagnostics of bacterial vaginosis consists in microscopy of stained smears from the vagina. They contain key cells - epithelial cells of the mucous membrane with microbial bodies adhered to their surface. The cell acquires a granular appearance, its borders become indistinct, dotted. Also, with microscopy, a sharp decrease in the number of lactobacilli is established, up to complete disappearance from the population. Instead of them, a nonspecific microflora is found: single cocci, streptococci, small sticks.

Bacteriological seeding of secretions is carried out in rare cases when it is necessary to accurately establish the composition of the altered microflora. The PCR method is used to search for the most common causative agents of genital infections (mycoplasma,), since they often join opportunistic microflora.

How does the disease affect conception and pregnancy?

Since bacterial vaginosis is a pathology of women of fertile age, many of them are concerned about the question: is it possible to get pregnant with a similar diagnosis? Changes in the microflora of the vagina do not entail inflammatory changes in the genital tract, therefore, it does not pose a problem for conceiving a child. Sperm normally have an alkaline environment, and when it enters the vagina, with an increased pH, the sperm are in a comfortable environment.

What is the danger of bacterial vaginosis in this case? Nonspecific microflora often enters the pregnant uterus and affects the developing child. This condition is called intrauterine infection of the fetus and entails consequences in the form of a lack of body weight, its developmental delay. In some cases, the infection leads to spontaneous miscarriage, premature rupture of amniotic fluid, and the birth of a premature baby. With bacvaginosis, the risk of sepsis and purulent complications in women in labor increases, especially after a cesarean section.

Treatment

Treatment of bacterial vaginosis is carried out by a gynecologist, if necessary, the patient is additionally monitored by an endocrinologist and a gastroenterologist. Hospitalization for this disease is not required, since it does not disturb the woman's well-being, does not threaten her life and is not contagious to others. Therapy is aimed at sanitizing the vagina from opportunistic microflora, colonizing it with lactobacilli and correcting the provoking factors of the disease. Acute bacterial vaginosis recurs in 35-50% of women in the first six months after one-stage treatment, so it must be carried out stepwise, observing the timing of each stage.

Initially, antibiotics are prescribed to a woman: they have a detrimental effect on nonspecific bacteria and cleanse the vaginal mucosa from them. The drugs of choice are Metronidazole, Tinidazole, Clindamycin, since they are active against anaerobes. Local use of antibiotics is preferable to avoid systemic side effects, but in some cases the gynecologist is forced to resort to tablet forms. The treatment regimen is selected individually:

• Metronidazole in the form of 0.75% gel is injected into the vagina once a day for 5 days;
• a cream with a 2% content of Clindamycin is injected into the vagina once a day for 7 days;
• Tinidazole 2.0 in the form of tablets is taken orally 1 time per day for 3 days;
• suppositories with Clindamycin 100 mg are injected into the vagina 1 time per day for 3 days;
• Metronidazole 2.0 tablets are taken orally once.

In pregnant women with bacterial vaginosis, the use of antibiotics is possible from the second trimester. They are prescribed in the form of tablets, the course of treatment lasts no more than 7 days.

At the time of antibiotic therapy and the day after its end, it is necessary to exclude the intake of alcohol, even in minimal doses. The drugs disrupt the metabolism of ethyl alcohol in the body, due to which the accumulation of toxic metabolites occurs and severe intoxication develops. In its course, it resembles a severe hangover: a woman experiences severe weakness, limbs tremble, blood pressure rises, a strong throbbing headache occurs, and excruciating nausea and vomiting develop.

Clindamycin cream contains fat, so it can damage the condom or latex contraceptive membrane. All topical forms of drugs are administered just before bedtime to prevent them from flowing down the walls of the vagina.

In case of intolerance to antibiotics or the presence of contraindications to their use, the first stage of treatment is carried out with local antiseptics:

• Geksikon, 1 suppository, is administered 2 times a day for 7-10 days;
• Miramistin in the form of a solution is irrigated with the vagina 1 time per day for 7 days.

Preparations for bacterial vaginosis, used in the second stage of treatment, contain lactobacilli and create favorable conditions for the restoration of the vaginal microflora. They are used 2-3 days after the completion of antibiotic therapy:

• Acylact 1 suppository 2 times a day is injected into the vagina for 5-10 days;
• Bifiliz, 5 doses, is taken orally 2 times a day for 5-10 days.

Antifungal suppositories for bacterial vaginosis, as a rule, are not prescribed. The need for them arises if a fungal infection joins the opportunistic microflora. In this case, clotrimazole suppositories are prescribed 1 time per day intravaginally for 6 days.

Self-treatment at home is not recommended, since an incorrectly selected dose of the drug or the duration of the course leads to the development of resistance in bacteria. In the future, it will be extremely difficult to cure such an infection and there will be a high risk of its chronic course. How to treat bacterial vaginosis in each case is best determined only by a specialist - a gynecologist.

How to prevent?

Despite the negative answer to the question "is bacvaginosis transmitted sexually," the effect of changing a sexual partner and unprotected sex on the development of the disease is clearly traced. Therefore, the main prevention is the use of barrier contraception - a condom, which can be supplemented with local antiseptics. Douching with Miramistin must be carried out no later than 2 hours after intercourse. In addition, preventive measures include timely treatment of chronic diseases, taking antibiotics strictly as prescribed by a doctor, and correcting hormonal disorders.

The term "bacterial vaginosis" is understood as a general infectious non-inflammatory syndrome associated with dysbiosis of the vaginal biotope, characterized by an excessively high concentration of obligate and facultative anaerobic opportunistic microorganisms and a sharp decrease or absence of lactic acid bacteria in vaginal discharge.

The modern term "bacterial vaginosis" was proposed in 1984 at the first International Symposium on Vaginitis in Sweden. Bacterial syndrome is called due to an increase in the number of aerobic and anaerobic bacteria (with a predominance of the latter) in the vagina, and the term "vaginosis" is due to the absence of leukocytes (cells responsible for inflammation).

SYNONYMS

Gardnerellosis (obsolete).
ICD-10 code
Absent.

EPIDEMIOLOGY

Bacterial vaginosis is recorded in 5-17% of apparently healthy women and in 30-38% of patients who complain of discharge from the genital tract, attending antenatal clinics and specialized clinics for the treatment of STIs. Bacterial vaginosis is significantly more likely to develop in women under 25 years of age. It is associated with risk factors for STIs (multiple sex partners, recent sex partner change). Among pregnant women, from 10 to 46% of patients with BV. Recent studies indicate an increase in the number of combined forms of bacterial vaginosis and candidiasis.

ETIOLOGY (CAUSES) OF BACTERIAL VAGINOSIS DURING PREGNANCY

The etiology of bacterial vaginosis is not always clear. Along with G. vaginalis, an important role in the occurrence of bacterial vaginosis belongs to the association of various anaerobic microorganisms, such as Mobiluncus, Bacteroides, etc., the concentration of which increases several times and reaches 1010 CFU / ml. The variety of microorganisms involved in the development of this disease is characterized by the term "bacterial", and due to the absence of leukocytes (cells responsible for the development of an inflammatory reaction) in the vaginal discharge, the term "vaginitis" was changed to the term "vaginosis".

PATHOGENESIS

Vaginal dysbiosis is caused by a violation of the physiological interaction of microorganisms.

Pathogenesis of complications of gestation

As a result of an ascending infection, the development of inflammatory processes in the upper parts of the genitourinary system, in the membranes of the fetus and AF during pregnancy is possible, which leads to late miscarriages, premature birth, IAR, chorioamnionitis.

With bacterial vaginosis, infectious complications are possible after obstetric and gynecological operations, in particular, postoperative pelvic cellulitis, endometritis and other PID.

CLINICAL PICTURE (SYMPTOMS) OF BACTERIAL VAGINOSIS IN PREGNANT WOMEN

Patients are worried about abundant liquid homogeneous grayish-white vaginal discharge with an unpleasant "fishy odor". In about 35-50% of patients, the disease is asymptomatic: they either do not notice discharge or any other subjective symptoms, or consider them as normal or associate with a violation of personal hygiene rules.

Complications of gestation

In pregnant women, due to ascending infection, infection of the membranes and OS is possible, which is the cause of spontaneous miscarriages and premature birth. The fetus can become infected both antenatally and intrapartum. In the presence of pregnancy complications in the anamnesis (PRPO, low birth weight, stillbirth, endometritis, premature birth, prematurity), it is advisable to conduct research to diagnose bacterial vaginosis within 12-16 weeks.

DIAGNOSIS OF BACTERIAL VAGINOSIS DURING PREGNANCY

The diagnosis must be made by a doctor at the reception.

There are the following criteria for the diagnosis of bacterial vaginosis.
· Complaints of profuse discharge with an unpleasant odor.
· Presence of "key" cells on microscopy of the vaginal smear.
· The pH of the vaginal contents is less than 4.5.
· Positive amine test (when a drop of 10% potassium hydroxide solution is added to vaginal discharge, a specific unpleasant odor appears due to the release of volatile amines - metabolic products of anaerobic microorganisms).

The presence of three of the four signs allows a diagnosis to be made.

Examination for bacterial vaginosis is carried out in the following groups of persons.
Women with background processes of the cervix (erosion, ectopia, leukoplakia, endocervicitis and endometriosis of the cervix with frequent recurrence of the pathological process after therapy).
· Women with a history of indications of late miscarriages, premature birth, infectious complications during pregnancy.
· Patients referred for termination of pregnancy.
· Pregnant women are examined 3 times (when registering, with a period of 27-30 weeks and 36-40 weeks of pregnancy). Outside of the specified periods, the examination of pregnant women is carried out according to indications (the appearance of discharge from the genital tract, subjective complaints, etc.).
· In maternity hospitals, all women in labor are examined without exchange cards, women with a complicated postpartum period, preferably 5–6 days after childbirth.

ANAMNESIS

When collecting anamnesis, attention is paid to the presence in the past of bacterial vaginosis, diabetes mellitus, other endocrinopathies, long-term treatment with antibacterial drugs, the use of hormonal methods of contraception.

The patients have the following complaints.
A thin, whitish-gray vaginal discharge that is usually negligible. With a long-term current process of excretion, they acquire a yellowish-greenish color, become thicker, foamy.
· Unpleasant odor of discharge (smell of "rotten fish"), which intensifies or appears after sexual intercourse, as well as during menstruation.

These symptoms can persist for years. Discomfort, itching, burning, dysuria, dyspareunia usually do not bother.

PHYSICAL STUDY

· The presence of homogeneous discharge, stringy and sticky, evenly distributed along the walls of the vagina. Their number varies from scanty to very abundant.
· The unpleasant odor of discharge is enhanced by the addition of potassium conhydroxide solution to the vaginal discharge ("amine" test).
· Increase in the pH of the vaginal discharge more than 4.5.

Hyperemia of the mucous membrane and other signs of inflammation are not noted.

LABORATORY RESEARCH

In the case when the obstetrician-gynecologist does not know the methods of direct "Bed Side" microscopy, the material taken from the vagina is sent to the laboratory. There are a number of rules for taking clinical material for research: the material is taken from the side walls of the vagina when viewed in mirrors, placed on 2 glass slides, dried in air and sent to the laboratory for research.
· The main method of laboratory diagnostics is microscopic. Wet (native) secretions are examined and a methylene blue smear is taken. With bacterial vaginosis, the following indicators of a vaginal smear are noted.
- The absence of leukocytes and lactobacilli in the smear (or a meager number).
- Abundant amount of bacteria covering the entire field of vision: small coccobacteria, cocci, vibrios.
- The presence of "key" cells - cells of the squamous vaginal epithelium, covered with many bacteria due to direct adhesion to the cell surface, as well as "superadhesion" to adhered microbial cells.

Table 48-1 presents the features of the vaginal microflora in normal conditions and in bacterial vaginosis.

DIFFERENTIAL DIAGNOSIS OF BACTERIAL VAGINOSIS

Due to the fact that patients mainly complain of vaginal discharge, differential diagnosis is necessary with vulvovaginitis (candidiasis, Trichomonas, nonspecific), with cervicitis (gonococcal, chlamydial, bacterial).

Table 48-1. Some features of the vaginal microflora in normal conditions and in bacterial vaginosis

EXAMPLE FORMULATING A DIAGNOSIS

Bacterial vaginosis.

TREATMENT OF BACTERIAL VAGINOSIS DURING PREGNANCY

OBJECTIVES OF TREATMENT

Treatment should be aimed at relieving the symptoms of the disease and normalizing the vaginal microbiocenosis.

NON-MEDICINAL TREATMENT

A diet aimed at replenishing intestinal lactic acid bacteria.

MEDICAL TREATMENT

Due to the fact that with bacterial vaginosis, anaerobic microorganisms prevail in the vaginal microflora (peptococci, peptostreptococci, vibrios of the genus Mobiluncus, gardnerella, bacteroids and others), antibacterial drugs acting on anaerobes are primarily prescribed.

In the first half of pregnancy, only local therapy is carried out, since systemic therapy is contraindicated. In the early stages of pregnancy, 2% clindamycin cream is prescribed intravaginally (5 g single dose). The drug is injected into the vagina using the supplied applicator once a day before going to bed for 3 days.

From the second half of pregnancy, it is possible to use systemic drugs, such as ornidazole, 500 mg 2 times a day for 5 days. As alternative drugs, a complex preparation ternidazole + neomycin + nystatin prednisolone (terginan ©) is used intravaginally, 1 tablet at bedtime for 10 days.

After completion of therapy with one of the above drugs, treatment is indicated aimed at normalizing the vaginal microbiocenosis and increasing local immunity with the help of eubiotics (lactobacillus acidophilus, etc.).

SURGERY

Do not carry out.

PREVENTION AND PREDICTION OF GESTION COMPLICATIONS

Prevention and prediction of complications of gestation is the timely treatment of bacterial vaginosis during pregnancy.

INDICATIONS FOR HOSPITALIZATION

Hospitalization is not indicated for bacterial vaginosis.

ASSESSMENT OF TREATMENT EFFICIENCY

The efficiency of elimination of anaerobes is assessed 7–10 days after the end of therapy - the standard examination is repeated. In general, the effectiveness of therapy can be assessed in 4-6 weeks. The criterion of cure is considered the restoration of the normobiocenosis of the vagina.

PATIENT INFORMATION

· Bacterial vaginosis is a vaginal dysbiosis, not a sexually transmitted disease, therefore, treatment of a sexual partner is not carried out.
· It is necessary to discuss with the patient the possibility and necessity of testing her for other STIs. Hepatitis B vaccination is recommended.
· The identification of predisposing factors and their elimination are shown.

Twenty percent of pregnant women experience bacterial vaginosis. In some pregnant women, it is asymptomatic, in others it goes away on its own, and still others experience an acute form of this disease. At first glance, the disease is not dangerous. But you can avoid many problems if you see a doctor in time.

Bacterial vaginosis in pregnant women

Normally, lactic acid bacteria - lactobacilli or they are also called Dederlein sticks - live in the vagina of a pregnant woman. There are about 98% of them in the body, the rest are various pathogenic microorganisms. Lactobacilli help create an acidic environment to fight harmful bacteria and keep them from growing.
Lactobacilli create a favorable environment in a woman's vagina

Under the influence of various factors, the number of beneficial bacteria decreases, the microflora of the vagina is disrupted and harmful microbes multiply. A pregnant woman develops bacterial vaginosis, in other words, vaginal dysbiosis.

Classification of bacterial vaginosis

There are several types of classification of bacterial vaginosis.

1. According to the severity, there are:

• Stage I: there is no microflora in the smear. The detected epithelial cells are not changed. There is a risk of contracting other sexually transmitted infections;
• Stage II: the number of Dederlein rods decreases, there is a slight increase in pathogenic microflora and leukocytes;
• Stage III: lactobacilli are completely absent, a high content of pathogenic microorganisms.

2. By the nature of the flow are distinguished:

• acute: rarely diagnosed in a pregnant woman. The main symptom of the disease is discharge with an unpleasant smell of fish;
• sluggish: mostly asymptomatic. A pregnant woman may not even know about bacterial vaginosis;
• chronic: is protracted with periods of exacerbation and decline of the disease.

The reasons for the development and provoking factors of bacterial vaginosis

One of the main causes of bacterial vaginosis in a pregnant woman is hormonal changes in the body. As a result, cervical mucus increases, which leads to a change in the pH environment in the vagina. It can become more alkaline, and the number of pathogenic microorganisms in it increases. One in five pregnant women experiences bacterial vaginosis

During pregnancy, both internal and external factors lead to bacterial vaginosis.

Internal include:

• intestinal dysbiosis;
• decreased immunity;
• inflammatory diseases and infectious processes;
• allergic reactions.

To external:

• stress;
• wearing tight or synthetic underwear;
• frequent intimate hygiene;
• use of daily sanitary pads;
• unhealthy diet, lack of lactic acid products in the diet;
• the use of antibiotics;
• climate change.

Symptoms of vaginal dysbiosis

Bacterial vaginosis is a non-inflammatory process that has nothing to do with sexually transmitted diseases and is not sexually transmitted.

Based on the results of observations of married couples and adolescents who have regular sex, the author of the article, Saidova Z.A. found no statistically significant transmission of bacterial vaginosis through sexual contact.

Although the Mexican researcher Hilda Villegas in 1997 proved the opposite.

Mexican researcher Hilda Villegas in 1997, when examining sperm samples from male sexual partners of women with bacterial vaginosis, proved the ability of gardnerella to colonize the lower genital tract of men, which can cause reinfection in women. The following facts also testify in favor of the sexual transmission route: G. vaginalis is simultaneously isolated from the secretion of the genital tract of women suffering from bacterial vaginosis and from their sexual partners. Reinfections are most common in women who are cured and whose sex partners have not been treated.

Bacterial vaginosis can last for months or even years and become sluggish. But some women have an acute period of the course of the disease.

It is accompanied by the following symptoms:

• abundant vaginal discharge of white or gray color, and with an advanced form, even greenish with an unpleasant fishy odor;
• discomfort in the vagina, with a long period of illness - itching, burning;
• pain during intercourse and when urinating.

Dangers that lie in wait for a pregnant woman with bacterial vaginosis

A woman can suffer from chronic bacterial vaginosis for years, and find out about it when she becomes pregnant.

If you ignore the symptoms, then vaginal dysbiosis can lead to serious consequences:

1. Leakage of amniotic fluid. Due to the rapid increase in the number of harmful bacteria, inflammation of the membranes can develop. In this case, the walls of the shells will become thinner and microcracks may form. Amniotic fluid will begin to leak.
2. Fetal infection. Since the pH in the vagina is reduced, a large number of pathogenic microbes through the cervix and amniotic fluid can get to the fetus and then infection will occur. As a result, the child will be born with a low weight, weakened, sick with pneumonia.
3. Spontaneous miscarriage or later stages of pregnancy, premature birth. Water can not only leak, the fetal membrane can rupture completely. Then miscarriage or premature birth will occur.
4. Postpartum infection of the woman herself. Infection of the uterus can occur, especially after a caesarean section. Breast infection, poor suture healing.

I had 19-20 weeks. There was ureaplasma and gardnerella (bacterial vaginosis) in very low titers. I was worried about yellowish discharge, the smell was only after PA, and the outcome was completely sad (The bacteria damaged the fetal bladder and the water began to leak, the inflammation began. The baby was fine, but I had to induce childbirth. After that, they were successfully treated, but nothing can be returned back. Now everything seems to be restored, we begin to plan)

https://www.babyblog.ru/community/post/happypregn/3169309

Video: consequences and dangers of vaginal bacteriosis during pregnancy

Treatment of bacterial vaginosis in a woman, depending on the duration of pregnancy

In most pregnant women, vaginal dysbiosis is asymptomatic and a woman learns about the disease only from her attending physician, after registration.
If you consult a doctor in time, then vaginal dysbiosis can be successfully treated in a short time.

Vaginal dysbiosis is diagnosed with the help of a gynecologist and in the laboratory.

1. The gynecologist examines the woman's vagina, assessing the discharge.
2. Takes a swab to identify harmful bacteria.
3. Determines the acidity of the vaginal environment using test strips. Normal pH ranges from 3.8 to 4.5.

If the diagnosis is confirmed, then such a disease cannot be ignored. You need to undergo a course of treatment. It is carried out taking into account the gestational age.

Photo gallery: medicines for the treatment of bacterial vaginosis

Chlorhexidine-based Geksikon suppositories
In candles Betadine, the active substance is povidone-iodine
Suppositories Pimafucin - antimicrobial antibiotic that can be prescribed at any stage of pregnancy
Gel Katejel not only helps in the fight against bacterial vaginosis, but also acts as an anesthetic Vaginal tablets Trichopolum - an antimicrobial agent based on metronidazole
Vaginal suppositories Polyzhinask - a combined antibiotic with the active substances of neomycin, nystatin, polymyxin B Metrovagin - vaginal suppositories that damage and destroy the simplest unicellular organisms Metrogyl gel is an antibacterial drug that contains metronidazole
Cheap and effective antimicrobial tablets

In the first trimester, oral pills cannot be prescribed, since the fetus is just forming in the womb. To begin with, the gynecologist will recommend a pregnant woman vaginal suppositories, tablets, capsules based on chlorhexidine, iodine.

Table: drugs for the treatment of bacterial vaginosis in the first trimester of pregnancy

Name	Release form	Action	Contraindications	Price
Hexicon	Vaginal suppositories	Local antiseptic agent. Active substance: chlorhexidine	Individual intolerance to the drug, cannot be used with preparations containing iodine	270-300 rubles for 10 pieces
Betadine	Vaginal suppositories	Antiseptic. Active ingredient: povidone iodine. Has an antiseptic, disinfectant, antifungal effect	II and III trimester of pregnancy, hypersensitivity to iodine, thyroid dysfunction.	330-390 rubles for 7 pieces
Pimafucin	Vaginal suppositories	Antimicrobial antibiotic. The drug is used if a fungal infection has joined bacterial vaginosis. Active substance: natamycin	Hypersensitivity to natamycin	250-360 rubles for 3 pieces

In the second and third trimester, suppositories and creams based on clindamycin, metronidazole can be used. If treatment with local medications does not help, antibiotics, antifungal drugs are prescribed.

Table: drugs for the treatment of bacterial vaginosis in the II and III trimester of pregnancy

Name	Release form	Action	Contraindications	Price
Catejel	Topical gel	Antiseptic and local anesthetic action based on chlorhexidine and ledocaine	I trimester of pregnancy, intolerance to active ingredients, not used with iodine-containing drugs	140-250 rubles per tube
Trichopol	Vaginal tablets	Antimicrobial and antiprotozoal agent based on metronidazole	I trimester of pregnancy, blood diseases, liver failure	250-300 rubles for 10 pieces
Polygynax	Vaginal capsules	Combined antibiotic with the active substances of neomycin, nystatin, polymyxin B. It has antibacterial, bactericidal and antifungal effects	I trimester of pregnancy, hypersensitivity to drug components	350-400 rubles for 6 pieces
Metrowagin	Vaginal suppositories	An antiprotozoal agent, that is, a drug that damages and destroys the simplest single-celled organisms. Active substance: metronidazole	I trimester of pregnancy, CNS lesions, metronidazole intolerance, blood diseases	140-180 rubles for 10 pieces
Metrogyl	Vaginal gel	A drug with antiprotozoal and antibacterial action. Active substance: metronidazole	I trimester of pregnancy, liver failure, diseases of the nervous system	200-250 rubles per tube
Tinidazole	Pills	Antiprotozoal agent with antibacterial action. Active substance: tinidazole	I trimester of pregnancy, disorders of hematopoiesis, diseases of the central nervous system	20-50 rubles for a pack of 500 mg

The course of treatment is designed for 1-2 weeks. Next, the doctor will take a second analysis and determine whether the treatment was successful. In the future, the gynecologist may prescribe gels or suppositories that have live lactobacilli to restore the vaginal microflora: Acylact, Vapigel, Lactagel, Femileks.

In this situation, I had the Hexicon + Femilex scheme. Hexicon kills all the infection and it is officially allowed for pregnant women, and Femilex then restores the normal flora in the vagina.

Diana

https://m.baby.ru/community/view/73449/forum/post/522317319/

Hi. I was prescribed Betadine suppositories, but this is just the beginning, stronger drugs are now impossible, since the period is short (14 weeks). The doctor said that these candles are up to 18 weeks, and after that there will be something more serious.

Lyubasha

https://deti.mail.ru/forum/v_ozhidanii_chuda/beremennost/beremennost_i_bakterialnyj_vaginoz/

I had vaginosis during pregnancy, a terrible thing !! At first I thought that she was a thrush, at least I was smart enough to go to the doctor first ... Otherwise, I would have cured myself to some unpleasant consequences! In general, he prescribed Vaginorm for me, it needs to be injected into the vagina at night for 7 days. I did not have any particular inconvenience, everything was normal)) and after 7 days passed, not a trace remained) this, in general, is a safe disease, the main thing is not to start it and then there will be no harm to you or your baby!

Helena

https://m.babyblog.ru/community/post/living/1705884

Folk remedies for the treatment of bacterial vaginosis

Folk remedies for the treatment of bacterial vaginosis have survived to this day.
There are folk recipes for the treatment of bacterial vaginosis

Consider several recipes for washing a pregnant woman.

1. Mix one tablespoon of chamomile with the same amount of cinquefoil or plantain. Fill with 1 liter of boiled water and leave for 30 minutes. We filter, bring the infusion to room temperature. We wash ourselves twice a day: in the morning and in the evening.
2. Pour 1 tablespoon of oak bark with 1 glass of boiling water and put in a steam bath for 30 minutes. Then pour into a thermos, let it brew for 3 hours. We filter, cool and wash overnight for 7 days.
3. Pour one tablespoon of bird cherry with 2 glasses of water, put on fire, bring to a boil and simmer for another 15–20 minutes. We wash off with the cooled and strained broth for a week.
4. Mix 3 tablespoons of coltsfoot and juniper fruits with 2 tablespoons of yarrow, horsetail, medicinal sweet clover, eucalyptus and pear. Take 2 g of this collection and pour 1 glass of boiling water. Let us brew for 20-30 minutes. Strain, bring the infusion to room temperature and wash off every other day 2 weeks.

To be honest, I would not trust folk methods, and even being pregnant. It is not known what degree of bacterial vaginosis a woman has. You can waste precious time using "grandmother's" methods. And then, instead of local treatment with candles and creams, when it is possible to cure the disease at stage I, start it up to stage II and III, and the treatment will be carried out with antibiotics. And the risk of infection of the unborn child is very high. And also the baby can be lost completely. Better to see a doctor and not self-medicate.