What is the recommended treatment for bacterial vaginosis (BV) in pregnancy?

Treatment of Bacterial Vaginosis in Pregnancy

For pregnant women with bacterial vaginosis, metronidazole 250 mg orally three times daily for 7 days is the recommended first-line treatment. 1

Treatment Recommendations for BV in Pregnancy

First-Line Treatment

• Metronidazole 250 mg orally three times daily for 7 days 1
  • Preferred over topical agents during pregnancy
  • Lower dose than non-pregnant regimen to minimize fetal exposure
  • Systemic therapy addresses possible subclinical upper genital tract infections

Alternative Treatment

• Clindamycin 300 mg orally twice daily for 7 days 1
  • Use when metronidazole is contraindicated or not tolerated
  • Avoid clindamycin vaginal cream during pregnancy due to increased risk of adverse pregnancy outcomes including prematurity 2, 1

Important Considerations

Treatment Indications

• All symptomatic pregnant women should be tested and treated for BV 2, 1
• BV in pregnancy is associated with serious adverse outcomes:
  • Premature rupture of membranes
  • Chorioamnionitis
  • Preterm labor and birth
  • Postpartum endometritis
  • Post-cesarean wound infection 2

Special Populations

• High-risk pregnant women (history of previous preterm birth):

  • Should be screened and treated even if asymptomatic 1
  • Preferably in early second trimester
  • Treatment has been shown to reduce preterm delivery in this population 2
  • Follow-up evaluation 1 month after treatment completion is recommended 1

• Low-risk pregnant women (no history of preterm birth):

  • Treatment is recommended if symptomatic
  • Routine screening and treatment of asymptomatic low-risk women is not recommended 3

Treatment Cautions

• Avoid single 2g dose metronidazole regimen during pregnancy
  • Has been shown to be ineffective in reducing preterm birth 1
• Avoid clindamycin vaginal cream during pregnancy
  • Associated with increased risk of prematurity and neonatal infections 2, 1
• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward 1

Partner Treatment

• Routine treatment of male sex partners is not recommended 1
• Clinical trials indicate that partner treatment does not affect a woman's response to therapy or likelihood of relapse/recurrence 2, 1

Follow-Up

• For high-risk pregnant women, consider follow-up evaluation 1 month after treatment completion 1
• For all women, follow-up visits are unnecessary if symptoms resolve 1
• Patients should return for additional therapy if symptoms recur 1

Treatment Efficacy

• Both oral and vaginal metronidazole are effective in reducing concentrations of most BV-associated bacteria 4
• However, systemic (oral) therapy is preferred during pregnancy to address possible subclinical upper genital tract infections 1

Bacterial vaginosis in pregnancy requires prompt and appropriate treatment due to its association with adverse pregnancy outcomes. The lower-dose oral metronidazole regimen (250 mg three times daily) balances efficacy with minimizing fetal exposure to the medication.