From the Guidelines
For bacterial vaginosis in early pregnancy, metronidazole 250 mg orally three times a day for 7 days is the recommended treatment regimen. This recommendation is based on the 1998 guidelines for treatment of sexually transmitted diseases by the Centers for Disease Control and Prevention 1. The treatment of bacterial vaginosis in pregnant women is crucial as it has been associated with adverse pregnancy outcomes such as premature rupture of the membranes, preterm labor, and preterm birth.
Key points to consider in the treatment of bacterial vaginosis in early pregnancy include:
- Screening and treatment should be conducted at the earliest part of the second trimester of pregnancy, especially in high-risk pregnant women who have previously delivered a premature infant 1.
- Alternative regimens for the treatment of bacterial vaginosis include metronidazole 2 g orally in a single dose or clindamycin 300 mg orally twice a day for 7 days 1.
- It is essential to complete the full course of antibiotics even if symptoms resolve quickly to ensure the infection is fully cleared.
- Patients should be advised to avoid alcohol during metronidazole treatment due to potential disulfiram-like reactions.
- Partners typically do not require treatment as bacterial vaginosis is not considered a sexually transmitted infection but rather an imbalance of vaginal flora with overgrowth of anaerobic bacteria and reduction of protective lactobacilli.
The primary goal of treating bacterial vaginosis in early pregnancy is to reduce the risk of preterm delivery and other adverse pregnancy outcomes, thereby improving morbidity, mortality, and quality of life for both the mother and the baby.
From the FDA Drug Label
Pregnant patients should not be treated during the first trimester. In pregnant patients in whom alternative treatment has been inadequate, the one-day course of therapy should not be used, as it results in higher serum levels which can reach the fetal circulation
The treatment of bacterial vaginosis in early pregnancy with metronidazole is contraindicated in the first trimester. If treatment is necessary, a seven-day course may be considered, but the one-day course should be avoided due to higher serum levels that can reach the fetal circulation 2.
From the Research
Treatment Options for Bacterial Vaginosis in Early Pregnancy
- Oral metronidazole (500 mg twice daily for 7 days) is the preferred treatment for bacterial vaginosis 3
- Other effective treatment regimens include single-dose metronidazole (2 g orally), 2% clindamycin vaginal cream (once daily for 7 days), 0.75% metronidazole vaginal gel (twice daily for 5 days), and oral clindamycin (300 mg twice daily for 7 days) 3
- For pregnant women, treatment of bacterial vaginosis should focus on the elimination of symptoms, as data on adverse pregnancy outcomes for women with bacterial vaginosis remain insufficient to recommend treatment of asymptomatic patients 3
Treatment Recommendations for Pregnant Women
- For pregnant high-risk women (women with a prior preterm birth), the recommended treatment is metronidazole (250 mg orally three times a day for 7 days) to prevent adverse outcomes of pregnancy and relieve symptoms 4
- For pregnant low-risk women (women without a prior preterm birth) with symptomatic disease, the recommended treatment is metronidazole (250 mg orally three times a day for 7 days) to relieve symptoms 4
Comparison of Treatment Regimens
- A 3-day regimen of clindamycin, given as intravaginal ovules, was as effective as and better tolerated than a 7-day regimen of oral metronidazole 500 mg, given twice daily, for treatment of bacterial vaginosis 5
- Clindamycin cream is a safe, well-tolerated, and effective alternative to oral metronidazole for treatment of bacterial vaginosis 6
- Combining oral metronidazole with vaginal clindamycin or vaginal probiotic does not reduce bacterial vaginosis recurrence 7