Probiotics for preventing preterm labour (Review)

Othman M, Alfirevic Z, Neilson JP

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2012, Issue 2
http://www.thecochranelibrary.com

Probiotics for preventing preterm labour (Review)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Analysis 1.1. Comparison 1 Any probiotics versus any type of control, Outcome 1 Neonatal death or severe morbidity. 16
Analysis 1.2. Comparison 1 Any probiotics versus any type of control, Outcome 2 Preterm birth less than 32 weeks. 17
Analysis 1.3. Comparison 1 Any probiotics versus any type of control, Outcome 3 Preterm birth less than 37 weeks. 17
Analysis 1.8. Comparison 1 Any probiotics versus any type of control, Outcome 8 Genital infection. . . . . . . 18
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Probiotics for preventing preterm labour (Review) i

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Probiotics for preventing preterm labour

Mohammad Othman1 , Zarko Alfirevic1 , James P Neilson1

1 Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK

Contact address: Mohammad Othman, Department of Women’s and Children’s Health, The University of Liverpool, First Floor,
Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. mothman12399@yahoo.com.

Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: Edited (no change to conclusions), published in Issue 2, 2012.
Review content assessed as up-to-date: 19 August 2010.

Citation: Othman M, Alfirevic Z, Neilson JP. Probiotics for preventing preterm labour. Cochrane Database of Systematic Reviews 2007,
Issue 1. Art. No.: CD005941. DOI: 10.1002/14651858.CD005941.pub2.

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background

Preterm birth causes 60% to 80% of neonatal deaths. Survivors can experience life-long complications. Thirty to fifty per cent of
preterm labours are associated with maternal infection. Probiotics are defined as live micro-organisms which, when administered in an
adequate amount, confer a health benefit on the host. They have been shown to displace and kill pathogens and modulate the immune
response, thus potentially interfering with the inflammatory cascade that leads to preterm labour and delivery. During pregnancy, local
treatment restoring normal vaginal flora and acidity without systemic effects could be preferable to other treatments to prevent preterm
labour.

Objectives

To evaluate the effectiveness and the safety of probiotics for preventing preterm labour and birth.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (20 February 2010).

Selection criteria

All randomised controlled trials assessing the prevention of preterm birth in pregnant women, and women planning pregnancy, through
the use of probiotics to treat or prevent urogenital infections.

Data collection and analysis

All review authors independently assessed trial quality and extracted data.

Main results

We assessed seven trials for inclusion in the review and included three trials. Effects on very preterm birth (less than 32 weeks) (risk
ratio (RR) 0.65; 95% confidence interval (CI) 0.03 to 15.88) and preterm birth (less than 37 weeks) (RR 3.95; 95% CI 0.36 to 42.91)
showed very wide CIs and no effect of statistical significance (one trial; 238 women). Effects on neonatal death or severe morbidity were
not estimable. The impact of probiotics on vaginal infection was based on only 88 women in two trials. There was an 81% reduction
in the risk of genital infection with the use of probiotics (RR 0.19; 95% CI 0.08 to 0.48).
Probiotics for preventing preterm labour (Review) 1
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors’ conclusions

Although the use of probiotics appears to treat vaginal infections in pregnancy, there are currently insufficient data from trials to
demonstrate any impact on preterm birth and its complications.

PLAIN LANGUAGE SUMMARY

Probiotics for preventing preterm labour

Not enough evidence yet that probiotics will help reduce the chance of babies being born too early.

Being born early (before 37 weeks) or very early (before 34 weeks) can cause severe health problems for babies, and worry and anxiety
for parents. Women who go into labour too soon often have an infection and it is thought that this is what stimulates labour. Normally
the vagina has a layer of friendly micro-organisms, which prevent harmful organisms from growing. Sometimes the balance is upset
and harmful organisms can start to grow. Probiotics are friendly live micro-organisms which are used to displace the harmful ones, and
can be found in Lactobacillus preparations and yogurts containing live cultures. They can be taken by mouth or put into the vagina.
The review of trials looked at the use of probiotics to try to prevent early labour and birth. The review found three trials involving 344
women; two trial used probiotics given by mouth and the other looked at using probiotics in the vagina. The studies were too small
to look at effectiveness for preventing early labour and birth, but probiotics given vaginally reduced the number of harmful bacteria.
Further research is needed.

BACKGROUND
Preterm birth
Preterm birth, defined as birth before 37 complete weeks of ges-
tation, causes 60% to 80% of neonatal deaths (Cram 2002; Klein
2004; Leitich 2003; Yost 2000). Other important adverse out-
comes of preterm birth include respiratory distress syndrome, in-
traventricular haemorrhage, leukomalacia, necrotising enterocoli-
tis and prolonged hospitalisation (McGregor 1997). Survivors can
experience life-long complications including cerebral palsy, blind-
ness and deafness (Kiss 2004; McGregor 1997). The direct and
indirect costs of prematurity can be immense (McGregor 1997).
The lifetime costs per preterm birth (baby’s birthweight less than
2500 grams) have been estimated at £511,614 ($941,640; EUR
766,339) (Kiss 2004; Petrou 2001).
Since 1970, the incidence of preterm deliveries in developed coun-
tries (e.g. USA) has increased from 9% to 11% (Yost 2000).
Preterm premature rupture of the membranes and spontaneous
preterm labour accounts for approximately 80% of preterm de-
liveries; the remaining 20% are planned deliveries for maternal or
fetal reasons (for example, eclampsia) (Yost 2000).
Thirty to fifty per cent of preterm labours are associated with
maternal infection (Chaim 1997; Cram 2002; Crowther 2005;
Kiss 2004; Klein 2004; Reid 2003a; Romero 2002; VIPSG 1995).
Urogenital infections, including urinary tract infections, bacte-
Probiotics for preventing preterm labour (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
rial vaginosis, and yeast vaginitis, affect an estimated one billion
women in the world annually (Reid 2001), and these infections
have emerged in the last 20 years as an important contributing
factor to preterm labour (Chaim 1997; Kiss 2004; Leitich 2003;
McGregor 1997; Reid 2001; Reid 2003b; Romero 2002; VIPSG
1995).
Pathogenesis of ascending infection
The most common pathway for urogenital pathogens to cause
preterm labour is the ascending route (McGregor 1997; Romero
2002). The presence of bacterial sialidases facilitates its attachment
and the breakdown of mucin, while its mucinases assist ascent
into uterine tissues (Howe 1999; Klein 2004; McGregor 1997).
Proteolytic enzymes may act directly on cervical collagen and fetal
membranes leading to premature cervical ripening and weakening
of the fetal membranes with subsequent preterm premature rup-
ture of the membranes (McGregor 1997). Micro-organisms may
also stimulate the host monocytes and macrophages, resulting in
the production of phospholipase A2. A2 is an enzyme that liber-
ates arachidonic acid from the phospholipids of the membranes
leading to the synthesis of prostaglandins E2 and F2a by the pla-
cental membranes (Bejar 1981; Chaim 1997; Reid 2004; Riggs
2004; Yost 2000). Similarly, protease toxins activate the decidua
and fetal membranes to produce cytokines such as tumour necro-
2
sis factor, interleukins (IL1a, IL1b, IL6, IL8) and granulocyte-
macrophage colony-stimulating factor. In response to the activa-
tion of local inflammatory reaction, prostaglandin synthesis and
release are stimulated (Cram 2002; Klein 2004; Reid 2002a; Riggs
2004; Ugwumadu 1999), which may stimulate uterine contrac-
tions and preterm labour (Riggs 2004).
Lactobacilli
Lactobacilli are gram positive, catalase negative, non-sporing rods
that dominate vaginal flora (Sieber 1998). Types of Lactobacilli
found in the vaginal flora include: Lactobacillus acidophilus, fer-
mentum, crispatus, and jensenii (Reid 2003a). The human vagina
is normally lined by multilayered stratified squamous non-ker-
atinised epithelium. The middle and superficial layers contain
glycogen, which is set free by the breakdown of superficial cells.
Free glycogen is fermented by epithelial cells and by Lactobacilli,
producing lactic acid and hydrogen peroxide (Andreu 2004; Reid
2002b; Reid 2003d; Sieber 1998). The presence and dominance
of Lactobacillus in the vagina is associated with reduced risk
of bacterial vaginosis and urinary tract infection (Reid 2002b).
Women who have hydrogen-peroxide-producing strains of Lacto-
bacilli have a 4% prevalence rate of bacterial vaginosis compared
with 32% in women colonised by non-hydrogen-peroxide-pro-
ducing strains and 56% in those without Lactobacilli (Ugwumadu
1999). The protective mechanism of Lactobacilli includes blocking
pathogen attachment to vaginal epithelium, and producing hydro-
gen peroxide (H2 O2 ) and bacteriocins that inhibit pathogen mul-
tiplication (Andreu 2004; Reid 2003a; Riggs 2004; Sieber 1998;
Wilks 2004).
Certain Lactobacillus strains are able to colonise the vagina fol-
lowing vaginal suppository use and may therefore reduce the risk
of urogenital infections (Reid 2003b; Reid 2003c; Reid 2003d).
This raises the question as to whether restoration of Lactobacilli
by probiotic therapy can restore the normal flora and improve the
chances of having a healthy term pregnancy (Reid 2003a).
Probiotics
Probiotics are defined as live micro-organisms which, when ad-
ministered in an adequate amount, confer a health benefit on the
host (Andreu 2004; Elmer 2001; Reid 2003a; Reid 2003d). In
contrast, prebiotics are beneficial, non-digestible components of
ingested foods that stimulate the growth of beneficial bacteria that
they encounter while passing through the colon (Collins 1999).
Probiotics have been shown to displace and kill pathogens and
modulate the immune response by interfering with the inflamma-
tory cascade that leads to preterm labour and delivery (Bengmark
2001; Reid 2003a). As yeast can co-exist with Lactobacilli in the
vagina, and few Lactobacillus strains inhibit yeast growth, it is un-
likely that probiotics will cure yeast vaginitis. They are more likely
Probiotics for preventing preterm labour (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
to prevent recurrences by restoring the normal flora post-antifun-
gal treatment (Reid 2002a; Reid 2002b; Reid 2004). The actual
mechanism of action of probiotics in the vagina is probably multi-
factorial. The production of lactic acid, bacteriocin, and hydrogen
peroxide seems to be important, and modulation of immunity is
another possible mechanism (Reid 2004). The administration of
these Lactobacilli by mouth or intravaginally, or both (Reid 2003a;
Reid 2004), has been shown to be safe and effective in reducing,
or treating, or both, urogenital infections (see Table 1). The rec-
ommended dose, by whatever route of administration, is 109 to
1011 air-dried or freeze-dried bacteria (Andreu 2004; Elmer 2001;
Reid 2003d).
The current recommendation by the Centers for Disease Control
and Prevention (Atlanta, GA, USA) and the UK Drug and Ther-
apeutics Bulletin is to screen and treat bacterial vaginosis in high-
risk pregnancies (Ugwumadu 1999). While antimicrobial agents
are quite effective at providing clinical cure for bacterial infections,
urogenital pathogen drug resistance is on the increase. Also, drugs
have local side effects including disruption of the protective vaginal
flora, which create an increased risk of recurrent infections (Reid
2001; Reid 2002b; Reid 2004; Romero 2002; Shennan 2006; Yost
2000). Also, antibiotics can cause general adverse effects includ-
ing palpitations, flushes, nausea, vomiting, diarrhoea, abdominal
pain, rashes, headache and dizziness (Leitich 2003; Reid 2004;
Yost 2000). During pregnancy a treatment that restores normal
vaginal flora and acidity without systemic effects could be prefer-
able to any other treatment.
OBJECTIVES
To evaluate the effectiveness and the safety of using probiotics for
preventing preterm labour and birth.
METHODS
Criteria for considering studies for this review
Types of studies
All randomised controlled trials assessing the prevention of
preterm labour and birth through the use of probiotics to treat or
prevent urogenital infections, or both. We did not include quasi-
randomised controlled trials.
Types of participants
Pregnant women and women planning pregnancy.
3
Types of interventions
Probiotics versus placebo, no treatment, antibiotics, or any other
intervention to prevent preterm labour and birth.
Types of outcome measures
Primary outcomes
1. Neonatal death or severe morbidity, or both.
2. Preterm birth before 34 weeks.
Secondary outcomes
1. Preterm labour.
2. Preterm birth before 28 weeks, before 32 weeks, and before
37 weeks.
3. Preterm labour requiring hospital admission.
4. Genital infection (bacterial vaginosis, yeast infection).
5. Urinary tract infection.
6. Maternal side effects.
7. Women’s experiences and views.
Search methods for identification of studies
Electronic searches
We contacted the Trials Search Co-ordinator to search the
Cochrane Pregnancy and Childbirth Group’s Trials Register (20
February 2010).
The Cochrane Pregnancy and Childbirth Group’s Trials Register
is maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. quarterly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. handsearches of 30 journals and the proceedings of major
conferences;
4. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL and MEDLINE,
the list of handsearched journals and conference proceedings, and
the list of journals reviewed via the current awareness service can
be found in the ‘Specialized Register’ section within the edito-
rial information about the Cochrane Pregnancy and Childbirth
Group.
Trials identified through the searching activities described above
are each assigned to a review topic (or topics). The Trials Search
Co-ordinator searches the register for each review using the topic
list rather than keywords.
We did not apply any language restrictions.
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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data collection and analysis
For the methods used when assessing the trials identified in the
previous version of this review, see Appendix 1.
For this update we used the following methods when assessing the
reports identified by the updated search.
Selection of studies
The three review authors independently assessed for inclusion all
the potential studies identified as a result of the search strategy.
Data extraction and management
We designed a form to extract data. For eligible studies, all review
authors extracted the data using the agreed form. We entered data
into Review Manager software (RevMan 2008) and check for ac-
curacy.
When information regarding any of the above was unclear, we
attempted to contact authors of the original reports to provide
further details.
Assessment of risk of bias in included studies
All review authors independently assessed risk of bias for each
study using the criteria outlined in the Cochrane Handbook for
Systematic Reviews of Interventions (Higgins 2009).
(1) Sequence generation (checking for possible selection
bias)
We described each included study the method used to generate
the allocation sequence in sufficient detail to allow an assessment
of whether it should produce comparable groups.
We assessed the method as:
• adequate (any truly random process, e.g. random number
table; computer random number generator);
• inadequate (any non-random process, e.g. odd or even date
of birth; hospital or clinic record number); or
• unclear.
(2) Allocation concealment (checking for possible selection
bias)
We described for each included study the method used to conceal
the allocation sequence and determine whether intervention allo-
cation could have been foreseen in advance of, or during recruit-
ment, or changed after assignment.
We assessed the methods as:
• adequate (e.g. telephone or central randomisation;
consecutively numbered sealed opaque envelopes);
• inadequate (open random allocation; unsealed or non-
opaque envelopes, alternation; date of birth);
4
 • unclear.
(3) Blinding (checking for possible performance bias)
We described for each included study the methods used, if any, to
blind study participants and personnel from knowledge of which
intervention a participant received. We considered studies that are
at low risk of bias if they were blinded, or if we judge that the
lack of blinding could not have affected the results. We assessed
blinding separately for different outcomes or classes of outcomes.
We assessed the methods as:
• adequate, inadequate or unclear for participants;
• adequate, inadequate or unclear for personnel;
• adequate, inadequate or unclear for outcome assessors.
(4) Incomplete outcome data (checking for possible attrition
bias through withdrawals, dropouts, protocol deviations)
For each included study, and for each outcome or class of out-
comes, we described the completeness of data including attrition
and exclusions from the analysis. We stated whether attrition and
exclusions were reported, the numbers included in the analysis at
each stage (compared with the total randomised participants), rea-
sons for attrition or exclusion where reported, and whether miss-
ing data were balanced across groups or were related to outcomes.
Where sufficient information was reported, or could be supplied
by the trial authors, we re-included missing data in the analyses
which we undertook. We assessed methods as:
• adequate;
• inadequate;
• unclear.
(5) Selective reporting bias
We described for each included study how we investigated the
possibility of selective outcome reporting bias and what we found.
We assessed the methods as:
• adequate (where it is clear that all of the study’s pre-
specified outcomes and all expected outcomes of interest to the
review have been reported);
• inadequate (where not all the study’s pre-specified outcomes
have been reported; one or more reported primary outcomes were
not pre-specified; outcomes of interest are reported incompletely
and so cannot be used; study fails to include results of a key
outcome that would have been expected to have been reported);
• unclear.
(6) Other sources of bias
We described for each included study any important concerns we
have about other possible sources of bias. We assessed whether
each study was free of other problems that could put it at risk of
bias:
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• yes;
• no;
• unclear.
(7) Overall risk of bias
We made explicit judgements about whether studies are at high risk
of bias, according to the criteria given in the Handbook (Higgins
2009). With reference to (1) to (6) above, we assessed the likely
magnitude and direction of the bias and whether we consider it is
likely to impact on the findings. We planned to explore the impact
of the level of bias, if present, through undertaking sensitivity
analyses - see Sensitivity analysis.
Measures of treatment effect
Dichotomous data
For dichotomous data, we planned to present results as summary
risk ratio with 95% confidence intervals.
Continuous data
For continuous data, we planned to use the mean difference if out-
comes were measured in the same way between trials. We planned
to use standardised mean difference to combine trials that mea-
sured the same outcome, but used different methods.
Unit of analysis issues
Cluster-randomised trials
We planed to include cluster-randomised trials in the analyses
along with individually randomised trials. We planned to adjust
their sample sizes or standard errors using the methods described
in the Handbook (Higgins 2009) using an estimate of the intra-
cluster correlation co-efficient (ICC) derived from the trial (if pos-
sible), from a similar trial or from a study of a similar population.
If we used ICCs from other sources, we planned to report this
and conduct sensitivity analyses to investigate the effect of vari-
ation in the ICC. If we identified both cluster-randomised trials
and individually-randomised trials, we planned to synthesise the
relevant information. We considered it reasonable to combine the
results from both if there is little heterogeneity between the study
designs and the interaction between the effect of intervention and
the choice of randomisation unit is considered to be unlikely.
We also acknowledged heterogeneity in the randomisation unit
and perform an analysis (sensitivity or subgroup) to investigate the
effects of the randomisation unit.
5
Dealing with missing data
For included studies, we noted levels of attrition. We explored the
impact of including studies with high levels of missing data in the
overall assessment of treatment effect by using sensitivity analysis.
For all outcomes, we carried out analyses, as far as possible, on
an intention-to-treat basis, i.e. we attempted to include all partic-
ipants randomised to each group in the analyses, and all partici-
pants were analysed in the group to which they were allocated, re-
gardless of whether or not they received the allocated intervention.
The denominator for each outcome in each trial was the number
randomised minus any participants whose outcomes are known
to be missing.
Assessment of heterogeneity
We assessed statistical heterogeneity in each meta-analysis using
the T², I² and Chi² statistics. We regarded heterogeneity as sub-
stantial if T² is greater than zero and either I² is greater than 30%
or there is a low P value (less than 0.10) in the Chi² test for het-
erogeneity.
Assessment of reporting biases
If there are 10 or more studies in the meta-analysis we planned to
investigate reporting biases (such as publication bias) using funnel
plots. We planned to assess funnel plot asymmetry visually, and
use formal tests for funnel plot asymmetry. For continuous out-
comes we planned to use the test proposed by Egger 1997, and
for dichotomous outcomes we planned to use the test proposed
by Harbord 2006. If asymmetry is detected in any of these tests
or is suggested by a visual assessment, we planned to perform ex-
ploratory analyses to investigate it.
Data synthesis
We carried out statistical analysis using the Review Manager soft-
ware (RevMan 2008). We used fixed-effect meta-analysis for com-
bining data where it is reasonable to assume that studies are esti-
mating the same underlying treatment effect: i.e. where trials are
examining the same intervention, and the trials’ populations and
methods are judged sufficiently similar. If there is clinical hetero-
geneity sufficient to expect that the underlying treatment effects
differ between trials, or if substantial statistical heterogeneity is
detected, we planned to use random-effects meta-analysis to pro-
duce an overall summary if an average treatment effect across trials
is considered clinically meaningful. The random-effects summary
would be treated as the average range of possible treatment effects
and we planned to discuss the clinical implications of treatment
effects differing between trials. If the average treatment effect is
not clinically meaningful we planned to not combine trials.
If we used random-effects analyses, the results would be presented
as the average treatment effect with its 95% confidence interval,
and the estimates of T² and I².
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Subgroup analysis and investigation of heterogeneity
If we identify substantial heterogeneity, we planned to investigate
it using subgroup analyses and sensitivity analyses. We planned to
consider whether an overall summary is meaningful, and if it is,
use random-effects analysis to produce it.
We planned to carry out the following subgroup analyses.
1. Pregnant women versus women planning pregnancy.
2. Confirmed infection versus no confirmed infection.
3. Previous preterm labour versus no previous preterm labour.
4. Long-term treatment (seven days or more) versus short-
term treatment (less than seven days).
5. Oral versus vaginal administration of probiotics.
The following outcomes planned to be used in subgroup analysis.
1. Neonatal death or severe morbidity, or both.
2. Preterm birth before 34 weeks.
For fixed-effect inverse variance meta-analyses we assessed differ-
ences between subgroups by interaction tests. For random-effects
and fixed-effect meta-analyses using methods other than inverse
variance, we assessed differences between subgroups by inspec-
tion of the subgroups’ confidence intervals; non-overlapping con-
fidence intervals indicate a statistically significant difference in
treatment effect between the subgroups.
Sensitivity analysis
We planned to carry out sensitivity analysis to explore the effect of
trial quality where there is risk of bias associated with the quality of
some of the included trials. This involves analysis based on rating
of selection bias and attrition bias.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of studies awaiting classification.
We examined seven trials for inclusion in the review. One trial
started in February 2005 and was terminated in 2007 because the
tightly defined inclusion criteria were making recruitment very
slow (Bocking 2005). Another trial started in 2006 and was ter-
minated in 2009 because of limitation of funding (Krauss-Silva
2006). We have contacted both authors. We will update the review
again if we obtain data from the authors that can be entered into
the review. These two reports have been added to Studies awaiting
classification.
Of the remaining five trials, published between 1993 and 2010,
we excluded two. There were no data to be extracted from one
(Thiagarajan 1998). We tried to contact the author with no re-
sponse. The second trial was excluded because they used prebiotics
6
not probiotics in the trial (Shadid 2007). For a detailed descrip-
tion of the reasons for exclusion, see Characteristics of excluded
studies.
We included three trials in the review (Luoto 2010; Neri 1993;
Nishijima 2005). Nishijima 2005 was conducted in Japan, and
enrolled 24 women after 34 weeks of pregnancy. The probiotic
used was fermented milk, containing 109 colony-forming units
per millilitre of Lactobacillus johnsanii La1120 grams per day orally
for two weeks. The control group received placebo fermented milk
for the same period. Neri 1993 enrolled 84 women in the first
trimester, fulfilling at least three of the four diagnostic criteria for
bacterial vaginosis: vaginal pH greater than 4.7, grey homogenous
vaginal discharge, presence of clue cells in a wet mount prepara-
tion of vaginal fluid, positive amine test in which a fishy odour
is released after the addition of 10% potassium hydroxide to the
vaginal fluid. The first treatment group had vaginal douching us-
ing commercially available yogurt (Lactobacillus dose is hundred
million per millilitre and pH less than 4.5) 10 to 15 millilitres
two times a day for seven days and repeated in one week. The
second group received acetic acid tampons (tampons soaked in
10 to 15 millilitre of 5% acetic acid) two times a day for seven
days and repeated in one week. The control group did not re-
ceive any treatment. Luoto 2010 enrolled 256 women in Finland.
Participants were randomised into two experimental groups and
one placebo control group. One of the experimental groups re-
ceived placebo and dietary counselling while the other experimen-
tal group received probiotics (Lactobacillus rhamnosus GG and Bi-
fidobacterium lactis Bb12 once daily from the first trimester of
pregnancy to the end of breastfeeding) and dietary counselling.
Because dietary counselling was conducted to study the effects on
the baby but not the pregnancy, we added the results of the placebo
and the placebo and counselling groups as one control group. For
a detailed description of the study, see Characteristics of included
studies.
Risk of bias in included studies
In Nishijima 2005, randomisation was done using a computer-
generated table of random set numbers in permuted blocks of four,
and allocation was concealed in sealed disclosure envelopes. Both
participants and outcome assessor were blinded to the treatment
given. There was no description of the characteristics of the study
groups. All women enrolled completed the study. An intention-
to-treat analysis was performed. The only outcome assessed was
the presence of bacterial vaginosis after completion of treatment.
Neri 1993 was an open controlled trial. Women were divided
into two treatment groups and women who declined treatment
were controls. As these controls were not randomly allocated, they
were not included in the analysis. There was no description of the
characteristics of the study groups. All women enrolled completed
the study. An intention-to-treat analysis was performed. Outcomes
assessed were cure (defined as disappearance of at least one of
Probiotics for preventing preterm labour (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
the three bacterial vaginosis criteria found before randomisation)
and clinical improvement (subjective feeling of the woman). Since
the control group had declined to participate and were still used
against their will, we excluded them from this review.
Luoto 2010 used sealed envelopes of computer-generated block
randomisation. Both participants and outcome assessor were
blinded to the treatment given. Intention-to-treat analysis was
used with 25.4% loss of participants.
Effects of interventions
We included three trials involving 344 pregnant women in this
review. Effects on very preterm birth (less than 32 weeks) (risk
ratio (RR) 0.65; 95% confidence interval (CI) 0.03 to 15.88) and
preterm birth (less than 37 weeks) (RR 3.95; 95% CI 0.36 to
42.91) showed very wide CIs and no effect of statistical signifi-
cance. Effects on neonatal death or severe morbidity were not es-
timable. Results showed an 81% reduction in the risk of genital
infection with the use of probiotics (RR 0.19; 95% CI 0.08 to
0.48). The reduction in genital infection with oral yogurt (RR
0.14; 95% CI 0.01 to 2.50) was not statistically significant, but
the CIs were wide, reflecting the small number of women stud-
ied (25). The use of vaginal yogurt was associated with an 80%
reduction in genital infection (RR 0.20; 95% CI 0.08 to 0.52)
compared with acetic acid.
DISCUSSION
The primary results of this review were not statistically signifi-
cant, but in pregnancy, probiotics may be useful for the prevention
and treatment of bacterial vaginosis, especially through the vaginal
route. Unfortunately, two of the randomised studies included in
this review did not report any clinical outcomes other than re-
duction in genital infection. The result of this review, therefore,
neither supports nor refutes the use of probiotics in pregnancy to
prevent preterm labour.
AUTHORS’ CONCLUSIONS
Implications for practice
Although the use of probiotics appears to treat vaginal infections
in pregnancy, there are currently no data from trials to assess any
impact on preterm labour.
Implications for research
There is a need for randomised controlled trials to test whether
probiotics are effective in prevention preterm labour and birth. Fu-
ture trials should therefore be designed taking the following factors
7
into account. Trials should be appropriately sized and placebo-con-
trolled. Outcomes should include preterm labour and birth at clin-
ically significant gestational ages, adverse effects on the neonates
and the pregnant women.

ACKNOWLEDGEMENTS
Dr Koji Nishijima for his fast response in providing us with the in-
formation and data we requested for his trial; and Mrs Sonja Hen-
derson, Ms Lynn Hampson, Ms Denise Atherton, and Ms Rebecca
Smyth from the Cochrane Pregnancy and Childbirth Group, Liv-
erpool Women’s Hospital, Liverpool, UK, for their contributions
to the first version of this review.

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Shadid 2007 {published data only}
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Rjosk-Dendorfer D, et al.Effects of galactooligosaccharide
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of pregnant women at high risk for preterm delivery.
www.clinicaltrials.gov (accessed 2 November 2005).
Krauss-Silva 2006 {published data only}
Krauss-Silva L. Probiotics for the prevention of premature
birth and neonatal related morbidity (ongoing trial).
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Reid G, Burton J, Devillard E. The rationale for probiotics
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Riggs MA, Klebanoff MA. Treatment of vaginal infections
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Infection and prematurity and the role of preventive
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Shennan 2006
Shennan A, Crawshaw S, Briley A, Hawken J, Seed P, Jones
G, et al.A randomised controlled trial of metronidazole
for the prevention of preterm birth in women positive
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Sieber 1998
Sieber R, Dietz UT. Lactobacillus acidophilus and yogurt
in the prevention and therapy of bacterial vaginosis.
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Ugwumadu 1999
Ugwumadu AH, Hay P. Bacterial vaginosis: sequelae and
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Hillier SL, Nugent RP, Eschenbach DA, Krohn MA,
Gibb RS, Martin DH, et al.Association between bacterial
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∗
Indicates the major publication for the study
10
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Luoto 2010

Methods Single-centre double-blind placebo controlled clinical trial conducted in the city of Turku
and neighbouring areas in South-West Finland, using sealed envelopes of computer-
generated block randomisation

Participants 256 pregnant women with the first antenatal visit less than 17 weeks’ gestation with no
chronic metabolic diseases (allergic diseases were allowed)

Interventions 2 experimental groups and 1 placebo group. First experimental group received dietary
counselling and probiotics (Lactobacillus rhamnosus GG and Bifidobacterium lactis Bb12)
once daily from the first trimester of pregnancy to the end of breastfeeding. Second
experimental group received dietary counselling and placebo (microcrystalline cellulose
and dextrose anhydrate capsules) once daily from the first trimester of pregnancy to the
end of breastfeeding. Placebo group received placebo capsules once daily from the first
trimester of pregnancy to the end of breastfeeding

Outcomes The primary outcome was the effects of probiotics on the mother glucose metabolism.
Secondary outcomes include dietary energy-yielding nutrients, preterm birth < 32 weeks,
< 37 weeks, miscarriages, impact on neonates including neonatal death or sever morbidity

Notes Intention-to-treat analysis with 25.4% loss of participants because twins (3), abortion
(5), mother or baby disease (14), unwilling to continue (21), moved (5), unknown (11)
and missing control (6). Experiment groups were double blinded while control group
single blinded

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Computer-generated block randomisa-

bias) tion.

Allocation concealment (selection bias) Unclear risk Sealed envelopes.

Blinding (performance bias and detection Low risk Experiment groups were double blinded
bias) while control group single blinded
All outcomes

Incomplete outcome data (attrition bias) High risk 25.4% loss of participants because twins (3)
All outcomes , abortion (5), mother or baby disease (14)
, unwilling to continue (21), moved (5),
unknown (11) and missing control (6)

Selective reporting (reporting bias) Low risk

Probiotics for preventing preterm labour (Review) 11

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Luoto 2010 (Continued)

Other bias Low risk

Neri 1993

Methods Single-centre open controlled clinical trial conducted in Israel; participants were divided
into 2 treatment groups: women who declined treatment were controls

Participants 64 pregnant healthy women in the first trimester with at least 3 out of 4 of the following
criteria for diagnosis of bacterial vaginosis: vaginal pH greater than 4.7, grey homogenous
vaginal discharge, presence of clue cells on a wet mount preparation of vaginal fluid,
positive amine test in which a fishy odour is released after the addition of 10% potassium
hydroxide to the vaginal fluid.
Women with diagnosed yeast infection, trichomonas vaginalis, chlamydia trachomatis,
and neisseria gonorrhoea were excluded

Interventions First group received vaginal douching using commercially available yogurt (Lactobacillus
dose is 100 million per millilitre and pH less than 4.5) 10-15 millilitre 2 times a day for
7 days and repeated in 1 week.
Second group received acetic acid tampons (tampons soaked in 10-15 millilitre of 5%
acetic acid) 2 times a day for 7 days and repeated in 1 week.
Control group did not receive any treatment.

Outcomes Cure (disappearance of 1 of the 3 bacterial vaginosis criteria), clinical improvement

(subjective feeling of the woman)

Notes Control group were excluded from this review. Data from the 2 treatment groups were
used.
We tried to contact the author with no response.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk No sequence generation.

bias)

Allocation concealment (selection bias) High risk Women who declined treatment were con-
trols.

Blinding (performance bias and detection High risk Participants were divided in to 2 treatment
bias) groups: women who declined treatment
All outcomes were controls

Incomplete outcome data (attrition bias) Low risk No loss of participants.

All outcomes

Selective reporting (reporting bias) Unclear risk The protocol of the study is not available
at the moment.

Probiotics for preventing preterm labour (Review) 12

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Neri 1993 (Continued)

Other bias Low risk

Nishijima 2005

Methods Single-centre double-blind placebo controlled clinical trial, using table of random set
numbers in permuted blocks of 4 and sealed opaque envelopes

Participants 24 healthy Japanese women, 35 weeks or more gestation of a singleton pregnancy.

Exclusion criteria included chronic or acute physical illness, history of smoking, and
being on medication at time of enrolment

Interventions Experiment group received 120 g per day of fermented milk (Nestle Japan Ltd) orally
containing 1 billion colony-forming units per millilitre of Lactobacillus johnsanii La1 for
2 weeks. Control group received placebo fermented milk for the same period

Outcomes Presence of pathogenic bacteria in vaginal fluid samples.

Notes Intention-to-treat analysis with no loss of participants.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Table of random set numbers in permuted
bias) blocks of 4.

Allocation concealment (selection bias) Low risk Sealed opaque envelopes.

Blinding (performance bias and detection Low risk Double-blind.

bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk No loss of participants.

All outcomes

Selective reporting (reporting bias) Unclear risk The protocol of the study is not available
at the moment.

Other bias Low risk Yes.

Probiotics for preventing preterm labour (Review) 13

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Shadid 2007 Double-blind, placebo- controlled pilot trial conducted in Munich, Germany. Participants randomised to either
prebiotics (not probiotics) or placebo

Thiagarajan 1998 Double-blind placebo-controlled trial, with unclear allocation and concealment.
There are no data to be extracted from the article.
We tried to contact the author with no response.

Characteristics of studies awaiting assessment [ordered by study ID]

Bocking 2005

Methods Randomised double blind placebo trial.

Participants Healthy pregnant women, more than 18 years old, less than or at 16th week of pregnancy, singleton pregnancy with
normal uterine cavity and being able to provide informed consent.
Exclusion criteria include medical complications (pre-eclampsia, thrombophilia, hypertension, diabetes), multiple
pregnancy, less than 18 years old, documented need for cervical cerclage, fetal complications (intrauterine growth
retardation, congenital abnormalities), taking antibiotics or any other antimicrobial at time of recruitment, and if
the woman enrolled in any other clinical trials

Interventions The treatment group will receive Lactobacilli preparation, and the control group will receive placebo.

Outcomes The ability of Lactobacilli preparations to maintain a normal vaginal flora in pregnant women

Notes All symptomatic bacterial vaginosis women will be treated with oral metronidazole prior to starting the trial.
160 women at high risk for preterm labour will be approached, 54 will be recruited, 27 women in each group
This study has been suspended since 2007 because tightly defined inclusion criteria were making recruitment very
slow. We are trying to contact the author. We will update the review again when we have the information from the
author

Krauss-Silva 2006

Methods Centralised blocked randomisation process used with no information on the rest of the process

Participants Healthy, 14 years and older asymptomatic pregnant women with no indication of elective preterm delivery, before
the 20th week of pregnancy
Exclusion criteria include major malformations in present pregnancy, cervical cerclage, symptomatic vaginosis, insulin
dependent diabetes, arterial hypertension, multiple gestation, antibiotic therapy in present pregnancy, syphilis or
gonorrhoea in present pregnancy, asthma requiring chronic or intermittent therapy, corticosteroid therapy(recent or
chronic), perinatal haemolytic disease, systemic lupus

Probiotics for preventing preterm labour (Review) 14

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Krauss-Silva 2006 (Continued)

Interventions The treatment group will receive probiotics capsules (Lactobacillus rhamnosus GR1 and Lactobacillus reuteri RC-14,
each capsule contain > 1 million bacilli), twice a day for 6 weeks. Control group will receive placebo capsules twice
a day for 6 weeks

Outcomes Spontaneous premature birth (< 37, < 35, < 32 weeks of pregnancy). Also, related neonatal events, variation in Nugent
Score and variation in cytokine levels

Notes Sample size 645 women.

Study was terminated in 2009 due to limitation of funding. We are trying to contact the author. We will update the
review again when we have information from the author

Probiotics for preventing preterm labour (Review) 15

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES

Comparison 1. Any probiotics versus any type of control

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Neonatal death or severe 1 241 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
morbidity
2 Preterm birth less than 32 weeks 1 238 Risk Ratio (M-H, Fixed, 95% CI) 0.65 [0.03, 15.88]
3 Preterm birth less than 37 weeks 1 238 Risk Ratio (M-H, Fixed, 95% CI) 3.95 [0.36, 42.91]
8 Genital infection 2 88 Risk Ratio (M-H, Fixed, 95% CI) 0.19 [0.08, 0.48]
8.1 Oral probiotics 1 24 Risk Ratio (M-H, Fixed, 95% CI) 0.14 [0.01, 2.50]
8.2 Vaginal probiotics 1 64 Risk Ratio (M-H, Fixed, 95% CI) 0.2 [0.08, 0.52]

Analysis 1.1. Comparison 1 Any probiotics versus any type of control, Outcome 1 Neonatal death or severe
morbidity.

Review: Probiotics for preventing preterm labour

Comparison: 1 Any probiotics versus any type of control

Outcome: 1 Neonatal death or severe morbidity

Study or subgroup Treatment Control Risk Ratio Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Luoto 2010 0/82 0/159 0.0 [ 0.0, 0.0 ]

Total (95% CI) 82 159 0.0 [ 0.0, 0.0 ]

Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours experimental Favours control

Probiotics for preventing preterm labour (Review) 16

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.2. Comparison 1 Any probiotics versus any type of control, Outcome 2 Preterm birth less than
32 weeks.
Review: Probiotics for preventing preterm labour

Comparison: 1 Any probiotics versus any type of control

Outcome: 2 Preterm birth less than 32 weeks

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Luoto 2010 0/80 1/158 100.0 % 0.65 [ 0.03, 15.88 ]

Total (95% CI) 80 158 100.0 % 0.65 [ 0.03, 15.88 ]

Total events: 0 (Treatment), 1 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.26 (P = 0.79)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours experimental Favours control

Analysis 1.3. Comparison 1 Any probiotics versus any type of control, Outcome 3 Preterm birth less than
37 weeks.
Review: Probiotics for preventing preterm labour

Comparison: 1 Any probiotics versus any type of control

Outcome: 3 Preterm birth less than 37 weeks

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Luoto 2010 2/80 1/158 100.0 % 3.95 [ 0.36, 42.91 ]

Total (95% CI) 80 158 100.0 % 3.95 [ 0.36, 42.91 ]

Total events: 2 (Treatment), 1 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.13 (P = 0.26)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours experimental Favours control

Probiotics for preventing preterm labour (Review) 17

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.8. Comparison 1 Any probiotics versus any type of control, Outcome 8 Genital infection.

Review: Probiotics for preventing preterm labour

Comparison: 1 Any probiotics versus any type of control

Outcome: 8 Genital infection

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Oral probiotics
Nishijima 2005 0/12 3/12 14.9 % 0.14 [ 0.01, 2.50 ]

Subtotal (95% CI) 12 12 14.9 % 0.14 [ 0.01, 2.50 ]

Total events: 0 (Treatment), 3 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.33 (P = 0.18)
2 Vaginal probiotics
Neri 1993 4/32 20/32 85.1 % 0.20 [ 0.08, 0.52 ]

Subtotal (95% CI) 32 32 85.1 % 0.20 [ 0.08, 0.52 ]

Total events: 4 (Treatment), 20 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 3.30 (P = 0.00096)
Total (95% CI) 44 44 100.0 % 0.19 [ 0.08, 0.48 ]
Total events: 4 (Treatment), 23 (Control)
Heterogeneity: Chi2 = 0.05, df = 1 (P = 0.83); I2 =0.0%
Test for overall effect: Z = 3.57 (P = 0.00036)
Test for subgroup differences: Chi2 = 0.05, df = 1 (P = 0.83), I2 =0.0%

0.001 0.01 0.1 1 10 100 1000

Favours treatment Favours control

ADDITIONAL TABLES
Table 1. Commercially available probiotics

PROBIOTIC FORM ADMINISTRATiON PRESCRIBED USE

Intrafresh Vaginal pessaries Vaginally Bacterial vaginosis, yeast vaginitis

Cervagyn Vaginal cream Vaginally Bacterial vaginosis, yeast vaginitis

Döderlein med Vaginal capsules Vaginally Bacterial vaginosis, yeast vaginitis

GY-Natren Vaginal tablets Vaginally Bacterial vaginosis, yeast vaginitis

Vivag Vaginal tablets Vaginally Bacterial vaginosis, yeast vaginitis

Probiotics for preventing preterm labour (Review) 18

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Commercially available probiotics (Continued)

Yeast infection no more Vaginal drops To be added to tampons Yeast vaginitis

Veganicity multi probiotic Capsules Orally Yeast vaginitis

Acidophilus bifidus fos Capsules Orally Yeast vaginitis, urinary tract infection

Primadophilus Capsules Orally Yeast vaginitis, urinary tract infection, maintain in-
testinal integrity

Acidophilus Bifidobacterium Capsules Orally Yeast vaginitis, urinary tract infection, maintain in-
fos testinal integrity

Acidophilus Tablets Orally Vaginal infections, digestive disorders, other illnesses

Probiotic plus Chewable tablet Orally Yeast vaginitis, improve digestion

Dairy health start system Powder Orally Vaginal infections, urinary tract infection, digestive
disorders

Threelac Powder Orally Vaginal infections, urinary tract infection, digestive

disorders

APPENDICES

Appendix 1. Methods used to assess trials included in previous versions of this review

Selection of studies
We assessed for inclusion all potential studies identified as a result of the search strategy. We resolved any disagreement through
discussion.

Data extraction and management

We designed a form to extract data. We used the Review Manager software (RevMan 2003) to analyse the data. We attempted to
contact authors of the original reports to provide further details.

Assessment of risk of bias in included studies

We assessed the validity of each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2005).

Probiotics for preventing preterm labour (Review) 19

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) Selection bias
We assigned a quality score for each trial, using the following criteria:
(A) adequate concealment of allocation: such as telephone randomisation or consecutively-numbered sealed opaque envelopes;
(B) unclear whether adequate concealment of allocation: such as list or table used, sealed envelopes, or study does not report any
concealment approach;
(C) inadequate concealment of allocation: such as open list of random-number tables, use of case record numbers, dates of birth or
days of the week.

(2) Attrition bias (loss of participants, for example, withdrawals, dropouts, protocol deviations)
We assessed completeness to follow up using the following criteria:
(A) less than 5% loss of participants;
(B) 5% to 9.9% loss of participants;
(C) 10% to 19.9% loss of participants;
(D) more than 20% loss of participants.

(3) Performance bias (blinding of participants, researchers and outcome assessment)

We assessed blinding using the following criteria:
(A) blinding of participants (yes/no/unclear);
(B) blinding of caregiver (yes/no/unclear);
(C) blinding of outcome assessment (yes/no/unclear).

Measures of treatment effect

We carried out a statistical analysis using the Review Manager software (RevMan 2003). We used fixed-effect meta-analysis for combining
data in the absence of significant heterogeneity. If heterogeneity was found, this was to be explored by sensitivity analysis, followed by
random-effects analysis if required. For dichotomous data, we presented results as summary relative risk with 95% confidence intervals.
For continuous data, we planned to use the weighted mean difference if outcomes were measured in the same way between trials. We
planned to use the standardised mean difference to combine trials that measure the same outcome, but use different methods. If there
was evidence of skewness, this would be reported.

Unit of analysis issues

We planned to include cluster-randomised trials in the analysis, along with individually randomised trials. Their sample size was to be
adjusted (Gates 2005) using an estimate of the intracluster correlation co-efficient (ICC) derived from the trial (if possible), or from
another source. If ICCs from other sources were used, this would be reported and sensitivity analysis would be conducted to investigate
the effect of variation in the ICC. If we identified both cluster and individually randomised trials, we planned to synthesise the relevant
information. We considered it reasonable to combine the results from both if there was little heterogeneity between the study designs
and the interaction between the effect of intervention and the choice of randomisation unit was considered to be unlikely. We would
also acknowledge heterogeneity in the randomisation unit and perform a separate meta-analysis. Therefore the meta-analysis would be
performed in two parts as well.

Dealing with missing data

We analysed data on all participants with available data in the group to which they were allocated, regardless of whether or not they
received the allocated intervention. If in the original reports participants were not analysed in the group to which they where randomised,
and there was sufficient information in the trial report, or if the necessary information was obtained from the trial authors, we attempted
to restore them to the correct group.

Probiotics for preventing preterm labour (Review) 20

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Assessment of heterogeneity
We planned to apply tests of heterogeneity between trials using the I² statistic. If we identified high levels of heterogeneity among trials
(exceeding 50%), we planned to explore it by prespecified subgroup analysis and perform sensitivity analysis. A random-effects meta-
analysis was to be used as an overall summary if this was considered appropriate.

Subgroup analysis and investigation of heterogeneity

We planned to conduct subgroup analysis classifying whole trials by interaction tests (Deeks 2001). The following subgroups were to
be analysed.
1. Pregnant women versus women planning pregnancy.
2. Confirmed infection versus no confirmed infection.
3. Previous preterm labour versus no previous preterm labour.
4. Long-term treatment (seven days or more) versus short-term treatment (less than seven days).
5. Oral versus vaginal administration of probiotics.

Sensitivity analysis
We carried out sensitivity analysis to explore the effect of trial quality. This involved analysis based on rating of selection bias and
attrition bias.

WHAT’S NEW
Last assessed as up-to-date: 19 August 2010.

Date Event Description

13 December 2011 Amended Contact details edited.

HISTORY
Protocol first published: Issue 2, 2006
Review first published: Issue 1, 2007

Date Event Description

10 January 2011 Amended Contact details edited.

20 May 2010 New search has been performed The review has been updated. One new trial has been included (Luoto 2010)
.

20 February 2010 Amended Search updated. Seven reports added to Studies awaiting classification

1 May 2008 Amended Converted to new review format.

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CONTRIBUTIONS OF AUTHORS
M Othman: extracted the data and wrote the first draft of the review. In the update, he extracted the data and wrote the review.
JP Neilson: supervised the progress of the review. In the update, he supervised the progress of the review.
Z Alfirevic: supervised the progress of the review. In the update, he supervised the progress of the review.

DECLARATIONS OF INTEREST
None known.

SOURCES OF SUPPORT

Internal sources
• The University of Liverpool, UK.

External sources
• No sources of support supplied

INDEX TERMS

Medical Subject Headings (MeSH)

Obstetric Labor, Premature [∗ prevention & control]; Probiotics [∗ therapeutic use]; Randomized Controlled Trials as Topic; Vaginosis,
Bacterial [∗ prevention & control]

MeSH check words

Female; Humans; Pregnancy

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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.