The expert clarifies the doubts of future mothers.

When the vaginal swab test shows the presence of one or both types of Ureaplasma and, perhaps, also Mycoplasma, expectant mothers ask themselves many questions. Here are the answers from a specialist with great experience in infectious diseases in obstetrics.

It means that they naturally belong to the so-called microbiota, once defined as the vaginal ecosystem or bacterial flora.

Within this ecosystem, they normally do not cause any problems. But not only that: if present in low concentrations, they contribute with all the other agents of the bacterial flora to protect the vagina from infections.

However, in some cases, they can dominate others, leading to the development of an infection. This infection, in most cases, manifests symptoms.

As for Mycoplasma genitalium, it is usually present in sexually active people (women and men). When identified, healthcare providers must always treat the infection, possibly extending the treatment to both partners of the couple.

Vaginal swabs for all pregnant women?

Should we conduct vaginal swabs on all pregnant women to identify the likely presence of the three microorganisms, namely Urea urealyticum, Urea parvum, and Mycoplasma hominis, since they are almost certain to be present as part of the vaginal bacterial flora?

The medical community still debates this issue in obstetrics, which raises many doubts, and I define it as the black hole of our discipline. However, there can only be one answer: no, everyone should not undergo the swab.

In other words (but they remain the same), we should not subject a healthy woman with a physiological pregnancy devoid of any risk factors and symptoms of vaginal infection to an STD swab test for these four microorganisms.

But what harm would there be in subjecting all women to this swab? Performing it poses no risk (it is not particularly invasive, as the swab is inserted into the first section of the vaginal canal). It can also reassure you about the absence of potentially pathogenic agents (which can trigger infections). What do you think?

The sore point is precisely the fact that in many cases, the swab test helps to identify microorganisms, at least one of the two types of Ureaplasma, even if there is no infection, therefore even if they have not taken over the others, just because they belong to the vaginal bacterial flora. But the moment I find, for example, Ureaplasma urealyticum, I also have to treat it. The “good clinical practice” criteria obligate me to do so, requiring treatment for anything that could cause harm.

This is valid, therefore, even if the risk is only potential.

Unfortunately, establishing a scientifically acceptable minimum bacterial load that warrants antibiotic treatment and the therapy of choice in the absence of symptoms remains a critical issue.

In other words, it is not clear in what quantities and when Ureaplasma and Myco are present in the vaginal mucosa, not as commensals but as hosts that could cause problems. This means that the mere finding of Urea or Mycoplasma requires us to administer the antibiotic. To administer it regardless, when we arbitrarily deem any bacterial load as pathological and thus deserving of treatment, even if the pregnant woman lacks specific symptoms.

What are the first choice antibiotics that are prescribed?

The antibiotics of first choice to treat Ureaplasma and Mycoplasma belong to the macrolide class. The two active ingredients compatible with pregnancy are azithromycin and clarithromycin. When it’s indicated, take the antibiotic for 5-7 days.

Even with antibiotic treatment, Urea and Myco often persist, and the swab test detects them again during a follow-up check after treatment. The woman then thinks she has a chronic infection and becomes scared, fearing that this situation could damage the fetus…

Normally, they do not completely eradicate since these bacteria are commensal, usually present in the vaginal ecosystem. Performing a vaginal swab test on all women indiscriminately and then prescribing antibiotics lacks sense because doctors must treat any identified bacteria.

You can use the cervical swab to search.

So, professor, how should one act with this swab? When and to whom should we give it so as not to create unnecessary alarm and, above all, not to make a pregnant woman take antibiotics just as unnecessarily?

I firmly believe that we should exclusively search for the 4 microorganisms in the following three cases:

1. In women experiencing reproductive problems and struggling to start a pregnancy.
2. In women exhibiting symptoms of infection.
3. In women with pregnancies (current or previous) at high risk, such as miscarriage or premature birth.

Imbalances in the local microbiota can hinder conception, so you must have a clear idea of the vaginal environment.

Symptoms indicate the development of an infection, requiring the identification of the responsible pathogen and establishing a cure.

Eradicating Urea and Mycoplasma is essential, as their overgrowth could lead to infection, jeopardising the outcome of a high-risk pregnancy. When searching for the 4 microorganisms, it’s advisable to perform a cervical swab test, not a vaginal one.

During pregnancy, what risks do the infections expose you to?

The greatest risk is preterm birth. An infection extending to the amniotic sac could cause it to rupture early, sometimes resulting in premature water loss. Reportedly, cases of pulmonary infection in newborns have also occurred.

Does the same reasoning apply regarding the vaginal-rectal swab for detecting group B streptococcus?

No, there are no longer any doubts on this front.