What is the recommended treatment for bacterial vaginosis (BV) at 28 weeks gestation?

Treatment for Bacterial Vaginosis at 28 Weeks Gestation

For bacterial vaginosis at 28 weeks gestation, oral metronidazole 500 mg twice daily for 7 days is the recommended first-line treatment. 1

First-Line Treatment Options for BV During Pregnancy

The CDC specifically recommends the following regimen for pregnant women with bacterial vaginosis:

• Preferred regimen:

  • Metronidazole 500 mg orally twice daily for 7 days 1

• Alternative regimens:

  • Metronidazole 250 mg orally three times daily for 7 days
  • Clindamycin 300 mg orally twice daily for 7 days 1

Safety Considerations in Pregnancy

• At 28 weeks (second trimester), metronidazole is considered safe for use in pregnancy
• Metronidazole is contraindicated during the first trimester of pregnancy, but the CDC supports its use during the second trimester as it does not represent a major teratogenic risk when used in recommended doses 1
• For women in the first trimester, clindamycin vaginal cream would be the preferred treatment, but this doesn't apply to your patient at 28 weeks 1

Important Clinical Considerations

• Patients should avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 1
• Metronidazole is secreted in human milk, so breastfeeding considerations should be discussed if applicable 1
• Follow-up evaluation 1 month after treatment completion is recommended for high-risk pregnant women (those with previous preterm birth) 1

Rationale for Treatment

Treatment of bacterial vaginosis during pregnancy is important because:

• BV is associated with adverse pregnancy outcomes including premature rupture of membranes, chorioamnionitis, preterm labor and birth, postpartum endometritis, and post-cesarean wound infection 1
• All symptomatic pregnant women with BV should be treated to prevent these adverse outcomes 1

Special Considerations for High-Risk Pregnant Women

For pregnant women with a history of previous preterm birth:

• These women are considered high-risk
• The American College of Obstetricians and Gynecologists recommends screening and treating high-risk asymptomatic pregnant women for BV, preferably in the early second trimester 1
• Follow-up evaluation 1 month after treatment is particularly important for this group 1

Partner Treatment

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

Common Pitfalls and Caveats

1. Inadequate treatment duration: The full 7-day course must be completed even if symptoms resolve earlier
2. Alcohol consumption: Patients must avoid alcohol during treatment and for 24 hours afterward
3. Failure to follow up: High-risk pregnant women should be evaluated 1 month after treatment
4. Recurrence: BV has a high recurrence rate (50-80% within a year), so patients should be informed about possible recurrence 1, 2