Bacterial vaginosis is associated with second trimester miscarriage and preterm birth, although most pregnant women with bacterial vaginosis will have a normal pregnancy. At present there is no clear evidence that treatment of bacterial vaginosis in pregnancy prevents adverse outcomes. Until definitive studies are published, it would seem reasonable to consider pre-pregnancy screening and treatment of women with a history of late miscarriage or preterm birth.
Trichomonas vaginalis is a protozoon that is a relatively harmless sexually transmitted vaginal pathogen. It can cause severe vaginal inflammation, but may also be asymptomatic and diagnosed on a routine cervical smear. Although it may occasionally be linked to adverse pregnancy outcome or possibly pelvic inflammatory disease, its main importance is that it can be a marker for other sexually transmitted diseases and indicates the need for screening.
Symptoms and signs
Women with trichomoniasis may complain of an intensely irritating, bubbly, purulent discharge and vaginal soreness (more than irritation). There may be a fishy smell due to associated bacterial vaginosis.
This is by culture and microscopy of a high vaginal or cervical swab, either in Stuart’s medium or special T. vaginalis transport medium. T. vaginalis may also be seen on a cervical smear and associated with inflammatory changes.
Metronidazole 2 g stat or 400 mg b.d. for 5 days will cure 90% of women with trichomoniasis. Intravaginal 2% clindamycin cream may sometimes be used during pregnancy. Sexual partners should be treated. Ideally, both the woman and her partner should be screened for other sexually transmitted infections.
Cervical Chlamydia trachomatis infection is the commonest bacterial sexually transmitted disease in women, with prevalences in general practice populations of 2 – 12%. In 2001, 38 248 women were diagnosed with genital chlamydia in English genitourinary clinics, and numbers are rising, especially in teenagers.
Untreated chlamydia can cause pelvic inflammatory disease, leading to tubal infertility, ectopic pregnancy, or chronic pelvic pain. Since many women with chlamydia infection are asymptomatic, the first sign that a woman has had chlamydia infection may be when she presents with infertility. Forty per cent of women thought to have uncomplicated chlamydial cervicitis have histological evidence of endometritis. Although the exact risk of infertility following cervical chlamydia infection is unkown, estimates suggest it may be 2 – 4%.
Symptoms and signs
Up to 70% of women with cervical chlamydia infection have no symptoms. The remainder may have mild symptoms of vaginal discharge, intermenstrual or post coital bleeding, lower abdominal pain or dysuria. Occasionally, the first indication of infection in a mother may be chlamydial conjunctivitis in a neonate. Pelvic examination may be normal or show mucopurulent cervicitis or a friable cervix. Signs of pelvic inflammatory disease (see page 00) indicate the need to take endocervical swabs for N. gonorrhoeae as well as C. trachomatis. Since clinical findings in chlamydial infection are often variable or absent, opportunistic screening should also be performed on the basis of risk factors (Box Indications for opportunistic chlamydia screening in sexually active young women attending general practice). These have been established in two studies involving more than 2000 asymptomatic women attending UK general practices.
The test used will depend on arrangements with the local laboratory. Previously, only antigen-detections tests – enzyme immunoassay or direct fluorescent antibody test – were available to most UK general practices. These are less than 80% sensitive (CMO’s Expert Advisory Group) and involve a speculum examination. general practitioners and their patients should demand access to modern, sensitive, non-invasive DNA tests such as ligase chain reaction (LCR) or polymerase chain reaction (PCR) on first-pass urines or self-administered vaginal swabs. These are currently being introduced in primary care. These tests also allow the possibility of home testing.
Box Indications for opportunistic chlamydia screening in sexually active young women attending general practice
- Before termination of pregnancy
- Age <25, especially sexually active teenagers
- Two or more sexual partners in previous year
- Mucopurulent vaginal discharge
- Black African or Afro-Caribbean ethnic origin
- Friable cervix with contact bleeding
The method of taking the endocervical swab is described on site. Specimens for chlamydia must contain endocervical cells, not pus or discharge.
- Doxycycline 100 mg b.d. for 7 days or azithromycin 1 g stat
- If pregnant or lactating: erythromycin 500 mg q.d.s. for 7 days or 250 mg q.d.s. for 14 days
It is vital that the woman’s sexual partner is treated to prevent reinfection. She should be advised not to have sex with him until he can show her his empty bottle of tablets. In most cases, the patient should also be referred to the genitourinary clinic for follow-up and contact tracing and given a clinic leaflet.
A test of cure is only needed if there is a risk that the patient or her partner may not have complied with treatment, reinfection may have occurred, or a less effective antibiotic such as erythromycin was used. It should be done 2 – 4 weeks after completion of treatment. It also provides an opportunity for further patient education.
Neisseria gonorrhoeae is unusual in general practice. Symptoms, signs and sequelae are similar to those of chlamydia infection, but patients with gonorrhoea are less likely to be asymptomatic. Rarely, gonococcal bacteraemia may produce skin lesions or septic arthritis.
An endocervical swab in Stuart’s transport medium will diagnose 90% of cases. In genitourinary clinics, urethral and rectal swabs are also taken to increase sensitivity.
- Amoxicillin 3 g with probenecid 1 g in single oral dose, but the large number of tablets may cause problems with compliance
- Alternatively, ciprofloxacin 500 mg orally in a single dose may be used. This is contraindicated in women who are pregnant or have a history of fits.
In the UK the prevalence of penicillin-resistant infection is more than 5% (penicillinase-producing Neissera gonorrhoeae; PPNG), but imported infection should be presumed to be penicillin resistant when treated blind before antimicrobial sensitivity is known. The local laboratory should be consulted about appropriate antibiotic treatment.
If the patient has signs of pelvic inflammatory disease, longer treatment is required, for example an additional 10-day course of co-amoxiclav 375 mg t.d.s. (or erythromycin 500 mg q.d.s. in patients allergic to penicillin). Since contact tracing and screening and treatment for other sexually transmitted infections such as chlamydia are vital, referral to a genitourinary clinic is strongly recommended. A test of cure is advised (http://www.mssvd.org.uk).
Pelvic inflammatory disease
There is overwhelming evidence that sexually transmitted micro-organisms play a major role in the pathogenesis of pelvic inflammatory disease. Despite this, many women are still treated for pelvic inflammatory disease without their contacts being screened and treated. In England and Wales over the past decade, the increase in the number of new cases of uncomplicated sexually transmitted infections in women has been paralleled by a rise in the prevalence of pelvic inflammatory disease and ectopic pregnancy. Up to 50% of acute pelvic inflammatory disease has been shown to be due to chlamydia and many episodes are “silent” or subclinical. More than 10% of women who have had one episode of pelvic inflammatory disease, and more than 50% of those who have had three episodes, develop tubal infertility. The risk of ectopic pregnancy is increased 10-fold after an episode of pelvic inflammatory disease.
Symptoms and signs
Patients may have pelvic pain, dyspareunia, malaise, dysuria, purulent vaginal discharge, or be asymptomatic. In practice, pelvic inflammatory disease is notoriously difficult to diagnose clinically with any degree of accuracy. In a study of 147 women presenting with abdominal pain and clinical signs of acute salpingitis (cervical motion pain, adnexal tenderness, and one of the following: pyrexia >38, ESR >15 mm/h, white cell count >10 000/ml), only 70% had acute pelvic inflammatory disease diagnosed at laparoscopy. Of these, 45% had chlamydia infection, 14% had gonorrhoea and 8% had both.
Endocervical swabs for chlamydia and gonorrhoea are vital in all women with suspected pelvic inflammatory disease.
If the patient is ill, hospital admission may be considered. Otherwise treatment should be started immediately after swabs have been taken with a 2-week course of both metronidazole 400 mg b.d. and doxycycline 100 mg b.d. Erythromycin may be used instead of doxycycline if the patient is pregnant or lactating. If gonorrhoea is suspected, ciprofloxacin 500 mg stat may be given (or amoxicillin 3 g and probenecid 1 g if the patient is pregnant).
Rest and sexual abstinence are recommended. It is vital that the patient returns after one week for the swab results so that treatment for gonorrhoea and contact tracing can be arranged if required.