Vaginal washing behaviour and fecundability among Kenyan women in a prospective preconception cohort.

BACKGROUND: Intravaginal washing, practised by a significant proportion of women globally, is associated with acquisition of human immunodeficiency virus (HIV), sexually transmitted infections and bacterial vaginosis (BV). A single prior study among women in the United States found that vaginal washing was associated with lower fecundability. OBJECTIVE: To examine the association between vaginal washing and fecundability among Kenyan women. METHODS: HIV-negative Kenyan women who were trying to conceive and reported no history of infertility care-seeking were followed prospectively for incident pregnancy for up to six months. At monthly visits, participants reported the first day of last menstrual period, sexual behaviour, vaginal washing behaviour, underwent pregnancy testing and provided vaginal swabs for detection of BV by Gram stain (Nugent score ≥7). Discrete time proportional probability models were used to estimate fecundability ratio (FR) and 95% confidence interval (CI) comparing menstrual cycles when women reported vaginal washing to menstrual cycles when no vaginal washing was reported. RESULTS: Four hundred and fifty-eight women contributed 1,376 menstrual cycles and 255 pregnancies. At enrolment, a third (35.2%, 161 of 458) of participants reported vaginal washing with the majority using water only (73.9%, 119 of 161). After adjustment for age, frequency of unprotected intercourse and study site, vaginal washing in the prior four weeks was associated with a 29% lower fecundability (adjusted FR [aFR] 0.71, 95% CI 0.53, 0.94), which did not change after further adjustment for BV at the visit prior to each pregnancy test (aFR 0.71, 95% CI 0.54, 0.95). CONCLUSIONS: Periconceptual vaginal washing may reduce fecundability. Potential mechanisms include vaginal washing-associated changes in the vaginal microbiota, inflammation, disruption of cervical mucus and effects on sperm function. Vaginal washing has no known health benefits, and cessation may improve women's likelihood of conceiving.

Association between vaginal washing and detection of Lactobacillus by culture and quantitative PCR in HIV-seronegative Kenyan women: a cross-sectional analysis.

OBJECTIVES: Vaginal washing has been associated with reductions in cultivable Lactobacillus and an increased risk of both bacterial vaginosis (BV) and HIV infection. The effect of vaginal washing on the quantity of individual Lactobacillus species is not well characterised. This analysis tested the hypothesis that vaginal washing would be associated with a lower likelihood of Lactobacillus spp. detected by both culture and quantitative PCR (qPCR). METHODS: We conducted a cross-sectional study of 272 HIV-seronegative women enrolled in an open-cohort study in Mombasa, Kenya. Vaginal washing and sexual risk behaviours were assessed using face-to-face interviews. Vaginal Lactobacillus spp. were detected using cultivation and PCR methods, with L. crispatus, L. jensenii and L. iners concentrations measured using qPCR assays targeting the 16S rRNA gene. Poisson regression with robust SEs was used to assess associations between vaginal washing and Lactobacillus detection by culture and qPCR. RESULTS: Eighty percent (n=217) of participants reported vaginal washing in the prior week. One-fifth (n=58) of participants had BV by Nugent score. In unadjusted analysis, vaginal washing was associated with a 45% decreased likelihood of Lactobacillus spp. detection by culture (prevalence ratio (PR): 0.55, 95% CI 0.37 to 0.82). Adjusting for age and condomless sex in the prior week did not change the magnitude of the association (adjusted PR (aPR): 0.56, 95% CI (0.37 to 0.85). Vaginal washing was associated with approximately a 40% reduction in L. crispatus detection (aPR: 0.57, 95% CI 0.36 to 0.92), but was not significantly associated with L. jensenii (aPR: 0.68, 95% CI 0.42 to 1.09) or L. iners detection (aPR: 1.03, 95% CI 0.92 to 1.15). CONCLUSIONS: Vaginal washing in the prior week was associated with a significantly reduced likelihood of detecting cultivable Lactobacillus and L. crispatus by qPCR. Given associations between Lactobacillus detection and improved reproductive health outcomes, these results provide motivation for additional study of vaginal washing cessation interventions to improve vaginal health.

Effect of vaginal washing before intravaginal dinoprostone insertion for labor induction: A randomized clinical trial.

AIM: Prostaglandins have a dual action of cervical ripening and induction of uterine contraction. This study was designed to compare the effectiveness of vaginal washing just before insertion of intravaginal dinoprostone. METHODS: A randomized controlled trial was conducted at the Zeynep Kamil Women and Children's Health Training and Research Hospital. One hundred and ninety-one women with singleton, term pregnancy who underwent labor induction were randomly assigned to two groups: Group 1 consisted of 95 pregnant women with vaginal washing before intravaginal dinoprostone (Propess system for slow release system of 10 mg of dinoprostone) insertion (study group), and 96 pregnant women constituted the control group who did not undergo vaginal washing before intravaginal dinoprostone insertion. A parallel randomized controlled trial was conducted with an allocation ratio of 1:1 to compare the effectiveness of vaginal washing before intravaginal dinoprostone insertion. RESULTS: The groups had similar mean age, body mass index, gestational age, gravidity, parity and Bishop score before agent insertion (P > 0.05). Duration of dinoprostone kept intravaginally, duration from the beginning of dinoprostone insert vaginally to the active phase of labor and duration from the time of intravaginal dinoprostone insertion to delivery were significantly longer in the control group (P < 0.05). Uterine hyperstimulation rate was significantly higher in study group compared to control group (P < 0.05). Meconium passage, fetal infection and neonatal intensive care unit admission were significantly higher in the control group (P < 0.05). CONCLUSION: Vaginal washing before intravaginal dinoprostone insertion may increase Prostaglandin E2 bioavailability as we found shorter duration and better outcome of labor induction in the present study.

Aspartate aminotransferase and free thyroid hormones in vaginal washing fluid as markers for preterm pre-labor rupture of membranes.

AIM: To evaluate the diagnostic value of vaginal fluid aspartate aminotransferase (AST), free triiodothyronine (T3) and free thyroxine (T4 ) in women with preterm pre-labor rupture of membranes (PPROM). METHODS: A case-control study was carried out of 100 women: 50 with PPROM (study group) and 50 age-, gestational age- and weight-matched women with intact membranes (control group). All women underwent sterile speculum vaginal examination. The vaginal posterior fornix was irrigated and the retrieved fluid was sent for AST, free T3 and free T4 assays. RESULTS: Median vaginal fluid free T3, free T4 and AST were significantly higher in the PPROM group compared with the control group, with vaginal fluid free T4 having the largest area under the curve on receiver operating characteristic curve analysis (P<0.001). Sensitivity, specificity, positive and negative predictive values for free T3 (cut-off, 1.06 pg/mL) were 88%, 70%, 74.6% and 85.4%, respectively, while those for free T4 (cut-off 0.063 ng/dL) were 86%, 72%, 75.4% and 83.7%, and those for AST (4.5 IU/L) were 56%, 70%, 65.1% and 61.4%, respectively. Vaginal fluid AST had less diagnostic accuracy when compared with either free T3 or free T4. CONCLUSIONS: Vaginal fluid AST, free T3 and free T4 seem to be useful and simple markers in diagnosis of PPROM.

Prolidase, matrix metalloproteinases 1 and 13 activity, oxidative-antioxidative status as a marker of preterm premature rupture of membranes and chorioamnionitis in maternal vaginal washing fluids.

OBJECTIVE: Etiology of premature preterm rupture of membranes (PPROM) is not yet completely known and chorioamnionitis is one of the most important complications of its. We aimed to evaluate whether prolidase, matrix metalloproteinases, oxidative-antioxidative status, and inflammation markers in vaginal washing fluid (VWF) were associated with etiology of PPROM and whether these markers could be used to predict chorioamnionitis in PPROM. STUDY DESIGN: This prospective case control study enrolled fifty pregnant women with PPROM and 50 healthy pregnant women. The VWF samples were taken at the time of admission in the PPROM group and patients were followed for chorioamnionitis. Prolidase, matrix metalloproteinases, oxidative-antioxidative status, and inflammation markers in VWF were assayed. RESULTS: VWF levels of prolidase, matrix metalloproteinases 1-13 (p< 0.001), oxidative stress parameters, total oxidative stress (TOS) (p < 0.001) and oxidative stress index (OSI) (p = 0.002), and hs-CRP (p = 0.045) were significantly higher in the PPROM group than in the controls. Antioxidative status parameters, levels of paroxanase (PON-1) (p < 0.001) and total antioxidant capacity (TAC) (p < 0.001), were significantly lower in the PPROM group than in the controls. Mean VWF levels of prolidase (p < 0.001), metalloproteinases (p<0.05), and oxidative-antioxidative status parameters (p<0.05) were significantly different in women with versus women without chorioamnionitis in the PPROM group. Prolidase, MMP-13, TOS, TAC, and PON-1 were found as important predictors for chorioamnionitis in the PPROM group by the multivariate logistic regression analysis. When the ROC curve analysis for prolidase, MMP-13, TOS, TAC, and PON-1 were performed, all of them were statistically significant for area under the curve (areas under the curve were 0.94, 0.90, 0.80, 0.25, and 0.19, respectively). CONCLUSIONS: This study showed that collagen turnover mediators, especially prolidase, and increased oxidative stress are significantly associated with PPROM. Also, chorioamnionitis can be predicted with prolidase, MMP-13, TOS, TAC, and PON-1 in PPROM patients.

Effect of vaginal washing before Misoprostol insertion on cervical ripening before induction of labor: A randomized single-blind clinical trial.

BACKGROUND: Vaginal pH is acidic in pregnancy, but there is no information about pH changes in pregnancy, and contradictory results have been reported from the effectiveness of Misoprostol at different vaginal pH. This study aimed to evaluate the effect of vaginal washing before Misoprostol insertion on cervical ripening before induction of labor in comparison with the control group. METHODS: This randomized single-blind clinical trial was performed on 148 pregnant women who were candidates for induction of labor. Subjects were randomly divided into two groups of intervention (vaginal washing with 20 cc of normal saline 0.9% before Misoprostol insertion) and the control group (without vaginal washing). Vaginal pH and Bishop scores were measured before and after the intervention. The two groups were compared in demographic-obstetric variables, the success rate of induction of labor, maternal and neonatal outcomes, and Misoprostol dose. RESULTS: After the intervention, there was no statistically significant difference between the pH before and after in the group with vaginal washing. There was no significant difference between the two groups in the type and duration of labor, and maternal and neonatal outcomes (P > .05). The frequency of normal delivery less than 12 hours in the intervention group was higher than in the control group. Although this difference was not statistically significant due to the small number of subjects, it is clinically significant. CONCLUSION: The results of the present study showed that vaginal washing with normal saline before Misoprostol insertion for induction of labor did not affect the success of induction and duration of labor.

Diagnosis of premature rupture of membranes by assessment of urea and creatinine in vaginal washing fluid.

BACKGROUND: Rupture of fetal membranes can occur at any gestational age. Premature rupture of membranes (PROM) means rupture of fetal membranes before the onset of labor. OBJECTIVE: The purpose of this study was to evaluate and compare the reliability of the vaginal washing fluid urea and creatinine for the diagnosis of PROM and to determine cut-off values. MATERIALS AND METHODS: A total of 179 pregnant women were recruited. All patients underwent different examinations. These included nitrazine paper test, fern test, amniotic fluid pooling, vaginal washing fluid urea and creatinine sampling. The one group consisted of 126 pregnant women between 14 and 41 weeks of gestation with the complaint of vaginal fluid leakage. Patients who had positive pooling, nitrazine paper test and fern test were considered as confirmed PROM group (group 1). On the other side, patients with pooling (-) and/or nitrazine paper test (-) and/or fern test (-) were taken as suspected unconfirmed PROM cases (group 2). The control group consisted of 53 pregnant women between 14 and 41 weeks of gestation without any complaint or complication. Weconducted one-way ANOVA test on the urea and creatinine measures and post-hoc comparison test. Cut-off value was determined by receiver operating characteristic (ROC) curve. RESULTS: Vaginal fluid concentrations of urea and creatinine were significantly different between the three groups (p<0.001). The sensitivity, specificity, positive and negative predictive values and accuracy were all 100% in detecting premature rupture of membranes by evaluation of vaginal fluid creatinine concentration with a cut-off value of 0.45 mg/dl, respectively. CONCLUSION: This study demonstrates that of two markers investigated creatinine has the higher diagnostic power.

The diagnostic power of cervico-vaginal fluid prolactin in the diagnosis of premature rupture of membranes.

BACKGROUND: Premature rupture of membranes (PROM) is one of the most common complications of pregnancy that has a major impact on pregnancy outcomes. A diagnostic tool that is non-invasive, specific and quick is needed to predict PROM. The purpose of this study was to evaluate the diagnostic power of the vaginal washing fluid prolactin for the diagnosis of premature rupture of membranes and to determine cut-off values. METHODS: A total of 114 pregnant women were recruited in this diagnostic trial. The PROM group consisted of 54 pregnant women between 20 and 41 weeks of gestation with diagnosis of confirmed PROM [amniotic fluid pooling (+) and Nitrazine paper test (+) and fernt test (+)]. The control group consisted of 60 pregnant women between 20 and 41 weeks of gestation without any complaint or complication. All patients underwent speculum examination for amniotic fluid pooling, nitrazine paper test, fern test, vaginal washing fluid prolactin sampling. RESULTS: Vaginal fluid concentrations of prolactin was significantly different between the two groups (P < 0.001). The sensitivity, specificity, positive and negative predictive values and accuracy were 87.03%, 75.0%, 75.80%, 86.53% and 83.33% in detecting PROM by evaluation of vaginal fluid prolactin concentration with a cut-off value of 9.50 µIU/ml, respectively. CONCLUSIONS: The prolactin levels in the washing fluid of the posterior vaginal fornix in our experience is reliable and non-invasive diagnostic tests of PROM.