Norman et al. (Norman et al., 2009), randomized 500 women with twin pregnancy to 90 mg vaginal progesterone or placebo daily from 24-34 weeks' gestation. Again, no effect was seen on the primary outcome of delivery or intrauterine death before 34 weeks' gestation (OR 1.36; 95% CI, 0.89-2.09). In both trials (Rouse et al and Normal et al), a non-significant increase in intrauterine death was seen in the treatment group. Similarly, Caritis et al. (Caritis et al., 2009) demonstrated no reduction in PTB in women with triplet pregnancies treated with 17OHP-C. Healthy women (n= 134) with triplets were randomly assigned to weekly intramuscular injections of either 250 mg of 17OHP-C or placebo, starting at 16 to 20 weeks' gestation and ending at delivery or 35 weeks' gestation. Eighty-three percent of women in the treatment group vs. 84% in the placebo group delivered before 35 weeks' gestation. Another double-blind, randomized (2:1) trial by Combs et al (Combs et al., 2010) on triplets showed no statistically significant difference with regard to primary outcome i.e. composite neonatal morbidity in 17OHP-C (n= 56) and placebo (n=25) groups (38% vs.

**4. Timing and duration of the administration of progestin in women with risk**

There are 2 published observational data regarding the use of 17 OHP-C in the prevention of recurrent PTB. Rebarber et al. (Rebarber et al., 2007), in a retrospective analysis of data from 481 women who were enrolled for outpatient weekly IM 17OHP-C administrations. They found that women with elective early cessation of weekly 17OHP-C at < 32 weeks' gestation were significantly more likely to have spontaneous recurrent PTD at < 37 weeks, < 35 weeks and < 32 weeks' gestation when compared to the women who received weekly 17OHP-C injections until PTD or 36.9 weeks. Discontinuation of 17OHP-C was defined as being elective when it occurred for any reason other than hospitalization for eminent delivery or an acute condition that led to delivery within 10 days. In this study, whether the elective discontinuation was patient or physician driven is not available from the database. A letter to the AJOG editor, Bernstein (Bernstein, 2008) provided an alternative explanation stating that the 17OHP-C is maybe of no benefit but that the sudden withdrawal of 17OHP-C may be involved in triggering spontaneous PTL. However, most clinicians continue treatment until 37 weeks, with the last injection at 36 weeks, and while the majority begin treatment at 16 weeks, it appears that later initiation of treatment up to 28-30 weeks' gestation may be

How et al. (How et al., 2007), performed a retrospectively analysis of database of women enrolled for outpatient 17OHP-C prophylaxis for prevention of spontaneous PTB. The data were divided into three groups according to the number of PTB (1, 2, > 2) and stratified to initiation of 17OHP-C at 16-20.9 weeks' and 21-26.9 weeks' gestation. The authors found that the rates of spontaneous PTB were significantly higher in those with > 2 PTB (n=159, 51% vs. 27% at < 37 weeks and 21% vs. 9% at < 35 weeks in the 17OHP-C start at 16-20.9 weeks' gestation group; 18% vs. 2% at < 32 weeks in the 17OHP-C start at 21-26.9 weeks' gestation group) as compared to those with one PTB (n=440). There were no significant differences in spontaneous PTB rates according to the time of initiation of 17OHP-C at 16-20.9 weeks' gestation vs. 21-26.9 weeks' gestation. The authors concluded that women with history of > 2 PTD have a high risk of recurrent spontaneous PTB at < 37 and < 35 weeks despite 17OHP-C prophylaxis. Later second trimester initiation of 17OHP-C prophylaxis is as effective as initiation in the early second trimester. However, these conclusions should be

41%).

**factors**

helpful (Rebarber 2007).

interpreted with caution because data such as baseline CL, the GA or circumstances of the prior PTB, maternal race, and complete neonatal outcomes were not available.

## **5. Progestins and threatened or established PTL**

Facchinetti et al. (Facchinetti et al., 2007) reported a randomized clinical trial in which symptomatic women with PTL and intact membranes at 25-34 weeks' gestation were allocated to either observation or intramuscular administration of 341 mg of 17OHP-C twice a week until 36 weeks' gestation or delivery. The rationale for using a higher dose in this trial was the onset of PTL requiring tocolysis. In these patients, cervical ripening and the cascade of PTL was already initiated. In this study, 60 women presenting in PTL, treated with atosiban and not delivering within 48 hours were randomly assigned to either treatment with 17OHP-C (n= 30, including 16 with CL </= 25 mm) or expectant management (n=30, including 17 with </= 25 mm). Treatment with 17OHP-C was associated with a reduction in the risk of PTD (OR 0.15; 95% CI, 0.04-0.58). Cervical shortening, as measured by ultrasound performed 7 and 21 days post randomization, was significantly less in the 17OHP-C treated group as compared with placebo.

Another study on progesterone use in patients presenting in PTL was published in 2008 by Borna et al. (Borna & Sahabi et al. 2008). Women between 24 and 34 weeks' gestation with intact membranes were randomized to receive 400 mg of progesterone vaginal suppository (n=37) vs. no treatment (n=33) within 48 hours of arrest of labor with intravenous magnesium sulfate. Progesterone group demonstrated a longer mean latency until delivery (36 +/- 18 days vs. 24 +/- 27) days. However, it failed to reduce the incidence of readmission for PTL. A Cochrane meta-analysis done in 2010 (Su et al., 2010), suggests that progestational agents may be use in the treatment of threatened and preterm labor. However the number of participants in each included study ranged from 35 and 60. Further larger studies are needed.

## **6. Progestins and preterm premature rupture of membranes**

Preterm premature rupture of membranes complicates nearly 3% of all pregnancies and is responsible for one third of all PTB (Mercer et al., 2003). Overall 75% deliver within one week after rupture, but approximately 15% may extend gestation for several weeks (ACOG #1, 1998; Lieman et al., 2005). Briery et al (Briery et al., 2011) randomized women with PPROM at 20-30 weeks' gestation with fetus in cephalic presentation to receive weekly 17OHP-C (n=33) or placebo (n=36) in an attempt to prolong the pregnancy. The report showed that there was no difference in GA at the time of delivery or the interval between randomization and delivery between the 2 groups. The neonatal outcome statistics of morbidity and mortality were similar between the two groups. The authors concluded that in patient with PPROM, 17OHP-C did not extend gestation vs. placebo and cannot be recommended for treatment in such women.

## **7. Safety and tolerability**

Synthetic progestins, including 17OHP-C have been associated with a less desirable sideeffect profile than that of natural progesterone, including mood swings, headaches, bloating, abdominal pain, perineal pain, constipation, diarrhea, nausea, vomiting, joint pain,

Progestins and Preterm Birth 223

(Bailit &Votruba, 2007). Three U.S. cost-effective analysis studies using decision analysis have been published (Odibo et al., 2006; Cahill et al., 2010; Werner et al., 2011). Odibo et al. (Odibo et al., 2006) compared the cost-effectiveness of using 17OHP-C for the prevention of PTD in cost-savings in women with prior PTD results in cost-savings in women with prior PTD less than 32 weeks and 32 to 37 weeks' gestation. (Cahill et al., 2010) compared the cost effectiveness of universal cervical screening/vaginal progesterone vs. no screening/no treatment on an estimated annual delivery rate of 4 million. The calculated annual cost, based on spontaneous PTBs < 34 weeks' gestation and severe morbidity prevented, fell from \$46.2 billion to \$33.3 billion annually, an annual saving of \$12.9 billion, which was greater than calculated savings from 17OHP-C treatment on the basis of maternal history (\$7.9 billion) or cervical-length screening in high risk pregnancies (\$3.9 billion). Using a mean estimate of \$70 for the second trimester CL scan and \$206 for vaginal progesterone treatment, Werner et al. (Werner, 2011) analyze their model using data of Fonseca et al. (Fonseca et al., 2007), the cost saving was \$12.1 million for every 100,000 women in the universal screened/vaginal progesterone group. Whereas, using data of Hassan et al (Hassan et al., 2011), the cost saving was \$19.6 million

In 2006, a New Drug Approval application was submitted to the FDA for 17 OHP-C, and the rights to produce the drug eventually were bought by KV Pharmaceutical. FDA recommended that the pharmaceutical company perform a confirmatory randomized controlled trial with a larger sample size than the Meis study. Once that confirmatory study was underway and 10% of the total sample size had been recruited from U.S. sites, the FDA approved Makena under the agency's accelerated approval regulations in February 2011. On February 15, 2011, KV Pharmaceutical announced the price of Makena at \$1500 per injections, 75-150 times more than what formerly was being charged for the same medication that previously was available through locally regulated compounding pharmacies. The cost of the 17OHP-C was \$10 to \$20 per injection or \$200 or \$300 per pregnancy and about \$150 per week when home care agencies were used to provide the necessary services. On April 1, 2011, the ACOG and SMFM state that there is no evidence that Makena is more effective or safer than the currently used compounded version. On the same day, KV pharmaceutical reduced the price of Makena from \$1500 to \$690 per injection or \$14,000 to \$16,000 per pregnancy. ACOG, SMFM, March of Dimes, American Academy of Family physicians all have responded that this reduction in price is insufficient (Cohen et al., 2011). On May 11, 2011 the pharmacy compounding accreditation board sent a letter to SMFM stating that "unlike most other new FDA approved drugs, the makers of Makena do not have a patent on this preparation. The commercial preparation Makena was approved under the FDA's orphan drug program using an older medication with a formula in the public domain and supported by research conducted by the National Institute of Health. Under the orphan drug program, manufacturers are granted seven years of market exclusivity meaning that they and only they have the ability to promote market and advertise that product for the particular use. While a compounding pharmacy cannot market and promote a commercial competitor to Makena, it can legally compound 17OHP-C on the basis of a prescriber's valid prescription". For comparison, the cost of progesterone USP suppositories is \$1-2 per suppository or \$ 5-10 per week or \$200 per pregnancy, whereas the cost of crinone gel 8% is \$15 per week or \$100 per week or \$2500 per pregnancy

per every 100,000 women.

 Although these side effects have been reported with any form of progesterone (for example contraceptive), they rarely are severe and do not usually necessate discontinuing the drug at this dose when given to prevent preterm birth. A case in point, would be the MFM Network trial ( Meis et al., 2003), the most common undesirable side effect was injection site pain (35%), injection site swelling (17%), urticaria (12%), pruritus (8%), injection site pruritus (6%), nausea (6%), contusion (6%), injection site nodule (4%), and vomiting (3%) (FDA, 2006). Meis (Meis et al., 2003) and Heinonen (Heinonen et al., 1977) reported a small, statistically non-significant increased in miscarriage and stillbirths in women receiving progesterone. Data from animal studies, suggest that increased plasma levels of progesterone may influence fetal behavior and induce fetal arousal states (Crossley et al., 1997; Nicol et al., 1997). There were no human data regarding long term outcome of women and infants who were exposed to progesterone in-utero until the published NICHD trial (Northen et al., 2007)reported a comprehensive 4 year follow up of children exposed to 17OHP-C in-utero. The children were 30-64 months of age at the time of the follow-up assessments. Of the 348 eligible surviving children, 278 (80%) were available for evaluation (194 17OHP-C, 84 placebo). No significant differences were seen in health status and conditions, or physical exam, including genital anomalies between 17OHP-C and placebo children. The developmental screen including communication, gross motor, fine motor, problem solving, and personal-social issues was not significantly different between 17OHP-C and placebo group. Therefore, it appears that at least with 17OHP-C there are no long term adverse effects in the offspring when used at 250mg per week.

Retrospective data indicate that 17OHP-C exposure may be associated with an increased risk of gestational diabetes (Rebarber et al., 2007; Waters et al., 2009). Hepatic dysfunctions, including cholestasis of pregnancy, have also been reported at a higher rate in women treated with oral micronized progesterone in France (Benifla et al., 1997; Bacq et al., 1997). Weekly IM injections of 17 OHP-C may be undesirable to a portion of the population at risk for PTB. Progesterone administered intramuscularly has been associated with several systemic and local skin complications. Some women may find transvaginal delivery to be more acceptable than injection, but others may not agree. Suppositories can be difficult to place high in the vagina and may liquefy, potentially leads to vaginal discharge, irritation, and infection. Vaginal cream and gel, which do not liquefy and are easier to apply, may alleviate some of the problems associated with transvaginal suppositories. Comparative data on the various methods of administration are thus needed to determine pharmacokinetic or tolerability differences, however, before one method can be recommended over the others.

## **8. Cost**

Treatment with 17OHP-C or progesterone provides a significant reduction in the risk of recurrent PTB. In addition, there is a reduction in direct and indirect costs associated with PTD.  Although these side effects have been reported with any form of progesterone (for example contraceptive), they rarely are severe and do not usually necessate discontinuing the drug at this dose when given to prevent preterm birth. A case in point, would be the MFM Network trial ( Meis et al., 2003), the most common undesirable side effect was injection site pain (35%), injection site swelling (17%), urticaria (12%), pruritus (8%), injection site pruritus (6%), nausea (6%), contusion (6%), injection site nodule (4%), and vomiting (3%) (FDA, 2006). Meis (Meis et al., 2003) and Heinonen (Heinonen et al., 1977) reported a small, statistically non-significant increased in miscarriage and stillbirths in women receiving progesterone. Data from animal studies, suggest that increased plasma levels of progesterone may influence fetal behavior and induce fetal arousal states (Crossley et al., 1997; Nicol et al., 1997). There were no human data regarding long term outcome of women and infants who were exposed to progesterone in-utero until the published NICHD trial (Northen et al., 2007)reported a comprehensive 4 year follow up of children exposed to 17OHP-C in-utero. The children were 30-64 months of age at the time of the follow-up assessments. Of the 348 eligible surviving children, 278 (80%) were available for evaluation (194 17OHP-C, 84 placebo). No significant differences were seen in health status and conditions, or physical exam, including genital anomalies between 17OHP-C and placebo children. The developmental screen including communication, gross motor, fine motor, problem solving, and personal-social issues was not significantly different between 17OHP-C and placebo group. Therefore, it appears that at least with 17OHP-C there are no long term adverse effects in the offspring when used at 250mg per

Retrospective data indicate that 17OHP-C exposure may be associated with an increased risk of gestational diabetes (Rebarber et al., 2007; Waters et al., 2009). Hepatic dysfunctions, including cholestasis of pregnancy, have also been reported at a higher rate in women treated with oral micronized progesterone in France (Benifla et al., 1997; Bacq et al., 1997). Weekly IM injections of 17 OHP-C may be undesirable to a portion of the population at risk for PTB. Progesterone administered intramuscularly has been associated with several systemic and local skin complications. Some women may find transvaginal delivery to be more acceptable than injection, but others may not agree. Suppositories can be difficult to place high in the vagina and may liquefy, potentially leads to vaginal discharge, irritation, and infection. Vaginal cream and gel, which do not liquefy and are easier to apply, may alleviate some of the problems associated with transvaginal suppositories. Comparative data on the various methods of administration are thus needed to determine pharmacokinetic or tolerability differences, however, before one method can be

Treatment with 17OHP-C or progesterone provides a significant reduction in the risk of recurrent PTB. In addition, there is a reduction in direct and indirect costs associated with PTD. For women with a prior PTD treated with 17OHP-C, the projected discounted lifetime medical costs of their offspring could be reduced by more than 2 billion dollars annually

week.

**8. Cost**

recommended over the others.

(Bailit &Votruba, 2007). Three U.S. cost-effective analysis studies using decision analysis have been published (Odibo et al., 2006; Cahill et al., 2010; Werner et al., 2011). Odibo et al. (Odibo et al., 2006) compared the cost-effectiveness of using 17OHP-C for the prevention of PTD in cost-savings in women with prior PTD results in cost-savings in women with prior PTD less than 32 weeks and 32 to 37 weeks' gestation. (Cahill et al., 2010) compared the cost effectiveness of universal cervical screening/vaginal progesterone vs. no screening/no treatment on an estimated annual delivery rate of 4 million. The calculated annual cost, based on spontaneous PTBs < 34 weeks' gestation and severe morbidity prevented, fell from \$46.2 billion to \$33.3 billion annually, an annual saving of \$12.9 billion, which was greater than calculated savings from 17OHP-C treatment on the basis of maternal history (\$7.9 billion) or cervical-length screening in high risk pregnancies (\$3.9 billion). Using a mean estimate of \$70 for the second trimester CL scan and \$206 for vaginal progesterone treatment, Werner et al. (Werner, 2011) analyze their model using data of Fonseca et al. (Fonseca et al., 2007), the cost saving was \$12.1 million for every 100,000 women in the universal screened/vaginal progesterone group. Whereas, using data of Hassan et al (Hassan et al., 2011), the cost saving was \$19.6 million per every 100,000 women.

In 2006, a New Drug Approval application was submitted to the FDA for 17 OHP-C, and the rights to produce the drug eventually were bought by KV Pharmaceutical. FDA recommended that the pharmaceutical company perform a confirmatory randomized controlled trial with a larger sample size than the Meis study. Once that confirmatory study was underway and 10% of the total sample size had been recruited from U.S. sites, the FDA approved Makena under the agency's accelerated approval regulations in February 2011. On February 15, 2011, KV Pharmaceutical announced the price of Makena at \$1500 per injections, 75-150 times more than what formerly was being charged for the same medication that previously was available through locally regulated compounding pharmacies. The cost of the 17OHP-C was \$10 to \$20 per injection or \$200 or \$300 per pregnancy and about \$150 per week when home care agencies were used to provide the necessary services. On April 1, 2011, the ACOG and SMFM state that there is no evidence that Makena is more effective or safer than the currently used compounded version. On the same day, KV pharmaceutical reduced the price of Makena from \$1500 to \$690 per injection or \$14,000 to \$16,000 per pregnancy. ACOG, SMFM, March of Dimes, American Academy of Family physicians all have responded that this reduction in price is insufficient (Cohen et al., 2011). On May 11, 2011 the pharmacy compounding accreditation board sent a letter to SMFM stating that "unlike most other new FDA approved drugs, the makers of Makena do not have a patent on this preparation. The commercial preparation Makena was approved under the FDA's orphan drug program using an older medication with a formula in the public domain and supported by research conducted by the National Institute of Health. Under the orphan drug program, manufacturers are granted seven years of market exclusivity meaning that they and only they have the ability to promote market and advertise that product for the particular use. While a compounding pharmacy cannot market and promote a commercial competitor to Makena, it can legally compound 17OHP-C on the basis of a prescriber's valid prescription". For comparison, the cost of progesterone USP suppositories is \$1-2 per suppository or \$ 5-10 per week or \$200 per pregnancy, whereas the cost of crinone gel 8% is \$15 per week or \$100 per week or \$2500 per pregnancy (Silver & Cunningham, 2011).

Progestins and Preterm Birth 225

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## **9. Future of progestins and PTB**

Data has shown that there is a place for progesterone in the prevention of PTB. However, the optimal dosage, route and timely delivery of the drug remain controversial. It is encouraging that there are multiple ongoing trials that should further clarify the role of progesterone in PTB prevention (www.clincialtrials.gov/ct/show and; www.charttrials.abdn.ac.uk/). To et al (To et al., 2006) , from the fetal Medicine Foundation (FMF), developed a model combining maternal risk factors with CL and found that the inclusion of maternal age and previous history of PTB improved the prediction. The detection rate of screening for PTD before 32 weeks at a fixed false-positive rate of 10% was 38% for maternal factors, 55% for CL and 69% for combined testing. This concept is important when considering which patients to include in spontaneous PTB prevention programs.

## **10. Conclusions**

In summary, the exact mechanism of progestins on reducing preterm birth is speculative at this point. The absence of effect in multiple gestation together with a positive results in women with historical risk, short cervix and the recent cerclage data, suggests that progesterone's effect on preterm birth rates may be related to reducing inflammation rather than acting as a tocolytic agent (Elovitz & Gonzalez et al., 2008). More information is needed not only regarding the mechanism of action, but also in regard to maternal outcomes following antenatal therapy, preference by patient in terms of mode of delivery, satisfaction of care, optimal dose, optimal route of administration and optimal gestational age at which to begin therapy ( ACOG #419, 2008).

Although no specific regimen is cited as superior or preferable (ACOG #419, 2008), evidence at this time supports prophylactic administration of progesterone be offered to women with a singleton pregnancy and a previous spontaneous PTB and to pregnant women with a short cervix of </= 25 mm at mid-gestation scan for prevention of PTB (250 mg of weekly IM 17OHP-C or progesterone 100 mg daily vaginally). Current evidence does not support the routine use of progesterone in women with multiple gestations and PPROM nor as a treatment for threatened or established PTL.

## **11. References**

Data has shown that there is a place for progesterone in the prevention of PTB. However, the optimal dosage, route and timely delivery of the drug remain controversial. It is encouraging that there are multiple ongoing trials that should further clarify the role of progesterone in PTB prevention (www.clincialtrials.gov/ct/show and; www.charttrials.abdn.ac.uk/). To et al (To et al., 2006) , from the fetal Medicine Foundation (FMF), developed a model combining maternal risk factors with CL and found that the inclusion of maternal age and previous history of PTB improved the prediction. The detection rate of screening for PTD before 32 weeks at a fixed false-positive rate of 10% was 38% for maternal factors, 55% for CL and 69% for combined testing. This concept is important when considering which patients to include in spontaneous PTB prevention

In summary, the exact mechanism of progestins on reducing preterm birth is speculative at this point. The absence of effect in multiple gestation together with a positive results in women with historical risk, short cervix and the recent cerclage data, suggests that progesterone's effect on preterm birth rates may be related to reducing inflammation rather than acting as a tocolytic agent (Elovitz & Gonzalez et al., 2008). More information is needed not only regarding the mechanism of action, but also in regard to maternal outcomes following antenatal therapy, preference by patient in terms of mode of delivery, satisfaction of care, optimal dose, optimal route of administration and optimal gestational age at which

Although no specific regimen is cited as superior or preferable (ACOG #419, 2008), evidence at this time supports prophylactic administration of progesterone be offered to women with a singleton pregnancy and a previous spontaneous PTB and to pregnant women with a short cervix of </= 25 mm at mid-gestation scan for prevention of PTB (250 mg of weekly IM 17OHP-C or progesterone 100 mg daily vaginally). Current evidence does not support the routine use of progesterone in women with multiple gestations and PPROM nor as a

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**10**

*Belgium*

**Management of Abnormal Vaginal Flora**

**as a Risk Factor for Preterm Birth**

*1Department of Obstetrics and Gynaecology of the Regional Hospital, Heilig Hart Tienen and University Hospital Gasthuisberg Leuven,*

Prevention of preterm birth remains a major challenge in obstetrics. While over the years a lot of attention has been given to the structural deficiencies, like uterine abnormalities, or 'weak' or 'insufficient' cervix, during the last decades the importance of ascending infection as a possible cause of preterm birth, preterm rupture of the membranes and intrauterine infection has become increasingly evident (Martius & Eschenbach, 1990). The earlier the preterm labor starts, the higher the likelihood an underlying chorio-amnionitis will be found. While for term deliveries the risk of chorio-amnionitis is around 1%,it is more than 45% in preterm deliveries (Scherman et al., 1997). The damage intrauterine infection causes to the fetus is not limited to the complications and sequels of being born preterm, but also is due to brain damage, like intra- or peri-ventricular hemorrhages and cerebral palsy, caused by the inflammatory reaction due to infection (Romero et al., 2007). Furthermore, such gestational ascending infections may cause maternal complications like sepsis, septic

Bacterial vaginosis (BV) in pregnancy has an acknowledged increased risk of preterm delivery, but treatment with metronidazole is not beneficial, and if anything, harmful for the pregnancy. Use of broader spectrum antibiotics like clindamycin, or combination antibiotherapy, have shown better results, but still not all studies are in agreement with this. Therefore, critical reappraisal of the prevailing data are crucial, and new studies may need to incorporate new findings and insights. For one, the diagnostic accuracy needs to be refined, as it became increasingly clear that aerobic pathogens and the inflammation caused by aerobic vaginitis (AV), may play a more important role than previously thought. In recent studies meticulously discriminating these differences between BV, AV and mixed AV-BV flora by phase contrast microscopy, it became evident that not only BV may be primarily associated to intrauterine growth restriction and preterm birth, but also the aerobic component may lead to inflammatory reactions in placenta, amniotic fluid and fetus, preterm rupture of the membranes and preterm birth. In this review, emphasis is placed on the most crucial differential diagnostic characteristics, and the treatment adjustments these findings require. Part of this review has been published in the British Journal of Gynecology

arthritis, maternal respiratory distress (Garland et al., 2002).

**1. Introduction**

(Donders et al, 2011).

Gilbert G.G. Donders1,2 and Gert Bellen2

*2Femicare vzw, Clinical Research for Women, Tienen,*

## **Management of Abnormal Vaginal Flora as a Risk Factor for Preterm Birth**

Gilbert G.G. Donders1,2 and Gert Bellen2

*1Department of Obstetrics and Gynaecology of the Regional Hospital, Heilig Hart Tienen and University Hospital Gasthuisberg Leuven, 2Femicare vzw, Clinical Research for Women, Tienen, Belgium*

## **1. Introduction**

230 Preterm Birth - Mother and Child

To MS, Skentou CA, Royston P, et al. (2006). Prediction of patient-specific risk of early

Tucker JM, Goldenberg RI, Davis RO, et al. (1991). Etiologies of preterm birth in an indigent population: Is prevention a logical expectation? *Obstet Gynecol.* 77, 343-7. Vaisbuch E, Hassan SS, Mazaki-Tovi S, et al. (2010). Patients with an asymptomatic short

Waters TP, Schultz BAH, Mercer BM. et al. (2009). Effect of 17 alpha- hydroxyprogesterone caproate on glucose intolerance in pregnancy. *Obstet Gynecol. 114:45-9.*  Werner EF, Han CS, Pettker CM et al. (2011). Universal cervical-length screening to prevent preterm birth:a cost-effective analysis. *Ultrasound Obstet Gynecol 38:32-7*  Yemini M, Borenstein R, Dreazen E, et al. (1985). Prevention of premature labor by 17 alphahydroxyprogesterone caproate. *Am J Obstet Gynecol.* 293,675-80.

implications for patient counseling. *Am J Obstet Gynecol* 202,433.e1-8. von Eye Corleta H, Capp E, Ferreira MBC. (2004). Pharmacokinetic of natural progesterone

vaginal suppository. *Gynecol Obstet Invest.* 58, 105-8.

delivery. *Pediatrics.* 109(3), 399-403.

preterm delivery using maternal history and sonographic measurement of cervical length: a population-based prospective study. *Ultrasound Obstet Gynecol* 27,362-7. Tough SC, Newburn-Cook C, Johnston DW. (2002). Delayed childbearing and its impact on

population rate changes in lower birth weight, multiple birth, and preterm

cervix (< or = 15 mm) have a high rate of subclinical intraamniotic inflammation:

Prevention of preterm birth remains a major challenge in obstetrics. While over the years a lot of attention has been given to the structural deficiencies, like uterine abnormalities, or 'weak' or 'insufficient' cervix, during the last decades the importance of ascending infection as a possible cause of preterm birth, preterm rupture of the membranes and intrauterine infection has become increasingly evident (Martius & Eschenbach, 1990). The earlier the preterm labor starts, the higher the likelihood an underlying chorio-amnionitis will be found. While for term deliveries the risk of chorio-amnionitis is around 1%,it is more than 45% in preterm deliveries (Scherman et al., 1997). The damage intrauterine infection causes to the fetus is not limited to the complications and sequels of being born preterm, but also is due to brain damage, like intra- or peri-ventricular hemorrhages and cerebral palsy, caused by the inflammatory reaction due to infection (Romero et al., 2007). Furthermore, such gestational ascending infections may cause maternal complications like sepsis, septic arthritis, maternal respiratory distress (Garland et al., 2002).

Bacterial vaginosis (BV) in pregnancy has an acknowledged increased risk of preterm delivery, but treatment with metronidazole is not beneficial, and if anything, harmful for the pregnancy. Use of broader spectrum antibiotics like clindamycin, or combination antibiotherapy, have shown better results, but still not all studies are in agreement with this. Therefore, critical reappraisal of the prevailing data are crucial, and new studies may need to incorporate new findings and insights. For one, the diagnostic accuracy needs to be refined, as it became increasingly clear that aerobic pathogens and the inflammation caused by aerobic vaginitis (AV), may play a more important role than previously thought. In recent studies meticulously discriminating these differences between BV, AV and mixed AV-BV flora by phase contrast microscopy, it became evident that not only BV may be primarily associated to intrauterine growth restriction and preterm birth, but also the aerobic component may lead to inflammatory reactions in placenta, amniotic fluid and fetus, preterm rupture of the membranes and preterm birth. In this review, emphasis is placed on the most crucial differential diagnostic characteristics, and the treatment adjustments these findings require. Part of this review has been published in the British Journal of Gynecology (Donders et al, 2011).

Management of Abnormal Vaginal Flora as a Risk Factor for Preterm Birth 233

One of the disadvantages of the Nugent score system that is used on Gram stained specimens to diagnose BV (Nugent et al., 1991), is that one does not realize more than one condition may co-occur. In studying wet mounts and applying the BV and AV criteria at the same time, pure BV can be clearly distinguished from pure AV, but at the same time combined forms can be discovered where wherein anaerobic BV flora and AV flora coincide. This mixed AV-BV flora may well be a transient condition between BV and AV, but most

For a few genital infections with severe impact on the outcome of the pregnancy, such as syphilis and gonorrhoea, a 'screen and treat' policy is almost always cost-effective (Donders et al., 1993a; Elliot et al., 1990), while for other infectious conditions, like vaginal overgrowth with mycoplasmata, the jury is still out there to define its precise role in the pathogenesis of infection related preterm birth and fetal injury (Lee et al., 2009; Harada et al., 2008; Carey et

From the early 90ies it became evident that not only typical pathogens like *C. trachomatis*, *T. vaginalis* and *N. gonorrhoeae* could harm the pregnancy, but also merely aberrations from the normal lactobacilli dominant vaginal flora could endanger the fetus. Although all in the same line, these aberrations were all studied form a different perspective. Most studies used Nugent's or Spiegel's score on Gram stains to detect an association between bacterial vaginosis (BV) and intermediate flora with adverse pregnancy outcome (Hay et al., 1994; Elliot et al., 1990; Lee et al., 2009; Thorp et al., 2008; Cauci et al., 2002c; Hauth et al., 2003; Kekki et al., 2001; Kiss et al., Klebanoff et al., 2005; McDonald et al., 1997; Oakeshott et al., 2004; Verstraelen et al., 2007), but similar findings could be obtained with clinical Amsel criteria to diagnose BV (Honest et al., 2004; Rouse et al., 2009), abnormal lactobacillary grades on both Pap smears, gram stains, and wet mount preparations (Hay et al., 1994; Donders et al., 1993b; Mass et al., 1999; Donders et al., 2009) and with other abnormalities of the bacterial flora than full BV (Donders et al., 2002; Donders et al., E pub ahead of print

As is generally acknowledged, Nugent score above 7 on Gram stained specimens corresponds well with BV, and is nowadays accepted as golden standard for the diagnosis of BV in most clinical trials. Compared to this method, wet mount is said to be less sensitive. However, some constraints have to be taken into consideration. First of all, on a continuous scale of 1 to 10, there is no consensus on what the intermediate group with a score of 4 to 6 stands for. If Nugent were an ideal scoring system for bacterial vaginosis, with score 1 to 3 being normal and 7 or above being full blown BV, score 4 to 6 should be transitional, partial or intermediate BV, but in reality it is not. Ideally this intermediate flora state represents a turning point from a normal state into BV, or on the opposite, from BV to normal. However, most of these women with so-called intermediate BV according to Nugent will neither have BV, nor will they become normal. In fact, as they are not having normal flora, nor BV, they rather resemble a sort of 'garbage bin', but this does not mean that they do not represent important pathology. Most intriguing, in almost all studies addressing the importance of BV and the intermediate group as a separate category, it was clear that the intermediate group was linked to a different, and usually more serious scope of complications (e.g. mid trimester pregnancy loss) than the 'classic', full-blown BV (Hay et al., 1994; McDonald et al.,

likely a prolonged co-infection of both may also occur.

al., 1991; Gravett & Eschenbach, 1986).

2010; Donders et al., 2009).

1994).

**3. Abnormal vaginal flora subtypes in pregnancy**

## **2. Definition of AV**

Diagnosis of AV is based on wet mount microscopy. Normal and abnormal lactobacillary flora are divided into 3 to 4 flora types, also depicted as lactobacillary grades (LBG's). LBG 1 corresponds to a 'healthy' microflora, and has predominant lactobacillary morphotypes of variable size. Lactobacillary grade III is a condition wherein the lactobacillary morphotypes are completely replaced by other bacterial morphotypes. Lactobacillary grade II is an intermediate group, with partial replacement of the lactobacilli by other bacteria. Due to their specific link to pathology, we refined the three grades, and divided grade 2 (LBGII) in a less severe (LBGIIa) and a more severe (LBGIIb) variety (Donders, 1999). As LBG 3, and to a lesser extent LBG IIb are more likely to be linked with pathological conditions, they are entitled 'abnormal vaginal flora'. LBG's are the basis for a composite score to which the following four variables were added: 1) proportional number of leukocytes, 2) presence of toxic leukocytes, 3) presence of parabasal epithelial cells and 4) type of background flora (Donders, 2002). This condition is a screening tool that should not be confused with bacterial vaginosis. Bacterial vaginosis is a condition with abnormal vaginal flora, but abnormal vaginal flora is not always bacterial vaginosis. Some studies demonstrate that the absence of lactobacilli is a more powerful predictor of preterm birth than the presence of bacterial vaginosis (Donders et al., 2008a; Hay et al., 1994). In order to diagnose such abnormal lactobacillary grades, the use of wet mount is preferred above the use of Gram stains due to superior accuracy (Donders et al., 2000c; Donders et al 1996) and better correlation with lactate in the vaginal content (Donders et al., 1998), a functional test for lactobacillary defence function.

Therefore, in this classification, the immune reaction of the host is also taken into account for the diagnosis. Parabasal cells are considered a sign of severe epithelial inflammation usually not seen in uncomplicated BV. They are encountered only in moderate or severe forms of aerobic vaginitis (AV), such as in desquamative inflammatory vaginitis (Newbern et al., 2002; Sobel, 1994). Background flora was allocated score 0 if the background flora was unremarkable or showed debris and bare nuclei from lysed epithelial cells (cytolysis), score 1 if the lactobacillary morphotypes were very coarse or resembled small bacilli (rather than lactobacilli), and 2 if there were prominent cocci, or chained cocci visible. Leukocytes were scored according to their proportional number when compared with epitheliocytes. More than 10 leukocytes per epithelial cell is assigned 2 points, while less than 10 per epithelial cell, but more than 10 per high power field corresponds to 1 point. Adding these points together comprises a composite score, the 'AV'-score. A composite score of 1 to 4 represents normal flora. A score of 5 to 6 to moderate AV, and a score above 6 (to max. 10) to severe AV. In practice, a score of 8 to 10 matches the definition of 'desquamative inflammatory vaginitis'.

The use of this AV criterion enables us to divide the flora in a more detailed and comprehensive way, avoiding undefined and unclear categories. Bacterial flora is lactobacillary type predominant (normal), or it is abnormal. If abnormal the flora can be disturbed by anaerobic overgrowth (BV) or by aerobic micro-organisms, such as E coli, group B streptococci, enterococci etc (AV), or can be a mixture of both (mixed AV-BV). Therefore one has to be continuously aware that concomitant infections may occur, and also concurrent infections with *Candida sp.*, *Trichomonas vaginalis*, mycoplasmata or cervicitis (*Chlamydia trachomatis*, *Neisseria gonorrhoeae* and other) (Donders et al., 1993b).

Diagnosis of AV is based on wet mount microscopy. Normal and abnormal lactobacillary flora are divided into 3 to 4 flora types, also depicted as lactobacillary grades (LBG's). LBG 1 corresponds to a 'healthy' microflora, and has predominant lactobacillary morphotypes of variable size. Lactobacillary grade III is a condition wherein the lactobacillary morphotypes are completely replaced by other bacterial morphotypes. Lactobacillary grade II is an intermediate group, with partial replacement of the lactobacilli by other bacteria. Due to their specific link to pathology, we refined the three grades, and divided grade 2 (LBGII) in a less severe (LBGIIa) and a more severe (LBGIIb) variety (Donders, 1999). As LBG 3, and to a lesser extent LBG IIb are more likely to be linked with pathological conditions, they are entitled 'abnormal vaginal flora'. LBG's are the basis for a composite score to which the following four variables were added: 1) proportional number of leukocytes, 2) presence of toxic leukocytes, 3) presence of parabasal epithelial cells and 4) type of background flora (Donders, 2002). This condition is a screening tool that should not be confused with bacterial vaginosis. Bacterial vaginosis is a condition with abnormal vaginal flora, but abnormal vaginal flora is not always bacterial vaginosis. Some studies demonstrate that the absence of lactobacilli is a more powerful predictor of preterm birth than the presence of bacterial vaginosis (Donders et al., 2008a; Hay et al., 1994). In order to diagnose such abnormal lactobacillary grades, the use of wet mount is preferred above the use of Gram stains due to superior accuracy (Donders et al., 2000c; Donders et al 1996) and better correlation with lactate in the vaginal content (Donders et al., 1998), a functional test for lactobacillary

Therefore, in this classification, the immune reaction of the host is also taken into account for the diagnosis. Parabasal cells are considered a sign of severe epithelial inflammation usually not seen in uncomplicated BV. They are encountered only in moderate or severe forms of aerobic vaginitis (AV), such as in desquamative inflammatory vaginitis (Newbern et al., 2002; Sobel, 1994). Background flora was allocated score 0 if the background flora was unremarkable or showed debris and bare nuclei from lysed epithelial cells (cytolysis), score 1 if the lactobacillary morphotypes were very coarse or resembled small bacilli (rather than lactobacilli), and 2 if there were prominent cocci, or chained cocci visible. Leukocytes were scored according to their proportional number when compared with epitheliocytes. More than 10 leukocytes per epithelial cell is assigned 2 points, while less than 10 per epithelial cell, but more than 10 per high power field corresponds to 1 point. Adding these points together comprises a composite score, the 'AV'-score. A composite score of 1 to 4 represents normal flora. A score of 5 to 6 to moderate AV, and a score above 6 (to max. 10) to severe AV. In practice, a score of 8 to 10 matches the definition of 'desquamative inflammatory

The use of this AV criterion enables us to divide the flora in a more detailed and comprehensive way, avoiding undefined and unclear categories. Bacterial flora is lactobacillary type predominant (normal), or it is abnormal. If abnormal the flora can be disturbed by anaerobic overgrowth (BV) or by aerobic micro-organisms, such as E coli, group B streptococci, enterococci etc (AV), or can be a mixture of both (mixed AV-BV). Therefore one has to be continuously aware that concomitant infections may occur, and also concurrent infections with *Candida sp.*, *Trichomonas vaginalis*, mycoplasmata or cervicitis

(*Chlamydia trachomatis*, *Neisseria gonorrhoeae* and other) (Donders et al., 1993b).

**2. Definition of AV**

defence function.

vaginitis'.

One of the disadvantages of the Nugent score system that is used on Gram stained specimens to diagnose BV (Nugent et al., 1991), is that one does not realize more than one condition may co-occur. In studying wet mounts and applying the BV and AV criteria at the same time, pure BV can be clearly distinguished from pure AV, but at the same time combined forms can be discovered where wherein anaerobic BV flora and AV flora coincide. This mixed AV-BV flora may well be a transient condition between BV and AV, but most likely a prolonged co-infection of both may also occur.

## **3. Abnormal vaginal flora subtypes in pregnancy**

For a few genital infections with severe impact on the outcome of the pregnancy, such as syphilis and gonorrhoea, a 'screen and treat' policy is almost always cost-effective (Donders et al., 1993a; Elliot et al., 1990), while for other infectious conditions, like vaginal overgrowth with mycoplasmata, the jury is still out there to define its precise role in the pathogenesis of infection related preterm birth and fetal injury (Lee et al., 2009; Harada et al., 2008; Carey et al., 1991; Gravett & Eschenbach, 1986).

From the early 90ies it became evident that not only typical pathogens like *C. trachomatis*, *T. vaginalis* and *N. gonorrhoeae* could harm the pregnancy, but also merely aberrations from the normal lactobacilli dominant vaginal flora could endanger the fetus. Although all in the same line, these aberrations were all studied form a different perspective. Most studies used Nugent's or Spiegel's score on Gram stains to detect an association between bacterial vaginosis (BV) and intermediate flora with adverse pregnancy outcome (Hay et al., 1994; Elliot et al., 1990; Lee et al., 2009; Thorp et al., 2008; Cauci et al., 2002c; Hauth et al., 2003; Kekki et al., 2001; Kiss et al., Klebanoff et al., 2005; McDonald et al., 1997; Oakeshott et al., 2004; Verstraelen et al., 2007), but similar findings could be obtained with clinical Amsel criteria to diagnose BV (Honest et al., 2004; Rouse et al., 2009), abnormal lactobacillary grades on both Pap smears, gram stains, and wet mount preparations (Hay et al., 1994; Donders et al., 1993b; Mass et al., 1999; Donders et al., 2009) and with other abnormalities of the bacterial flora than full BV (Donders et al., 2002; Donders et al., E pub ahead of print 2010; Donders et al., 2009).

As is generally acknowledged, Nugent score above 7 on Gram stained specimens corresponds well with BV, and is nowadays accepted as golden standard for the diagnosis of BV in most clinical trials. Compared to this method, wet mount is said to be less sensitive. However, some constraints have to be taken into consideration. First of all, on a continuous scale of 1 to 10, there is no consensus on what the intermediate group with a score of 4 to 6 stands for. If Nugent were an ideal scoring system for bacterial vaginosis, with score 1 to 3 being normal and 7 or above being full blown BV, score 4 to 6 should be transitional, partial or intermediate BV, but in reality it is not. Ideally this intermediate flora state represents a turning point from a normal state into BV, or on the opposite, from BV to normal. However, most of these women with so-called intermediate BV according to Nugent will neither have BV, nor will they become normal. In fact, as they are not having normal flora, nor BV, they rather resemble a sort of 'garbage bin', but this does not mean that they do not represent important pathology. Most intriguing, in almost all studies addressing the importance of BV and the intermediate group as a separate category, it was clear that the intermediate group was linked to a different, and usually more serious scope of complications (e.g. mid trimester pregnancy loss) than the 'classic', full-blown BV (Hay et al., 1994; McDonald et al., 1994).

Management of Abnormal Vaginal Flora as a Risk Factor for Preterm Birth 235

of the Amsel diagnosis of BV, pH is often used as such a surrogate point of care test for BV (Madhivanan et al., 2009). However, in a study where pH was used as a screening tool in pregnancy, only 40% of women with increased vaginal pH had BV (Zodzika et al., 2011). When screening random women in Uganda, we discovered BV in only 27% of women with pH above 4.4 and 39% of women with pH above 4.7 had BV, while another 11% and 25% had coccoid AV respectively (unpublished results). The study demonstrated that AV and mixed AV-BV flora is also a frequent cause of abnormal pH in pregnancy. Hoyme et al. installed a screening in a German state by self measurements of the vaginal pH followed by treatment and found a dramatic reduction of preterm births (<37 gestational weeks at delivery) and early preterm births (<32 weeks) (Hoyme & Saling, 2004). As no specific search for BV was done, the proportion of women treated for other conditions than BV in

On several occasions, our group could demonstrate that the finding of decreased lactobacilllary morphotypes in the beginning of pregnancy is a marker which is strongly linked to preterm birth, even more convincingly so than full BV on its own (Donders et al., 2008a; Donders et al., 1993b; Donders et al., 2009; Madhivanan et al., 2009; Donders et al., 2008b). As is the case with increased pH, also deficient lactobacillary grades are part of the clinical diagnosis of BV, without implying that all abnormal cases necessarily have BV.

Although BV is linked to the increased incidence of spontaneous first and second trimester miscarriage (Hay et al., 1994; Donders et al., 2000b; Larsson et al., 2006; Oakeshott et al., 2002) and reduced baby-take-home-rates in pregnancies obtained through assisted fertility procedures like in vitro fertilization, these data are less clear for AV. In in vitro fertilization procedures, a relation was found between BV and implantation failures (Ralph et al., 1999), but this relation was not confirmed in another observation (Liversedge et al., 1999). Furthermore, amongst these patients a clear relation of BV with tubal infertility was present, (Liversedge et al., 1999; Wilson et al., 2002) indicating indirectly BV is a risk factor for ascending infection and tubal damage. Interestingly, in one study, not BV, but decreased lactobacilli (AVF) was found to be the risk factor of implantation failure at IVF (Eckert et al., 2003). In animals, experiments have shown that *E. coli* derived lipopolysaccharides (LPS) cause implantation failure associated with increased anti-inflammatory cytokines ( Deb et al., 2004a, 2004b). No data are available yet about the chances to conceive and keep the pregnancy in women with clinical AV or AV flora, but in sporadic cases pathogenic *E. coli*

serotypes were involved in recurrent abortion cases (Blum-Oehler et al., 1997).

The problem of amniotic fluid infection is that most of the time regular culture techniques are insufficiently sensitive to detect bacterial infection. Therefore, if PCR is used, frequent infection with E coli could be detected amongst these cases even when cultures were negative (Daoud et al., 2008). Also GBS and gram negative rods (Sherman et al., 1997) are frequent causes of intrauterine infections and histologic chorioamnionitis, often leading to midtrimester abortion, and even recurrences in two thirds of the women who have

this study in unkown.

**7. Outcome 7.1 Miscarriage**

**7.2 Midtrimester chorioamnionitis**

experienced it before.

### **4. Pathogenesis, immunology and genetics**

As AV only rather recently became recognized as an entity that differs in several aspects from BV, lot of its ethiology and pathogenesis remains unraveled. It is not known why the vagina harbours 2 to 3 predominant lactobacillary species (e.g. L. gasseri, L. cripatus, L. iners or L.) in normal women (Verstraelen et al., 2009) while in others anaerobes or aerobic commensals overgrow the vagina. It may well be that AV and BV are both ends of the same spectrum of bacterial abnormalities in the vagina, explaining the frequent occurrence of both conditions combined, also in pregnancy (Zodzika et al, 2011). Although it is not clear how the one condition can evolve into the other, it is certainly evident that both conditions express a completely different immunology pattern. Pro-inflammatory cytokines IL1b, IL6 and IL 8 are clearly linked to LBG's in pregnant women, cytokines going up with decreasing numbers of lactobacilli (Donders et al., 2003; Donders et al., 2000a). As was also shown by Cauci et al, BV does express an elevated pro-inflammatory cytokine IL1 b as well, but not the promoter cytokines of the prostaglandin cascade, IL-6 and IL-8 (Cauci et al., 2003), whereas in AV not only IL1b but also dramatic concentrations of IL6 and IL 8 are formed in the vagina (Donders, 2002). As the pro-inflammatory cytokine producers, especially IL-8, in BV women have a different pathogenesis than the (more common) non-producers, and are linked to several risk factors in pregnancy (Cauci et al., 2008; Cauci et al. 2002a, 2002b), likewise the enormous production of prostaglandin provoking cytokines IL 6 and IL 8 in AV patients make them likely candidates for causing preterm labor and delivery (Donders, 2002; Donders, 2007). The links between the presence of vaginal infections, increased levels of IL 6 and IL 8 in both vagina and amniotic fluid and chorio-amnionitis, PPROM and preterm birth are confirmed in several studies (Massaro et al., 2009; Hitti et al., 2001; Rizzo et al., 1996).

## **5. Prevalence**

Prevalence of BV in pregnancy is very variable according to the geographical and sociodemographic area of sampling and ranges from as low as 9% (Larsson et al., 2007) to as high as 48% (Tann et al., 2006). Longitudinal studies show invariably a decrease of BV during pregnancy and a lower likelihood to acquire I with the weeks the gestation progresses (Waters et al., 2008). The prevalence of abnormal aerobic flora or aerobic vaginitis is much more difficult to determine. Besides the prevalence studies on GBS colonization, which ranges between 7 and 25% between 35 and 37 weeks, until recently only sporadic papers have been published on the frequency of AV. Due to the high concentrations of circulating estrogens, severe AV, typically with increased numbers of parabasal cells, is infrequent in pregnancy. However, the prevalence of less extensive types , mild to moderate AV, may range from 8 to 10% according to sporadic studies done during pregnancy (Donders et al., 2009; Zodzika et al., 2011; Rezeberga et al., 2008). Also, it has to be acknowledged that many BV patients have AV to a certain extent as well, - only, the score obtained by Nugent's method will never tell you. Therefore we plea to look for both AV and BV in pregnancy as both conditions are present, need different management approaches and are both linked to adverse pregnancy outcome.

#### **6. Diagnostic techniques and screening**

Some authors used aspecific substitute markers instead of Nugent Score for BV detection for exploring risk factors in the vaginal flora during pregnancy. Being one of the crucial criteria of the Amsel diagnosis of BV, pH is often used as such a surrogate point of care test for BV (Madhivanan et al., 2009). However, in a study where pH was used as a screening tool in pregnancy, only 40% of women with increased vaginal pH had BV (Zodzika et al., 2011). When screening random women in Uganda, we discovered BV in only 27% of women with pH above 4.4 and 39% of women with pH above 4.7 had BV, while another 11% and 25% had coccoid AV respectively (unpublished results). The study demonstrated that AV and mixed AV-BV flora is also a frequent cause of abnormal pH in pregnancy. Hoyme et al. installed a screening in a German state by self measurements of the vaginal pH followed by treatment and found a dramatic reduction of preterm births (<37 gestational weeks at delivery) and early preterm births (<32 weeks) (Hoyme & Saling, 2004). As no specific search for BV was done, the proportion of women treated for other conditions than BV in this study in unkown.

On several occasions, our group could demonstrate that the finding of decreased lactobacilllary morphotypes in the beginning of pregnancy is a marker which is strongly linked to preterm birth, even more convincingly so than full BV on its own (Donders et al., 2008a; Donders et al., 1993b; Donders et al., 2009; Madhivanan et al., 2009; Donders et al., 2008b). As is the case with increased pH, also deficient lactobacillary grades are part of the clinical diagnosis of BV, without implying that all abnormal cases necessarily have BV.

## **7. Outcome**

234 Preterm Birth - Mother and Child

As AV only rather recently became recognized as an entity that differs in several aspects from BV, lot of its ethiology and pathogenesis remains unraveled. It is not known why the vagina harbours 2 to 3 predominant lactobacillary species (e.g. L. gasseri, L. cripatus, L. iners or L.) in normal women (Verstraelen et al., 2009) while in others anaerobes or aerobic commensals overgrow the vagina. It may well be that AV and BV are both ends of the same spectrum of bacterial abnormalities in the vagina, explaining the frequent occurrence of both conditions combined, also in pregnancy (Zodzika et al, 2011). Although it is not clear how the one condition can evolve into the other, it is certainly evident that both conditions express a completely different immunology pattern. Pro-inflammatory cytokines IL1b, IL6 and IL 8 are clearly linked to LBG's in pregnant women, cytokines going up with decreasing numbers of lactobacilli (Donders et al., 2003; Donders et al., 2000a). As was also shown by Cauci et al, BV does express an elevated pro-inflammatory cytokine IL1 b as well, but not the promoter cytokines of the prostaglandin cascade, IL-6 and IL-8 (Cauci et al., 2003), whereas in AV not only IL1b but also dramatic concentrations of IL6 and IL 8 are formed in the vagina (Donders, 2002). As the pro-inflammatory cytokine producers, especially IL-8, in BV women have a different pathogenesis than the (more common) non-producers, and are linked to several risk factors in pregnancy (Cauci et al., 2008; Cauci et al. 2002a, 2002b), likewise the enormous production of prostaglandin provoking cytokines IL 6 and IL 8 in AV patients make them likely candidates for causing preterm labor and delivery (Donders, 2002; Donders, 2007). The links between the presence of vaginal infections, increased levels of IL 6 and IL 8 in both vagina and amniotic fluid and chorio-amnionitis, PPROM and preterm birth are confirmed in

**4. Pathogenesis, immunology and genetics**

several studies (Massaro et al., 2009; Hitti et al., 2001; Rizzo et al., 1996).

Prevalence of BV in pregnancy is very variable according to the geographical and sociodemographic area of sampling and ranges from as low as 9% (Larsson et al., 2007) to as high as 48% (Tann et al., 2006). Longitudinal studies show invariably a decrease of BV during pregnancy and a lower likelihood to acquire I with the weeks the gestation progresses (Waters et al., 2008). The prevalence of abnormal aerobic flora or aerobic vaginitis is much more difficult to determine. Besides the prevalence studies on GBS colonization, which ranges between 7 and 25% between 35 and 37 weeks, until recently only sporadic papers have been published on the frequency of AV. Due to the high concentrations of circulating estrogens, severe AV, typically with increased numbers of parabasal cells, is infrequent in pregnancy. However, the prevalence of less extensive types , mild to moderate AV, may range from 8 to 10% according to sporadic studies done during pregnancy (Donders et al., 2009; Zodzika et al., 2011; Rezeberga et al., 2008). Also, it has to be acknowledged that many BV patients have AV to a certain extent as well, - only, the score obtained by Nugent's method will never tell you. Therefore we plea to look for both AV and BV in pregnancy as both conditions are present, need different management approaches and are both linked to

Some authors used aspecific substitute markers instead of Nugent Score for BV detection for exploring risk factors in the vaginal flora during pregnancy. Being one of the crucial criteria

**5. Prevalence**

adverse pregnancy outcome.

**6. Diagnostic techniques and screening**

## **7.1 Miscarriage**

Although BV is linked to the increased incidence of spontaneous first and second trimester miscarriage (Hay et al., 1994; Donders et al., 2000b; Larsson et al., 2006; Oakeshott et al., 2002) and reduced baby-take-home-rates in pregnancies obtained through assisted fertility procedures like in vitro fertilization, these data are less clear for AV. In in vitro fertilization procedures, a relation was found between BV and implantation failures (Ralph et al., 1999), but this relation was not confirmed in another observation (Liversedge et al., 1999). Furthermore, amongst these patients a clear relation of BV with tubal infertility was present, (Liversedge et al., 1999; Wilson et al., 2002) indicating indirectly BV is a risk factor for ascending infection and tubal damage. Interestingly, in one study, not BV, but decreased lactobacilli (AVF) was found to be the risk factor of implantation failure at IVF (Eckert et al., 2003). In animals, experiments have shown that *E. coli* derived lipopolysaccharides (LPS) cause implantation failure associated with increased anti-inflammatory cytokines ( Deb et al., 2004a, 2004b). No data are available yet about the chances to conceive and keep the pregnancy in women with clinical AV or AV flora, but in sporadic cases pathogenic *E. coli* serotypes were involved in recurrent abortion cases (Blum-Oehler et al., 1997).

## **7.2 Midtrimester chorioamnionitis**

The problem of amniotic fluid infection is that most of the time regular culture techniques are insufficiently sensitive to detect bacterial infection. Therefore, if PCR is used, frequent infection with E coli could be detected amongst these cases even when cultures were negative (Daoud et al., 2008). Also GBS and gram negative rods (Sherman et al., 1997) are frequent causes of intrauterine infections and histologic chorioamnionitis, often leading to midtrimester abortion, and even recurrences in two thirds of the women who have experienced it before.

Management of Abnormal Vaginal Flora as a Risk Factor for Preterm Birth 237

While women with AV and inflammatory reaction are more likely to develop intrauterine infection, chorioamnionitis, funisitis (Rezeberga et al., 2008) and preterm delivery, the merely non-inflammatory bacterial vaginosis may rather cause growth restriction and preterm delivery of small for date fetuses (Rezeberga et al., 2008). Also in the work of Vedmedovska et al., it was found that genital infections, primarily bacterial vaginosis, was

It is not yet clear which should be the best approach to treat for AV in non-pregnant women, let alone during pregnancy. The inflammatory component of most patients with AV makes one think that antibiotics may not be the best, or not the only approach. But IF is chosen to give antibiotics in pregnancy to reduce preterm birth and intrauterine infection, it became clear after a placebo controlled studies that metronidazole is not the answer as it does not decrease the preterm birth rate in women with bacterial vaginosis (McDonald et al., 1997; McDonald et al., 2007; Carey et al., 2000; Odendaal et al., 2002). Even worse, Klebanoff's (Klebanoff et al., 2001) and Odendael's study (Odendaal et al., 2002) on the treatment of trichomoniasis and BV, respectively, rather demonstrated an increased risk of preterm birth after treatment with metronidazole, leading several authors to the compelling conclusion that metronidazole should not be used in pregnancy with the purpose to reduce the risk of preterm birth (Donders et al., 2009; Odendaal et al., 2002; Carey et al., 2003; Morency & Bujold, 2007). Investigators using broader spectrum antibiotics, also covering gram positive cocci and E coli, on the other hand, were successful in the reduction of preterm birth in several placebo controlled studies (Larsson et al., 2006; Lamont et al., 2003; Ugwumadu et al., 2003), although not all (Kekki et al., 2001; Kurkinen-Raty et al., 2000; Rosenstein et al., 2000). As most studies used a single treatment course of 5 to 7 days, and test of cure was not always done, one can ask whether a more intensive and repetitive treatment regimen would not be indicated, but studies are lacking. Use of other antibiotics, aiming at *U urealyticum* and *C trachomatis*, like amoxicillin and erythromycin, have not been successful in the reduction of preterm birth or other infectionrelated complications in pregnancy (Andrews et al., 2003; Goldenberg et al., 2006; McGregor et al., 1990). Tempera et al tested local kanamycin for paitents with AV and performed a detailed analysis of the culture results, proving this may be a successful approach (Tempera et al., 2004). However, even though this antibiotic is not absorbed, tests in pregnancy with this and other similar products have not yet been done yet. Some local, non absorbable with antibiotics, like rifaximin, may have a special promise, due to favorable anti- inflammatory action reducing pro-inflammatory cytokine production as a surplus (Brown et al., 2010). As this has lead to high cure rates in inflammatory bowel diseases such as Crohn's disease, diverticulitis and colitis ulcerosa (Guslandi, 2010; Shafran & Burgunder, 2010; Latella & Scarpignato, 2009), and given the non-absorbable nature, studies exploring the potential of this antibiotic in the

treatment of vaginal flora disturbances could be interesting, also in pregnancy.

Finally, also the level of preterm threat may play a crucial role in the efficiency of the BV treatment. Women with BV who have contractions and other symptoms of preterm labor extend their gestation longer when treated for BV than when untreated, whereas asymptomatic women show no difference between treatment versus placebo (Stevens et al,

**7.5 Intrauterine growth restriction**

**8. Treatment 8.1 Antibiotics**

2004; Briery et al, 2011).

linked to fetal growth restriction (Vedmedovska et al., 2010b).

#### **7.3 Preterm birth**

In one study H Mc Donald et al. found an association between midtrimester vaginal colonization with *U urealyticum* and bacterial vaginosis (culture of *G vaginalis*) and preterm birth, but not with enteropathogens such as E coli and enterococci (McDonald et al., 1992), but in another study the same authors found such enteropathogens and *S. aureus* to be predictive for preterm birth before 37 and 34 weeks (McDonald et al., 1991). Others have consistently linked colonization of *U urealyticum* of *M hominis* with preterm labor, short cervix, intrauterine infection and preterm birth (Donders et al., E pub ahead of print 2010; Donati et al., 2010; Holst et al., 2006; Hassan et al., 2006). In studies addressing the different subtypes of abnormal vaginal flora, aerobic vaginitis, mixed flora, and partial bacterial vaginosis show a significant relation with preterm birth alongside bacterial vaginosis (Donders et al., E pub ahead of print 2010; Donders et al., 2009; Donati et al., 2010), the latter being more related to growth restriction. After analyzing their studies, Carey and Klebanoff came to the conclusion that rather than just anaerobic BV, overgrowth with *S. aureus* and *E. coli* were the only vaginal bacterial flora linked to preterm birth (Carey et al., 2005). By looking at the microscopic flora patterns as possible risk factors early in pregnancy, we and others came to exactly the same conclusions, namely that aerobic abnormal flora early in pregnancy constitutes a significant risk of preterm labor, chorioamnionitis and funisitis of the newborn (Donders et al., 2008a; Donders et al., 2009; Rezeberga et al., 2008). Our hypothesis is that this link of preterm birth risk with the presence of vaginal flora disturbances associated with overgrowth of aerobic commensal bacteria may be the main reason why treatment with the broader spectrum antibitiotic clindamycin is a better approach to reduce preterm birth and preterm rupture of the membranes than metronidazole, which eliminates only the anaerobes (Donders et al., 2009; Larsson et al., 2006; Lamont et al., 2003).

#### **7.4 Intrauterine infection**

This would also explain why the pro-inflammatory cytokines that are most closely linked to intrauterine infection and preterm labor, IL 6 and IL 8 are not produced in uncomplicated full BV, but are found in dramatic concentrations in AV (Donders, 2002) and explain the closer association with these cytokines with lactobacillary grades than with anaerobic BV (Donders et al., 2003). In a comprehensive review Roberto Romero and coworkers summarized their voluminous work showing the importance of intrauterine inflammation induced by ascending infection and causing periventricular leucomalacia and cerebral palsy (Romero et al., 2004). Furthermore he and others emphasized the role of genetic variations in polymorphisms creating different responses amongst women to intrauterine infectious challenges (Holst & Garnier, 2008). While it was known since a long time that anaerobic BV associated bacteria can frequently recovered from the uterine cavity in amniocentesis specimens of women with preterm labor (Martius & Eschenbach, 1990; Hitti et al., 2001; Rizzo et al., 1996; Newton et al., 1997; Krohn et al., 1995; Hillier et al., 1995; Newton, 1993; Gibbs, 1993), most cases of neonatal sepsis are not caused by these BV associated bacteria, but by aerobic bacteria, mainly group B streptococcus, *E. coli* and *S. aureus.* Only recently, for the first time, Rezeberga et al could demonstrate that AV at the first prenatal visit before 12 weeks, detected both clinically as on cultures, was related to an increased risk of chorioamnionitis and funisitis (Rezeberga et al., 2008). Neonatal sepsis, most with *S. aureus* , was also a frequent finding in growth restricted fetuses (Vedmedovska et al., 2010a).

#### **7.5 Intrauterine growth restriction**

While women with AV and inflammatory reaction are more likely to develop intrauterine infection, chorioamnionitis, funisitis (Rezeberga et al., 2008) and preterm delivery, the merely non-inflammatory bacterial vaginosis may rather cause growth restriction and preterm delivery of small for date fetuses (Rezeberga et al., 2008). Also in the work of Vedmedovska et al., it was found that genital infections, primarily bacterial vaginosis, was linked to fetal growth restriction (Vedmedovska et al., 2010b).

#### **8. Treatment**

236 Preterm Birth - Mother and Child

In one study H Mc Donald et al. found an association between midtrimester vaginal colonization with *U urealyticum* and bacterial vaginosis (culture of *G vaginalis*) and preterm birth, but not with enteropathogens such as E coli and enterococci (McDonald et al., 1992), but in another study the same authors found such enteropathogens and *S. aureus* to be predictive for preterm birth before 37 and 34 weeks (McDonald et al., 1991). Others have consistently linked colonization of *U urealyticum* of *M hominis* with preterm labor, short cervix, intrauterine infection and preterm birth (Donders et al., E pub ahead of print 2010; Donati et al., 2010; Holst et al., 2006; Hassan et al., 2006). In studies addressing the different subtypes of abnormal vaginal flora, aerobic vaginitis, mixed flora, and partial bacterial vaginosis show a significant relation with preterm birth alongside bacterial vaginosis (Donders et al., E pub ahead of print 2010; Donders et al., 2009; Donati et al., 2010), the latter being more related to growth restriction. After analyzing their studies, Carey and Klebanoff came to the conclusion that rather than just anaerobic BV, overgrowth with *S. aureus* and *E. coli* were the only vaginal bacterial flora linked to preterm birth (Carey et al., 2005). By looking at the microscopic flora patterns as possible risk factors early in pregnancy, we and others came to exactly the same conclusions, namely that aerobic abnormal flora early in pregnancy constitutes a significant risk of preterm labor, chorioamnionitis and funisitis of the newborn (Donders et al., 2008a; Donders et al., 2009; Rezeberga et al., 2008). Our hypothesis is that this link of preterm birth risk with the presence of vaginal flora disturbances associated with overgrowth of aerobic commensal bacteria may be the main reason why treatment with the broader spectrum antibitiotic clindamycin is a better approach to reduce preterm birth and preterm rupture of the membranes than metronidazole, which eliminates only the anaerobes (Donders et al., 2009; Larsson et al.,

This would also explain why the pro-inflammatory cytokines that are most closely linked to intrauterine infection and preterm labor, IL 6 and IL 8 are not produced in uncomplicated full BV, but are found in dramatic concentrations in AV (Donders, 2002) and explain the closer association with these cytokines with lactobacillary grades than with anaerobic BV (Donders et al., 2003). In a comprehensive review Roberto Romero and coworkers summarized their voluminous work showing the importance of intrauterine inflammation induced by ascending infection and causing periventricular leucomalacia and cerebral palsy (Romero et al., 2004). Furthermore he and others emphasized the role of genetic variations in polymorphisms creating different responses amongst women to intrauterine infectious challenges (Holst & Garnier, 2008). While it was known since a long time that anaerobic BV associated bacteria can frequently recovered from the uterine cavity in amniocentesis specimens of women with preterm labor (Martius & Eschenbach, 1990; Hitti et al., 2001; Rizzo et al., 1996; Newton et al., 1997; Krohn et al., 1995; Hillier et al., 1995; Newton, 1993; Gibbs, 1993), most cases of neonatal sepsis are not caused by these BV associated bacteria, but by aerobic bacteria, mainly group B streptococcus, *E. coli* and *S. aureus.* Only recently, for the first time, Rezeberga et al could demonstrate that AV at the first prenatal visit before 12 weeks, detected both clinically as on cultures, was related to an increased risk of chorioamnionitis and funisitis (Rezeberga et al., 2008). Neonatal sepsis, most with *S. aureus* ,

was also a frequent finding in growth restricted fetuses (Vedmedovska et al., 2010a).

**7.3 Preterm birth**

2006; Lamont et al., 2003).

**7.4 Intrauterine infection**

#### **8.1 Antibiotics**

It is not yet clear which should be the best approach to treat for AV in non-pregnant women, let alone during pregnancy. The inflammatory component of most patients with AV makes one think that antibiotics may not be the best, or not the only approach. But IF is chosen to give antibiotics in pregnancy to reduce preterm birth and intrauterine infection, it became clear after a placebo controlled studies that metronidazole is not the answer as it does not decrease the preterm birth rate in women with bacterial vaginosis (McDonald et al., 1997; McDonald et al., 2007; Carey et al., 2000; Odendaal et al., 2002). Even worse, Klebanoff's (Klebanoff et al., 2001) and Odendael's study (Odendaal et al., 2002) on the treatment of trichomoniasis and BV, respectively, rather demonstrated an increased risk of preterm birth after treatment with metronidazole, leading several authors to the compelling conclusion that metronidazole should not be used in pregnancy with the purpose to reduce the risk of preterm birth (Donders et al., 2009; Odendaal et al., 2002; Carey et al., 2003; Morency & Bujold, 2007). Investigators using broader spectrum antibiotics, also covering gram positive cocci and E coli, on the other hand, were successful in the reduction of preterm birth in several placebo controlled studies (Larsson et al., 2006; Lamont et al., 2003; Ugwumadu et al., 2003), although not all (Kekki et al., 2001; Kurkinen-Raty et al., 2000; Rosenstein et al., 2000). As most studies used a single treatment course of 5 to 7 days, and test of cure was not always done, one can ask whether a more intensive and repetitive treatment regimen would not be indicated, but studies are lacking.

Use of other antibiotics, aiming at *U urealyticum* and *C trachomatis*, like amoxicillin and erythromycin, have not been successful in the reduction of preterm birth or other infectionrelated complications in pregnancy (Andrews et al., 2003; Goldenberg et al., 2006; McGregor et al., 1990). Tempera et al tested local kanamycin for paitents with AV and performed a detailed analysis of the culture results, proving this may be a successful approach (Tempera et al., 2004). However, even though this antibiotic is not absorbed, tests in pregnancy with this and other similar products have not yet been done yet. Some local, non absorbable with antibiotics, like rifaximin, may have a special promise, due to favorable anti- inflammatory action reducing pro-inflammatory cytokine production as a surplus (Brown et al., 2010). As this has lead to high cure rates in inflammatory bowel diseases such as Crohn's disease, diverticulitis and colitis ulcerosa (Guslandi, 2010; Shafran & Burgunder, 2010; Latella & Scarpignato, 2009), and given the non-absorbable nature, studies exploring the potential of this antibiotic in the treatment of vaginal flora disturbances could be interesting, also in pregnancy.

Finally, also the level of preterm threat may play a crucial role in the efficiency of the BV treatment. Women with BV who have contractions and other symptoms of preterm labor extend their gestation longer when treated for BV than when untreated, whereas asymptomatic women show no difference between treatment versus placebo (Stevens et al, 2004; Briery et al, 2011).

Management of Abnormal Vaginal Flora as a Risk Factor for Preterm Birth 239

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1beta levels with specific IgA response against Gardnerella vaginalis cytolysin in

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enzymes, immunoglobulin A against Gardnerella vaginalis toxin, and risk of early preterm birth among women in preterm labor with bacterial vaginosis or

interleukin-8 with interleukin-1beta and neutrophils in vaginal fluid of healthy and

the hydrolytic enzymes sialidase and prolidase are positively associated with

polymerase chain reaction method for detection of Escherichia coli in amniotic fluid

bacterial vaginosis: ogling into the causes of unfulfilled child-wish. Arch Gynecol

syphilis with premature birth and low birthweight. Genitourin Med 1993; 69(2):98-

Lactobacillary Flora in Wet Mount and Fresh or Delayed Gram's Stain. Infect Dis

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preterm birth? Am J Obstet Gynecol 2005; 192(4):1341-1346.

intermediate flora. Am J Obstet Gynecol 2002; 187(4):877-881.

interleukin-1beta. Am J Obstet Gynecol 2008; 198(1):132-137.

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2000; 53(4):308-313.

101.

## **8.2 Antiseptics**

Only sporadic and older studies addressed the topic of using antiseptic medication with chlorhexidin, povidine iodine or chloramine as a preventive measure to prevent perinatal and maternal infectious complications in pregnancy, usually without any success (Watanabe et al., 1998; Rouse et al., 1997; Broe et al., 1992). Hence the therapy has been largely abandoned during pregnancy. A recent study shows a beneficial effect of dequalinium chloride vaginal tablets on BV that is comparable to treatment with intravaginal clindamycin, but the effect of this new disinfectant on AV is not known, and studies in pregnancy were not yet performed (Weisenbacher et al., 2011).

## **8.3 Probiotics**

Acidifying or probiotic therapy has also sporadically been tested for women with AVF or BV in pregnancy, but not specifically for AV. In 1990, Holst et al reported a clear benefit of using acidifying cream for BV in a small group of women during pregnancy (Holst & Brandberg, 1990), but this paper was never followed by larger series. A Cochrane review of all randomized trial using probiotics indicated a clear reduction of vaginal infection after the use of oral or vaginal lactobacillus acidophilus containing milk products or yogurt, but data on the outcome of pregnancy were lacking (Othman et al., 2007).

## **9. References**

Only sporadic and older studies addressed the topic of using antiseptic medication with chlorhexidin, povidine iodine or chloramine as a preventive measure to prevent perinatal and maternal infectious complications in pregnancy, usually without any success (Watanabe et al., 1998; Rouse et al., 1997; Broe et al., 1992). Hence the therapy has been largely abandoned during pregnancy. A recent study shows a beneficial effect of dequalinium chloride vaginal tablets on BV that is comparable to treatment with intravaginal clindamycin, but the effect of this new disinfectant on AV is not known, and studies in

Acidifying or probiotic therapy has also sporadically been tested for women with AVF or BV in pregnancy, but not specifically for AV. In 1990, Holst et al reported a clear benefit of using acidifying cream for BV in a small group of women during pregnancy (Holst & Brandberg, 1990), but this paper was never followed by larger series. A Cochrane review of all randomized trial using probiotics indicated a clear reduction of vaginal infection after the use of oral or vaginal lactobacillus acidophilus containing milk products or yogurt, but data

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**8.3 Probiotics**

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**11**

*Germany*

**Strategies in the Prevention of**

*1Forschung, Beratung + Evaluation GmbH c/o Charité, Berlin,*

*2Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Munich,*

Preterm birth – defined as a childbirth before 259 days of gestation (<37 weeks) – is the major challenge in obstetrics and gynaecology worldwide. Preterm birth is associated with high perinatal mortality and surviving children often suffer higher morbidity throughout their lives. The incidence of preterm birth is very high in developing countries but also in some developed countries. According to a worldwide WHO report, Africa and North America, with rates of 11.9% and 10.6% in 2005, are the regions with the highest rates of incidence (Beck et al., 2010). Preterm birth not only causes much harm but also is associated with high costs. Despite considerable technical and medical improvements in obstetrics over recent decades, in developed countries preterm birth rates are not decreasing. On the contrary, the incidence continues to increase. In relation to possible preventive and epidemiologically well-founded measures, although onset and aetiology are not completely understood, our epidemiological knowledge concerning risk and protective factors of preterm birth is in no way poor. As regards preventive approaches, a distinction has to be made between primary and secondary preventive interventions, with this chapter focusing

After presenting some epidemiological and economic data on preterm birth, we will summarise the scope and results of certain programmes aiming to prevent preterm births. Subsequently, we will introduce the framework and methods of our prevention programme BabyCare. Special attention will be given to the evaluative methods and results achieved by our programme in terms of effectiveness and efficiency. While we can register a considerable and stable reduction in the incidence of preterm birth by at least 25% when comparing participants in the programme with a control data set, epidemiological analysis of our data indicates further that certain persistent risk factors of preterm birth observed in relation to programme participants require additional preventive measures which, ideally, should be implemented at the pre-conceptual stage. Consequently, after releasing the BabyCare Program in 2000, the PlanBaby Program was launched in 2007. In conclusion, interventional as well as evaluative problems and limitations of our programmes will be

**1. Introduction**

on the former.

discussed.

**Preterm Births During**

**and Before Pregnancy**

Wolf Kirschner1 and Klaus Friese2

## **Strategies in the Prevention of Preterm Births During and Before Pregnancy**

 Wolf Kirschner1 and Klaus Friese2 *1Forschung, Beratung + Evaluation GmbH c/o Charité, Berlin, 2Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Munich, Germany*

## **1. Introduction**

244 Preterm Birth - Mother and Child

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Verstraelen H, Verhelst R, Roelens K, Claeys G, Weyers S, De BE et al. Modified

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Treatment of Bacterial Vaginosis. Gynecol Obstet Invest, 2011, in press Wilson JD, Ralph SG, Rutherford AJ. Rates of bacterial vaginosis in women undergoing in

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disinfection on duration of gestation after premature rupture of the membranes

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vitro fertilisation for different types of infertility. BJOG 2002; Dec 23, e-pub ahead

Factors related to elevated vaginal pH in the first trimester of pregnancy. Acta

Preterm birth – defined as a childbirth before 259 days of gestation (<37 weeks) – is the major challenge in obstetrics and gynaecology worldwide. Preterm birth is associated with high perinatal mortality and surviving children often suffer higher morbidity throughout their lives. The incidence of preterm birth is very high in developing countries but also in some developed countries. According to a worldwide WHO report, Africa and North America, with rates of 11.9% and 10.6% in 2005, are the regions with the highest rates of incidence (Beck et al., 2010). Preterm birth not only causes much harm but also is associated with high costs. Despite considerable technical and medical improvements in obstetrics over recent decades, in developed countries preterm birth rates are not decreasing. On the contrary, the incidence continues to increase. In relation to possible preventive and epidemiologically well-founded measures, although onset and aetiology are not completely understood, our epidemiological knowledge concerning risk and protective factors of preterm birth is in no way poor. As regards preventive approaches, a distinction has to be made between primary and secondary preventive interventions, with this chapter focusing on the former.

After presenting some epidemiological and economic data on preterm birth, we will summarise the scope and results of certain programmes aiming to prevent preterm births. Subsequently, we will introduce the framework and methods of our prevention programme BabyCare. Special attention will be given to the evaluative methods and results achieved by our programme in terms of effectiveness and efficiency. While we can register a considerable and stable reduction in the incidence of preterm birth by at least 25% when comparing participants in the programme with a control data set, epidemiological analysis of our data indicates further that certain persistent risk factors of preterm birth observed in relation to programme participants require additional preventive measures which, ideally, should be implemented at the pre-conceptual stage. Consequently, after releasing the BabyCare Program in 2000, the PlanBaby Program was launched in 2007. In conclusion, interventional as well as evaluative problems and limitations of our programmes will be discussed.

Strategies in the Prevention of Preterm Births During and Before Pregnancy 247

In the German region of Lower Saxony, we can observe an increase from 7.0% in 1987 to 8.5% in 2009. Again, here, a slight reduction can be seen since 2002. The increased rate can be attributed to the increased age of primiparous women, increased prevalence of risk factors (e.g. smoking, abnormal body weight), iatrogenic effects resulting from saving very preterm infants and fertilisation methods which contribute to preterm birth through a higher incidence of multiple pregnancies. In Germany, at least, the decline in rates may be traced back to the restriction imposed in 2004 on the reimbursement of fertilisation costs which led to a strong reduction of fertility treatments (DIR- Deutsches IVF-Register,

Fig. 2. Incidence of preterm birth in Germany (Lower Saxony) 1987-2009 (Birth events)

A comparison of preterm birth rates between Europe and North America reveals considerable differences in the incidence of preterm birth. The highest rates are found in the USA, Austria, Germany and Hungary while Ireland and Finland have very low rates (EURO-PERISTAT project, 2008). These differences are probably associated with different risk constellations in the populations (see below), but also differences in the frequency of sonographic determination of gestational age cannot be ruled out completely. "This indicator is defined as the number of live births and fetal deaths at each completed week of gestation (starting from 22 weeks), expressed as a proportion of all live and stillbirths. In most countries, data on gestational age is based on the "best obstetrical estimate", which combines clinical and ultrasound data, but some countries favour use of last menstrual period and others use only ultrasound estimates. There are also differences within countries. The method of determining gestational age can influence the gestational age distribution; use of ultrasound estimates tends to shift the distribution to the left and increase the preterm birth rate, although not all studies have found

In addition to the variation in the preterm birth rate between countries, we must also note significant differences within an individual country. For example, in the German region of North Rhine-Westphalia, we can observe variations between municipalities with rates ranging from 9% to 14%, linked to socio-economic differences in the population, and with

Jahresbericht 2009, Annual Report English Version 2009).

(Perinatal Data from Medical association of Lower Saxony)

that this is the case". (European Perinatal Health Report, p. 129)