Do clue cells in pregnancy require treatment?

From the Guidelines

Trace clue cells in pregnancy do not require treatment unless accompanied by symptoms of bacterial vaginosis (BV), as the presence of symptoms is a key indicator for the need for intervention. The management of trace clue cells in pregnancy should prioritize the prevention of adverse pregnancy outcomes such as preterm birth, premature rupture of membranes, and postpartum endometritis, which are associated with untreated BV 1. If a pregnant woman has only trace clue cells on a vaginal smear but no symptoms like abnormal discharge, odor, or discomfort, watchful waiting is typically recommended, as the benefits of treatment in asymptomatic women at low risk for preterm delivery are not well established 1.

Key Considerations for Treatment

• The presence of symptoms such as abnormal discharge, odor, or discomfort is a key indicator for the need for treatment.
• Asymptomatic pregnant women at low risk for preterm delivery may not benefit from screening or treatment for BV, according to the USPSTF recommendation statement 1.
• For symptomatic BV in pregnancy, the recommended treatment options include oral metronidazole 500 mg twice daily for 7 days or oral clindamycin 300 mg twice daily for 7 days, with metronidazole gel 0.75% intravaginally once daily for 5 days as an alternative but potentially less effective option 1.
• Treatment is considered safe during all trimesters, though some providers may prefer to avoid metronidazole in the first trimester if possible.
• Partners do not require treatment as BV is not considered a sexually transmitted infection.

Approach to Asymptomatic Women

In asymptomatic pregnant women, especially those at low risk for preterm delivery, the approach should be watchful waiting rather than immediate treatment, given the lack of clear benefit from screening and treating asymptomatic BV in this population 1. However, for women at high risk for preterm delivery, the decision to screen and treat should be individualized, considering the potential benefits and harms of treatment.

Monitoring and Follow-Up

Follow-up testing after treatment is not routinely needed unless symptoms persist or recur, emphasizing the importance of symptom-based management rather than routine testing in the absence of symptoms. This approach aligns with the goal of minimizing unnecessary interventions while ensuring that women who are at risk or who develop symptoms receive appropriate care.

From the FDA Drug Label

A clinical diagnosis of bacterial vaginosis was based on Amsel's criteria and defined by the presence of an abnormal homogeneous vaginal discharge that (a) has a pH of greater than 4. 5, (b) emits a "fishy" amine odor when mixed with a 10% KOH solution, and (c) contains ≥20% clue cells on microscopic examination.

The presence of trace clue cells is not explicitly mentioned in the context of treatment. However, the drug label does mention that a clinical diagnosis of bacterial vaginosis requires the presence of ≥20% clue cells on microscopic examination.

• There is no information about the treatment of trace clue cells in pregnancy.
• The FDA label does not provide guidance on the treatment of trace clue cells. The FDA drug label does not answer the question.

From the Research

Trace Clue Cells in Pregnancy

• Trace clue cells are an indicator of bacterial vaginosis (BV), a common condition in pregnant women that can increase the risk of preterm birth and other complications 2, 3.
• The presence of clue cells is used to diagnose BV, but the treatment of asymptomatic BV in pregnant women is still a topic of debate 3, 4.

Treatment of Bacterial Vaginosis in Pregnancy

• Studies have shown that treatment of symptomatic BV in pregnant women can relieve symptoms, but the effect of treatment on preventing preterm birth and other complications is still unclear 2, 3.
• Different treatment options are available, including oral and vaginal metronidazole, as well as alternative antibiotics such as tinidazole and clindamycin 2, 5, 6.
• The choice of treatment may depend on the severity of symptoms, the presence of other health conditions, and the potential for adverse effects 5, 6.

Screening for Bacterial Vaginosis in Pregnancy

• Current guidelines do not recommend routine screening for BV in asymptomatic pregnant women, as the evidence for the benefits of treatment in preventing adverse outcomes is limited 3, 4.
• However, women who are symptomatic or have a history of preterm birth or other complications may benefit from screening and treatment 3, 4.