Treatment of Vaginitis During Pregnancy
For bacterial vaginosis during pregnancy, metronidazole 250 mg orally three times daily for 7 days is the recommended first-line treatment to reduce adverse pregnancy outcomes. 1
Diagnosis of Vaginitis in Pregnancy
Before initiating treatment, proper diagnosis is essential:
Bacterial Vaginosis (BV) requires three of the following:
- Homogeneous, white discharge coating vaginal walls
- Presence of clue cells on microscopy
- Vaginal pH > 4.5
- Positive whiff test (fishy odor with KOH)
Other causes of vaginitis should be ruled out (candidiasis, trichomoniasis)
Treatment Recommendations by Type
Bacterial Vaginosis
First-line treatment during pregnancy:
- Metronidazole 250 mg orally three times daily for 7 days 1
- Lower dose than non-pregnant regimen to minimize fetal exposure
- Effective for symptom relief and reducing risk of adverse pregnancy outcomes
Alternative regimen:
- Metronidazole 500 mg orally twice daily for 7 days 2
- Clindamycin 300 mg orally twice daily for 7 days 2
Important cautions:
- Avoid metronidazole during first trimester 3
- Avoid clindamycin cream during pregnancy due to increased risk of preterm delivery 1
- Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward 2, 1
Vulvovaginal Candidiasis
- Topical azole medications for 7 days 4
- Longer courses may be required for resolution during pregnancy 4
Trichomoniasis
- Oral metronidazole 2 g single dose or 500 mg twice daily for 7 days 4
- Treatment is warranted for prevention of preterm birth 4
- Avoid during first trimester 3
Treatment Considerations in Pregnancy
BV during pregnancy is associated with adverse outcomes including:
- Premature rupture of membranes
- Preterm labor and birth
- Postpartum endometritis
- Post-cesarean wound infection 1
High-risk pregnant women (history of previous preterm birth) with asymptomatic BV should be screened and treated, preferably in early second trimester 1
Follow-up evaluation is recommended 1 month after treatment completion for high-risk pregnant women 1
Efficacy of Treatment
Oral and vaginal metronidazole have similar cure rates (approximately 70-71%) in pregnancy 5
Both oral and vaginal metronidazole significantly decrease concentrations of most BV-associated anaerobic bacteria in pregnant women 6
Treatment of BV in pregnancy may reduce the risk of preterm delivery in high-risk women (those with previous preterm birth) 2, 1
Common Pitfalls to Avoid
Do not use the 2 g single-dose metronidazole regimen as first-line therapy during pregnancy, as it has lower efficacy 1
Do not treat male sex partners, as this has not been shown to improve outcomes or prevent recurrence 1
Do not use clindamycin cream during pregnancy due to increased risk of preterm birth 1
Do not forget to warn patients about alcohol interaction with metronidazole 2, 1
Do not use metronidazole during first trimester of pregnancy 3