Treatment of Bacterial Vaginosis in Pregnancy
All symptomatic pregnant women with bacterial vaginosis diagnosed by clue cells should be treated with oral metronidazole 250 mg three times daily for 7 days or oral clindamycin 300 mg twice daily for 7 days. 1
Why Treatment is Essential in Pregnancy
Bacterial vaginosis during pregnancy is associated with serious adverse outcomes that directly impact maternal and fetal morbidity:
- Premature rupture of membranes 1
- Chorioamnionitis 1
- Preterm labor and preterm birth 1
- Postpartum endometritis 1
- Post-cesarean wound infection 1
The established benefit of therapy is not only to relieve vaginal symptoms but also to reduce the risk for these infectious complications during pregnancy. 1
Recommended Treatment Regimens for Pregnant Women
First-Line Systemic Therapy (Preferred)
Oral metronidazole 250 mg three times daily for 7 days 1
OR
Oral clindamycin 300 mg twice daily for 7 days 1
Why Systemic Therapy is Preferred
Some specialists prefer systemic therapy over topical agents to treat possible subclinical upper genital tract infections, particularly in women at low risk for preterm delivery. 1 This approach addresses the broader infectious complications associated with BV beyond the vaginal compartment. 1
Important Safety Considerations
- Avoid topical clindamycin cream during pregnancy: Evidence from three trials suggests an increase in adverse events (particularly prematurity and neonatal infections) after use of clindamycin cream. 1
- Metronidazole is safe: Multiple studies and meta-analyses have not demonstrated a consistent association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns. 1
Special Population: High-Risk Pregnant Women
Who Qualifies as High-Risk
Women with a previous history of preterm delivery are considered high-risk. 1
Treatment Approach for High-Risk Women
Even asymptomatic high-risk pregnant women with BV may be evaluated for treatment, as this approach has reduced preterm delivery in three of four randomized controlled trials. 1 The screening and treatment should be performed at the first prenatal visit. 1
Alternative High-Dose Regimen
Some specialists recommend the higher dose regimen used in non-pregnant women (metronidazole 500 mg twice daily) for treatment of pregnant women, though the 250 mg regimen was specifically studied in pregnancy trials. 1
Treatment Precautions
- Avoid alcohol: Patients using metronidazole should avoid consuming alcohol during treatment and for 24 hours thereafter due to potential disulfiram-like reaction. 1
- Oil-based products: Clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms. 1
Follow-Up for Pregnant Women
A follow-up evaluation 1 month after completion of treatment should be considered to evaluate whether therapy was effective, particularly in high-risk pregnant women where treatment may prevent adverse pregnancy outcomes. 1
Partner Management
Routine treatment of male 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 or recurrence. 1