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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1411-1416

Screening for bacterial vaginosis before and after intrauterine device insertion


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Microbiology and Immunology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
3 Depertment of Obstetrics and Gynecology at Ministry of Health, Berket El Saba, Menoufia, Egypt

Date of Submission27-Dec-2018
Date of Decision16-Jan-2019
Date of Acceptance26-Jan-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Asmaa N Hasan
Berket El Saba, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_414_18

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  Abstract 


Objective
To screen for bacterial vaginosis (BV) before and after insertion of intrauterine device (IUD), screen for complications of IUD, and evaluate the relation between BV and complication of IUD.
Background
IUD is one of the most prevalent and effective reversible methods of contraception worldwide. Users of the IUD may be at increased risk for BV, pelvic inflammatory diseases, and other complications.
Patients and methods
An observational cohort study was done for 147 women who came for IUD insertion. Complete history was taken, questionnaire was filled out, and vaginal swabs were taken from the posterior vaginal fornix before insertion of IUD and at 1 and 2 months after insertion of IUD. Complications of IUD were recorded. BV was diagnosed using Amsel's criteria and Nugent scoring methods.
Results
The prevalence of BV was 27.2% before IUD insertion and 9.5% after insertion (fresh diagnosis) at 1 month. The commonest complications of IUD were pelvic pain, vaginal bleeding, followed by abnormal vaginal discharge and dyspareunia. These complications were significantly higher in Gram stain-positive group than Gram stain-negative group.
Conclusion
The prevalence of BV is within the range of BV found among women of reproductive age group worldwide. The current standard of care does not require screening for BV before IUD insertion. The complication rate appeared significantly higher in patients with BV than those without.

Keywords: bacterial vaginosis, clue cell, complications, intrauterine devices, Nugent's method, screening


How to cite this article:
Abd El-Hamid AN, Sayyed TM, Salem EH, Hasan AN. Screening for bacterial vaginosis before and after intrauterine device insertion. Menoufia Med J 2019;32:1411-6

How to cite this URL:
Abd El-Hamid AN, Sayyed TM, Salem EH, Hasan AN. Screening for bacterial vaginosis before and after intrauterine device insertion. Menoufia Med J [serial online] 2019 [cited 2020 Feb 16];32:1411-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1411/274275




  Introduction Top


The insertion of intrauterine devices (IUD) is one of the most prevalent and effective reversible methods of contraception worldwide, and millions of IUDs are inserted yearly. There are concerns about increased risk of pelvic inflammatory disease (PID) and subsequent complications such as infertility and ectopic pregnancy among the IUD users [1]. Scanning by electron microscopy was used to study the surfaces of IUDs and showed highly organized and often densely packed microcolonies of bacteria, a reflection of the possibility that the majority of these bacteria had been present on these surfaces for a long time, and this increases host susceptibility to infection, thus increasing the incidence of PID infections [2]. Bacterial vaginosis (BV) is a disease of the vagina caused by excessive growth of bacteria [3],[4]. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urination may occur. Itching is uncommon [3]. Occasionally, there may be no symptoms. Having BV approximately doubles the risk of infection by a number of other sexually transmitted infections, including HIV/AIDS [5],[6]. It also increases the risk of early delivery among pregnant women [7]. Imbalance of the naturally occurring bacteria in the vagina is the main cause for development of BV [8]. There is a change in the most common type of bacteria and a hundred- to thousand-fold increases in total numbers of bacteria present [3]. Typically, bacteria other than Lactobacilli become more common [9]. Risk factors include douching, new or multiple sex partners, antibiotics, and using an IUD, among others are the main ones. However, it is not considered a sexually transmitted infection [3]. According to the recommendation of the United States Centers for Disease Control and Prevention, treatment is recommended for women who develop symptoms [10]. The significance of BV is in its gynecologic complications, including cervicitis, postoperative infections, and PID (endometritis, salpingitis, and oophoritis with or without tubo-ovarian abscess), which is caused by the migration of Gardnerella vaginalis into the upper genital tract especially in the presence of IUD [11]. According to the WHO, the risk (PID) is highest within the first 20 days following insertion (1–10/1000 women) and then decreases to baseline (1.4/1000 women). Few studies are available on the importance of screening and possibly treating a symptomatic patient with BV before the procedure; therefore, this study was done.


  Patients and Methods Top


An observational cohort study was done for 147 women who came for IUD insertion. Complete history and questionnaire filling was done, and vaginal swabs were taken from the posterior vaginal fornix before insertion of IUD and at 1 and 2 months after insertion of IUD. History of complication of IUD was taken. Vaginal swabs were stained by Gram stain and examined using a light microscope under oil-immersion lens. All participants were volunteers. All of them signed a written informed consent with explaining the aim of study before the study initiation. Approval was obtained from Ethical Committee in Faculty of Medicine, Menoufia University. The sampling methods were based on past review of literature [12] that reported the prevalence of BV after IUD insertion to be 11.5%. The sample size had been calculated at 80% power and confidence interval of 9%, and it was estimated to be 146 women. The inclusions criteria included women who were able to provide informed consent and with age range of 18–48 years. The exclusion criteria included women with previous history of ectopic pregnancy, active PID, immunocompromised state and medical disorders (diabetes and anemia), presence of risk factors for BV (douching, smoking, and multiple sexual partners), clinical features of BV, and using of antibiotics 4 weeks before IUD insertion and within 1 month of IUD insertion.

Three vaginal swabs were taken from each participant from the posterior vaginal fornix before insertion of IUD and at 1 and 2 months after insertion of IUD for detection of BV.

During the first visit, at the time of IUD insertion, complete history taking was done including personal history (name, age, weight, address, education level, and occupation), medical history [diabetes, anemia, presence of PID, and genital tract infection, abnormal vaginal discharge (color), unpleasant vaginal odor, itching, and dyspareunia], and past history (previous attacks of PID 'number and type of treatment taken'). Moreover, each participant filled out a questionnaire detailing demographics, symptoms of BV, first episode of BV, recurrent episode of BV (known by its common symptoms, which usually include increased vaginal discharge white or gray in color and smells like fish), and possible prevention and treatment options.

During the second and the third visit, at 1 and 2 months after insertion of IUD, a history of complication of IUD was taken. It includes pelvic pain (mild, moderate or severe), fever more than 38, heavy vaginal bleeding, expulsion of IUD, abnormal vaginal discharge (color and odor), itching, and dyspareunia.

Vaginal swab for a Gram stain was repeated at this visit. The obtained results were recorded as BV positive or negative. Participants with positive first vaginal swab results were treated and followed up for detection of resistant cases of BV.

The BV score for Gram staining was calculated by Nugent's method. The individual scores for each of the three morphotypes of bacteria, that is, Lactobacilli spp., G.vaginalis, and anaerobic Gram-negative rods Mobiluncus spp., correspondingly, were added together to obtain the total score. The final BV score was described as 1–3 'normal vaginal flora', 4–6 'intermediate', and 7–10 'indicative of BV', as shown in [Table 1]. Diagnosis of BV was done also by Amsel's criteria which consisted of four important criteria: (a) foul-smelling discharge, (b) detection of 'clue cell', which are epithelial cells coated with Gram variable coccobacilli of G. vaginalis in vaginal or cervical swabs, (c) positive 'whiff' test, and (d) vaginal pH more than 4.5 [13].
Table 1: Nugent scoring criteria for the microscopic diagnosis of bacterial vaginitis

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Data analysis was carried out using statistical package for the social sciences (SPSS Inc., Chicago, Illinois, USA) program for statistical analysis.

Data were entered as numerical or categorical, as appropriate.

Two types of statistics were performed:

Descriptive statistics

  1. Quantitative data were shown as mean, SD, minimum, and maximum
  2. Quantitative data were expressed as frequency and percent.


Analytical statistics

χ2-Test and Fisher exact test were used to measure association between qualitative variables as appropriate.

P value was considered to be of statistical significance if it is less than 0.05.


  Results Top


The age of the studied group ranged between 18 and 47 years, with mean ± SD of 31.1 ± 7.5 years. Weight ranged from 57 to 85 kg, with mean ± SD of 70.45 ± 6.8 kg. The majority of the studied group had secondary and university education, with 33.3 and 34%, respectively, whereas a small percentage had primary education, with 2.7%. Most of the studied groups were unemployed (83.6%), whereas students and part-a time employee constituted a small percent, with 1.4% for both. Overall, 36.7% of the studied group had previous BV, whereas 63.3% of them did not have previous BV [Table 2]. None of the basic demographic features (age, weight, educational level, occupation, parity, or previous BV) were independent predictor for BV before and after IUD insertion (P > 0.05).
Table 2: Demographic data of the studied group

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The swab result of the first visit before IUD insertion was as follows: 27.2% of samples were positive by Gram stain, whereas 72.8% were negative by Gram stain. The Nugent score of the first swab ranged from 0 to 10, with mean ± SD of 3.44 ± 3.11. In the second visit, 1 month after IUD insertion, 35.4% of the studied group showed positivity by Gram stain (9.5% as new positive and 25.9% being positive from the first swab). In the third visit 2 month after IUD insertion, 8.2% of the studied group still showed positivity by Gram stain [Table 3].
Table 3: Swab result of the first, second, and third visits

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Complications of IUD in the form of pelvic pain, abnormal vaginal discharge, and dyspareunia were significantly higher in the first and second positive Gram stain groups than the negative Gram stain group in the second and third visits (P < 0.001), whereas other complications (fever, vaginal bleeding, and itching) were comparable (P > 0.05; [Table 4]).
Table 4: Relation between the first and second Gram stain results and the second visit complications

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  Discussion Top


This study was carried out on 147 women who attended the healthcare center asking for IUD insertion at the Family Planning Clinic of the Department of Obstetrics and Gynecology of Berket El Sabea Hospital. In the present study, no baseline characteristics (occupation, number of children and family setting) appeared to be significant predictors of BV. This was in agreement with Madden et al. [14] who found these baseline characteristics to be not significant predictors of BV. However, these results disagree with Akinajo et al. [12] who found that some baseline characteristics (occupation, number of children, and family setting) appear to be significant predictors of BV.

This study showed the prevalence of BV among women who opted for IUD to be 27.2% (pre-IUD insertion) with the incidence (fresh diagnosis) of 9.5% (post-IUD insertion). This prevalence rate is within the range that was found among women of reproductive age group worldwide, which was reported to range from 11 to 48%. This study showed the prevalence of BV in a typical population of sexually active, reproductive-aged women in a stable relationship [15]. This correlated with Akinajo et al. [12] who showed the prevalence of BV among women who opted for IUD in Ibadan to be 33.3% (pre-IUD insertion), with the incidence (fresh diagnosis) of 11.5% (post-IUD insertion).

In this study, 9.5% of the respondents developed a change in vaginal flora from BV negative to BV positive following IUD insertion, which supports the hypothesis that IUD might somehow contribute to a change in the vaginal flora in favor of BV-associated organisms [12].

In this study, 27.2% of the samples were positive by Gram stain, whereas 72.8% were negative by Gram stain before IUD insertion. In the second visit 1 month after IUD insertion, 35.4% of the studied group were positive by Gram stain (9.5% as new positive and 25.9% being positive from the first swab). This was in agreement with Joesoef et al. [16] and Madden et al. [14] who found the prevalence of BV was associated with the use of IUD. On the contrary, Neale et al. [17] performed vaginal smears before and after IUD insertion and found that BV was lower after IUD insertion than before IUD insertion.

In this study, 8.2% of the studied group patients after treatment uptake were still positive by Gram stain in the third swab in the third visit 2 months after IUD insertion, which was lower than that of the second swab, with statistically significant difference. This was in agreement with Neale et al. [17], who performed serial vaginal smears before and after IUD insertion and found that BV was improved after treatment, as well as Klebanof et al. [18], who suggested spontaneous remission of BV. However, Lessard et al. [19] and Watcharotone et al. [20] found that BV prevalence increased as the IUD might change cervicovaginal environment and suggested that women with IUD may be at a higher risk for BV.

The commonest complications in the second visit were pelvic pain, then vaginal bleeding, followed by abnormal vaginal discharge, and then dyspareunia, whereas the least complications were itching and displacement of the IUD. Fever did not occur in any patient. Overall, 61.9% of the cases did not receive any treatment; however, the commonest drug used was metronidazole. This result was nearer to the results found by Agarwal et al. [21], who found the main complications were vaginal discharge, abdominal pain, bleeding, and dyspareunia. This disagrees with Ferraz et al. [22], who found that the main complication was dysmenorrhea.

Compared with the second visit (1 month after IUD insertion), distribution of complication changed in the third visit (2 months after IUD insertion). Pelvic pain became of mild form only, and its percentage became significantly lower than the second visit (2% in third visit vs. 23.1% in the second one). The other complications decreased significantly in the third visit.

Similar to the second visit, in the third visit, most cases did not receive any treatment, whereas the commonest drug used was metronidazole.

In this study, pelvic pain, abnormal vaginal discharge, and dyspareunia in the second visit were higher in patients who were BV positive when compared with those who were BV negative, with statistically significant difference; however, the other complications were comparable. This result was in correlation with Akinajo et al. [12] who found the rate of complications (heavy vaginal bleeding, fever, sever pelvic pain, and IUD expulsion) was higher in patients who were BV positive when compared with those who were BV negative, but without statistical significant difference. On the contrary, Pham et al. [23] found that significant clinical complications occurred in patients who were BV negative.

In the third visit, the same complications were higher in the second swab-positive Gram stain group than the negative Gram stain group (in patients who were BV positive when compared with those who were BV negative) with statistically significant difference, whereas other complications were comparable.


  Conclusion Top


The prevalence rate of BV is within the range that was found among women of reproductive age group worldwide, which was reported to range from 11 to 48%. Complications of IUD mainly pelvic pain, vaginal bleeding, abnormal vaginal discharge, and dyspareunia were significantly higher in patients with BV than without BV. Further studies with a longer duration of follow-up are needed to investigate whether this association persists overtime. The current standard of care does not require screening for BV before IUD insertion. However, screening and treatment before IUD insertion must be offered to all users who are symptomatic to prevent complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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