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Sexually Transmitted Infections and Negative Birth Outcomes: Review Barbara Page

Sexually transmitted infections are well-characterize due to awareness campaigns sponsored by the CDC, WHO and other health promoting organizations. In most cases, negative birth outcomes is not included in such education efforts. I postulate that the seriousness and less known evidence demonstrates that there may be an association between the increase in STIs and the lack of improvement of the infant mortality rate (in Pennsylvania).

For example, a non-symptomatic sexually transmitted infection (STI) that was contracted when a women was in her early twenties and cured inadvertently when she was subsequently treated for a urinary tract infection three years later could be the cause of an ectopic pregnancy in her late twenties. Since such distressing NEGATIVE BIRTH OUTCOMES								Page 3 information is, without a doubt, not usually provided by the infertility physician. The etiology of this cause of infertility is explained to her by the describing her blocked fallopian tubes or adhesions. There is no therapeutic reason to confer blame upon a distressed women and her partner because of a treated, cured, and past sexually transmitted infection that the woman acquired before her attempts in conceiving. The formation of adhesions and the blockage of fallopian tubes is a common sequalae of pelvic inflammatory disease (PID). PID is a sexually transmitted disease that is often polymicrobial. It develops asymptomatically in most cases so that the women is unaware that damage is occurring. Yet it remains a major cause of infertility and ectopic pregnancies. STIs not only have a profound effect on fertility. STIs can have life-threatening consequences for a newborn and the developing infant months before birth. An STI is an infection that is almost always obtained through sexual intercourse, oral sex, and anal sex. In some cases a woman could possibly obtain an infection by another means outside of sexual activity but this is unlikely and not mentioned in the literature reviewed. Some sexually transmitted infections are treatable and the woman and her infant can be cured. Other infections cannot be cured. Viral sexually transmitted infections can be controlled but not eliminated from the body. Some sexually transmitted infections that could harm the baby can be prevented or controlled by prophylactic vaccination. Most still have little understanding of the severe consequences to an infant due to STIs. Even if the infant does not actually have the infection itself, the nature of the STI can result in the inability of the mother to bring the infant to term and in a healthy condition. “Intrauterine perinatally transmitted STDs can have severely debilitating effects on pregnant women their NEGATIVE BIRTH OUTCOMES								Page 4 partners and their fetuses.” (Workowsk, 2015) Many STIs can be passed to the baby in the womb or during birth. The short list of negative birth outcomes includes miscarriage, low birth weights, sepsis, premature rupture of membranes, premature birth, stillbirth and more conditions that may stay with the child for their entire life. (Pregnancy complications, 2010) Not every sexual encounter results in acquiring an infection and not all sexually transmitted infections result in a negative birth outcome or sterility. Almost all infections, including STIs include an inflammatory phase where the human body recognizes the pathogen and attempts to remove it. STIs also cause an inflammatory phase. This generalized assumption may provide the basic reason why these infections produce negative birth outcomes. Ljubin-Sternak, describes the inflammatory process associated with Chlamydia trachinosis, Mycoplasma hominis infection, Mycoplasma genitalium infection, Ureaplasma parvum infection, and Ureaplasma urealyticum infection. Inflamed tissues tend to deviate from performing their normal functions. Some sexually transmitted infections are only known by the organisms that are infective. But most of the others are familiar to most people. We are most familiar with the names of Syphillis, Gonnorhea or Chlamydia but not as familiar with infections designated by the name of the organism. Many sexually transmitted infectious microorganisms are only now (within the past ten years or so) being identified by more sophisticated techniques. Some of these same bacteria are virtually impossible to grow using standard culturing methods and not every bacterial laboratory has the expertise to discern between organisms. The newer methods that have identified more sexually transmitted infections were developed to determine the human genome. The technology NEGATIVE BIRTH OUTCOMES								Page 5 was then applied to determining the genome of other organisms. These newer methods include Polymerase Chain Reaction (PCR) and Immunohistochemical analysis. (Baud, 2011), (Waites and Katz, 2011) The PCR technology allows the identification of non-culturable microorganisms that occur in small numbers – a significant breakthrough in microbiology and for the description of the normal human flora in different areas of the human body. Most of this review will discuss the specific negative birth outcomes associated with each STI. Documentation is richer with some of the more familiar infections. But evidence for the ‘emerging’ STIs is still substantial. Each STI will be listed along with the negative birth outcomes associated with the infection. HIV HIV has been found to impact infants apart from being infected. HIV infection in the mother results in an increase of low birth weights, preterm birth, stillbirth and spontaneous abortion. Nairobi were attributable to HIV. prenatal life-long acquisition of a known lethal infection is not discussed in detail and is covered extensively in other sources. It is still worth mentioning simply because so many infants born with HIV truly do have a negative birth outcome based upon their place of birth and the unavailability of treatment to prolong their life beyond childhood. If an HIV-infected infant born in Sub-Sahara African has indeed been born with an untreatable sexually transmitted infection and will die within a short time, this can’t be anything other than a negative birth outcome.(Mullick, 2005) HIV infected women have conceived during treatment with anti-retro viral therapy (ART) to control the infection and delay progression to full-blown AIDS. There is no teratogenicity found to occur with ART alone. But there is some evidence when ART is used with folate antagonists. (Jungmann, 2001) NEGATIVE BIRTH OUTCOMES								Page 6 Syphilis The bacterium Treponema pallidum is responsible for causing this infection. Syphilis has been known to cause severe birth defects for hundreds of years. (Berkow, 2003, p.1176) Studies collaborate and agree on the associated negative birth outcomes of syphilis. The associated risks include the risk of miscarriage and stillbirth. Congenital syphilis can result in mental & physical problems. (Sexually Transmitted Diseases (STDs) and Pregnancy, 2016) Congenital syphilis is relatively well-studied when compared to other STIs of infants. Congenital Syphilis cases have also been increasing in frequency since 2012. This increasingly common prenatal infection can result in miscarriage, stillbirth failure to thrive and early infant death shortly after birth. These infants can also exhibit syphilitic rash, jaundice, hepatosplenomegaly, bone deformities, high white blood cell counts. (Bowen, 2015) Other manifestations include jaundice, blindness, deafness, seizures, anemia, meningitis, enlarged spleen, fever, irritability, no bridge to nose (saddle nose), and watery fluid from the nose (STD Facts - Congenital Syphilis)(Berkow, 1997, p. 1176)( Kaneshiro, 2016) NEGATIVE BIRTH OUTCOMES								Page 7

Chlamydia trachomatis

Chlamydia trachomatis can claim to be the fastest growing sexually transmitted infection in the US at this time and is the most common STI in women of reproductive age. It is a major cause of infertility because it is associated with tubal factor infertility, salpingitis, and tubo-ovarian abscess(Ljubin-Sternak, 2014) And although not technically considered a negative birth outcome, undoubtedly those experiencing infertility would consider it one. A chlamydia infection can be the cause of an ectopic pregnancy where a viable fetus may be present but must be removed to prevent severe hemorrhage in the pregnant woman. The etiology of negative birth outcomes related to a chlamydia infection include intrauterine growth retardation, low birth weight, newborn pneumonia, miscarriage, conjunctivitis, chorioamnionitis, blindness, PID, preterm delivery and neonatal sepsis. (Berkow, 2003, p.1180)(Baud, 2011)(Workowski, 2015). (Sexually Transmitted Diseases (STDs) and Pregnancy, 2016)(Mullick, 2005) Mycoplasma Hominis Many are not as familiar with other microorganisms that are associated with negative birth outcomes and these STIs are even often overlooked by those who treat those who are infected. This is because these ‘newer’ STIs are virtually unable to be cultured in a standard microbiology lab on growth medium.and are found by PCR. (Waites and Katz, 2011) Mycoplasma hominis is one of these. It is often involved in an STI-polymicrobial infection associated with PID. M hominis has been isolated from the endometria and fallopian tubes of approximately 10% of women with salpingitis This bacterium has also been associated with negative birth outcomes such as, premature rupture of membranes, preterm labor. It is sometimes

NEGATIVE BIRTH OUTCOMES								Page 8 found in the infection that causes tubal factor infertility.and bronchopulmonary dysplasia. (Waites and Katz, 2011) (Ljubin-Sternak, 2014) (Waites and Bronze, 2016) Mycoplasma genitalium Mycoplasma genitalium is very similar to M. hominis but can cause infection apart from the other species of Mycoplasma. It also is associated with premature birth, bronchopulmonary dysplasia. bacteremia, and meningitis, premature rupture of membranes, preterm labor, tubal factor infertility.(Ljubin-Sternak, 2014) (Waites and Bronze, 2016) This STI is developing resistance to antimicrobial agents, including beta-lactams. (Waites and Bronze, 2016}	Ureaplasma urealyticum	Ureaplasma urealyticum is another perinatal pathogen that can cause premature birth, bronchopulmonary dysplasia, bacteremia, meningitis, very low birth weight and death. (Waites and Bronze, 2016) Both Ureaplasma species can initiate inflammation of the placenta, spread to the amniotic sac precipitating premature birth. The bronchopulmonary dysplasia caused by Ureaplasma spp. is a probable cause of low-grade inflammation in the airways. This inflammation can cause a sustained requirement for oxygen administration. This situation paired with trauma of mechanical ventilation and the damaging effects of prolonged oxidant exposure contributes to the lasting respiratory damage caused by these pathogens. (Waites and Bronze, 2016)	Ureaplasma parvum	Ureaplasma urealyticum and Ureaplasma parvum are separate species and can infect alone or in a polymicrobial fashion. Similar to Ureaplasma urealyticum, an infant that acquires Ureaplasma parvum in utero can have meningitis, congenital pneumonia, and bacteremia. Death NEGATIVE BIRTH OUTCOMES								Page 9 can occur in infants with very low birth weight due to Ureaplasma or Mycoplasma infection of the lower respiratory tract. (Waites and Bronze, 2016) Neonates that are infected w uu up mh mg can have these pathogens spread to the bloodstream and cerebral spinal fluid.(Waites and Bronze, 2016) Bacterial Vaginosis Until recently, Bacterial Vaginosis was not considered an STI because it seems that this polymicrobial could not be fully characterized using standard culturing methods. sexual activity was not necessary for acquiring this infection. Older sources describing STIs do not list it with the other ‘classic’ STIs. Further studies have indicated, along with the CDC, Bacterial Vaginosis can cause preterm birth, premature rupture of membranes, preterm labor, and chorioamnionitis. low birth weight, postpartum sepsis, and spontaneous miscarriage, and spontaneous miscarriage. There is also a risk for subsequent pregnancies to result in preterm births.(Treatments for bacterial vaginosis, 2013) Bacterial Vaginosis may have the greatest effect on negative birth outcomes as part of a polymicrobial infection and when it is contracted after a previous preterm or low birth weight delivery or when there is comorbidity with Trichomonas vaginalis. (STDs during Pregnancy – CDC) (Schwiertz, 2016) (Mullick, 2005)(Treatments for bacterial vaginosis, 2013) When the pregnant women has a BV infection, this increases the risk of infection by other STIs by a factor of two. These coborbidities can cause negative birth outcomes. Unfortunately, this includes the increased susceptibility of acquiring HIV/AIDS. (Kenyon, 2013) Herpes II Virus A symptomatic outbreak of HPV in the first trimester of pregnancy can cause miscarriage. Neonatal herpes can be contracted during pregnancy and cross the placenta. NEGATIVE BIRTH OUTCOMES							      Page 10 Infection can also occur during delivery.(Sexually Transmitted Diseases (STDs). Unfortunately, this virus can cause many serious problems in an infant in utero and after birth. These conditions include: pulmonary pneumonitis, congenital pneumonia, bronchial pulmonary displasia, reactive airway disease, asthma, necrotizing enterocolitis, short bowel syndrome, failure to thrive, intraventricular hemorrhage, meningitis, hydrocephalus, developmental delays, retinal detachment, blindness, myopia, strabismus, pulmonary hypertension, bacteremia, leukocytosis, cytokinemia and death.(Viscardi, 2014)(Mullick 2005)	Cytomegalovirus	Cytomegalovirus is usually thought of as a viral STI that progresses to cervical cancer in women. Most are unaware that the danger of this virus also lies in its potential negative birth outcomes. These include: central nervous system infection, liver damage, lethargy, convulsions, jaundice, petechiae, intracerebral calcifications, intrauterine growth restriction, cognitive impairments, microcephaly, motor disabilities, hearing loss, and stillbirth (Heymann, 2015, p. 141) Human papillomavirus Human Papilloma Virus (HPV) Warts can develop in the baby’s throat which will require surgery.(Sexually Transmitted Diseases (STDs) and Pregnancy, 2016) (HPV and Pregnancy, 2016)

Neisseria gonorrhoeae The infection caused by the bacterium Neisseria gonorrhoeae or just Gonorrhea is also a familiar and it has been known for a while to result in negative birth outcomes. These are ectopic pregnancy, PID, premature birth, stillbirth, eye infections. low birth weight, corneal NEGATIVE BIRTH OUTCOMES							      Page 11 ulceration or perforation, and blindness. Strains are becoming resistant to some antibiotics. (Sexually Transmitted Diseases (STDs) and Pregnancy, 2016)( Mullick, 2005) Trichomonas vaginalis Trichomonas vaginalis Can cause fallopian tube damage, Premature birth, low birth weight (Sexually Transmitted Diseases (STDs) and Pregnancy, 2016) (Mullick, 2005), death, and premature rupture of membranes. Though rare, baby girls can contract the infection during a vaginal delivery.(Cirino, 2016) Infected infants can have vaginitis, urinary tract infections, respiratory distress, apnea, bacterial sepsis, (comorbity), and vaginal discharge.(Smith, 2002) Hepatitis B	Unless Hepatitis B infection results in a slight increase of miscarriage. It is treated with vaccination immediately after birth, the infant will be a life-long carrier and be at high risk at developing a form of liver cancer later in life. So though this infection does not result in an apparent symptomatic infection at birth, it is infectious This infection is communicated to all future sexual partners who then are able to pass on this infection to their offspring.(Sexually Transmitted Diseases (STDs) and Pregnancy, 2016) Hepatitis C	Infants born to mothers with Hepatitis C can be small for gestational age, premature and be of low birth weight.(STDs during Pregnancy – CDC)

NEGATIVE BIRTH OUTCOMES							      Page 12 Even in the most general sense, infection causes inflammatory responses that can cause tissues and organs to not function optimally. In the case of child-bearing and in the best of circumstances, maternal health should be optimal for positive birth outcomes. It is also not clearly understood that a relationship between STIs and the potential negative birth outcomes can occur as a result of sexual activity. Most sources of information are not as explicit as they could be in educating sexually active men and women about the possible results of STIs in their future attempts in establishing a family. (Endedersbe, 2000)( Dudley, 1999)(Perkins, 2008) In addition, such a long period of time can exist before the damage done from the infection presents itself, and when it is there is no point in informing the participants that it was their own risky behavior that contributed to a negative birth outcome or infertility. Despite the technological advances in neonatal, perinatal and materal care, the infant mortality rate has not statistically improved since 1998 (and probably before) in the state of Pennsylvania. NEGATIVE BIRTH OUTCOMES							      Page 13 This can only be due to the increasing number of STIs that have resulted in infants that are more premature, more that are low birth weight, more infected, and more that have severely compromised respiratory functions. Research continues to focus on yet-unidentified maternal factors that are the cause of unimproved rates of good birth outcomes. Even pregnancy screening is not mentioned in most of the sources regarding sexually transmitted infections, especially surprising when reviewing CDC websites. As far as this review goes, there are no professional or governmental sources of this information available that has pulled together the widely dispersed information on negative birth outcomes and STIs. It seems to be quite random as evidenced by the number and breadth of the references reviewed This topic needs further review by persons that are more highly trained due to the over-reaching conclusions that the increase in negative birth outcomes is the reason that the infant mortality rate in Pennsylvania has remained unchanged. And slightly in information regarding chlamydia and gonorrhea, it is not well known that STIs have a negative impact on birth outcomes – little to scant information was found during this review. Celebration should continue with every ‘survivor’ story when the smallest patients we have fight as hard as they can to survive and succeed. But perhaps researchers should be looking in other places to find the unchanging cause of negative birth outcomes.

References 2015 Sexually Transmitted Diseases Surveillance. Centers for Disease Control and Prevention. (October 18, 2016) Retrieved November 1, 2016 from http://www.cdc.gov/std/stats15/slides.htm [Note that a number of Power Point Presentations were downloaded from this website and this reference is used to cite information contained in those power point presentations.] Babies Born with CMV (Congenital CMV Infection) (September 14, 2016) Centers for Disease Control and Prevention. Retrieved November 1, 2016 from http://www.cdc.gov/cmv/congenital-infection.html Baud, David et. al. Role of Chlamydia trachomatis in Miscarriage - Volume 17, Number 9—September 2011. Emerging Infectious Disease journal - CDC. (September 2011) Retrieved 30 October 2016 from http://wwwnc.cdc.gov/eid/article/17/9/10-0865-f2 illustration Baud D, Goy G, Jaton K, Osterheld M-C, Blumer S, Borel N, et al. Role of Chlamydia trachomatis in miscarriage. Emerg Infect Dis .(2011 Sep) Retreived 30 October 2016 from http://wwwnc.cdc.gov/eid/article/17/9/10-0865_article#suggestedcitation Berkow, Robert, Mark H. Beers, and Andrew J. Fletcher. Merck manual of medical information. Whitehouse Station, N.J: Merck Research Laboratories, 1997. Print. Bowen, Virginia, Su, John, Torrone, Elizabeth, Kidd, Sarah, Weinstock, Hillard. Increase in Incidence of Congenital Syphilis — United States, 2012–2014. Morbidity and Mortality Weekly Report (MMWR), Centers for Disease Control and Prevention. (November 13, 2015) Retrieved October 31 2016 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6444a3.htm Bradshaw, Catriona S., Brotman, Rebecca M. Making inroads into improving treatment of bacterial vaginosis – striving for long-term cure. BMC Infect Dis 15: 292. (2015) Retrieved on November 4, 2016 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518586/ Cirino, Erica. What Is Trichomoniasis? Healthline. (2016) Retrieved on November 4, 2016 http://www.healthline.com/health/pregnancy/infections-trichomoniasis#IfYou’rePregnant2 Dudley, William. Epidemics : opposing viewpoints. San Diego, Calif: Greenhaven Press, 1999. Print. Endersbe, Julie K. Healthy sexuality : what is it. Mankato, Minn: LifeMatters, 2000. Print. Fox, Chelsea; Eichelberger, Kacey. Maternal microbiome and pregnancy outcomes. (2015). Fertility and Sterility. 104 (6): 1358–1363. doi:10.1016/j.fertnstert.2015.09.037. Retrieved October 31 2016 from http://www.fertstert.org/article/S0015-0282(15)01965-2/fulltext Glossary Index. Office on Women’s Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services. n.d. Retrieved October 31 2016 from https://www.womenshealth.gov/glossary/#low_birth_weight Glossary Index. Office on Women’s Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services. n.d. Retrieved October 31 2016 from https://www.womenshealth.gov/glossary/#pretermlabor Glossary Index. Office on Women’s Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services. n.d. Retrieved October 31 2016 from https://www.womenshealth.gov/glossary/#stillbirth Heymann, David L. Control of communicable diseases manual : an official report of the American Public Health Association. Washington, DC: APHA Press, an imprint of the American Public Health Association, 2015. Print. HPV and Pregnancy. WebMD. (2016) Retrieved on November 4, 2016 from http://www.webmd.com/sexual-conditions/hpv-pregnancy#2 Jungmann, Eva, Mercey Danielle, DeRuiter, Annemiek, Edwards,Simon, Donoghue, Sheila, Donoghue, Booth, Tamsin, Mohan, Depeeka, Lyall, Hermione, Taylor, Graham P Is first trimester exposure to the combination of antiretroviral therapy and folate antagonists a risk factor for congenital abnormalities? Sex Transm Infect 2001;77:441-443 doi:10.1136/sti.77.6.441 Retrieved November 1, 2016 from http://sti.bmj.com/content/77/6/441.full Kaneshiro, Neil K. ed. Congenital syphilis. Medline. (October 5, 2016) Retrieved November 2, 2016 from https://medlineplus.gov/ency/article/001344.htm Kenyon, Chris, Colebunders, Robert, Crucitti,Tania. (2013) The global epidemiology of bacterial vaginosis: a systematic review. American Journal of Obstetrics and Gynecology, Volume 209, Issue 6, Pages 505-523. Retrieved November 4, 2016 from https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S000293781300478X?returnurl=http:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS000293781300478X%3Fshowall%3Dtrue&referrer=http:%2F%2Fwww.sciencedirect.com%2Fscience%2Farticle%2Fpii%2FS000293781300478X Ljubin-Sternak, Suncanica; Mestrovic, Tomislav. Review: Clamydia trachomatis and Genital Mycoplasmias: Pathogens with an Impact on Human Reproductive Health".(2014) Journal of Pathogens. doi:10.1155/2014/183167. Retrieved 31 October 2016 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295611/ March of Dimes. Preemie miracles: Parents share their premature baby's story. BabyCenter Expert Advice. Retrieved November 1, 2016 from http://www.babycenter.com/0_preemie-miracles-parents-share-their-premature-babys-story_10300029.bc Mullick S, Watson-Jones D, Beksinska M., Mabey, D. Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries. Sex Transm Infect 2005;81:294-302 doi:10.1136/sti.2002.004077. (2005) Retrieved November 2, 2016 from http://sti.bmj.com/content/81/4/294.full Pregnancy complications. Office on Women’s Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services  (September 27, 2010) Retrieved October 31 2016 from https://www.womenshealth.gov/pregnancy/you-are-pregnant/pregnancy-complications.html# Premature Labor. American Pregnancy Association, (2016) Retrieved October 31 2016 from http://americanpregnancy.org/labor-and-birth/premature-labor/ STDs during Pregnancy - CDC Fact Sheet (Detailed). (February 11, 2016) Centers for Disease Control and Prevention. (October 18, 2016) Retrieved November 1, 2016 from http://www.cdc.gov/std/pregnancy/stdfact-pregnancy-detailed.htm STD Facts - Congenital Syphilis. Centers for Disease Control and Prevention. (October 28, 2016) Retrieved October 31 2016 from http://www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm Schwiertz, Andreas. Microbiota of the human body : implications in health and disease. Switzerland: Springer, 2016. Print. Sexually Transmitted Diseases (STDs) and Pregnancy. American Pregnancy Association, (2016) Retrieved October 31 2016 from http://americanpregnancy.org/pregnancy-complications/stds-and-pregnancy/ Smith, Lynne M, Wang, Michelle, Zangwill, Kenneth Zangwill and Yeh,Sylvia. Trichomonas vaginalis Infection in a Premature Newborn (2002) Journal of Perinatology. Retrieved on November 4, 2016 from http://www.nature.com/jp/journal/v22/n6/full/7210714a.html Taylor-Robinson, D. Infections due to species of Mycoplasma and Ureaplasma: an update. (Oct 1996) Clin Infect Dis. 23 (4): 671–82. doi:10.1093/clinids/23.4.671 Retrieved 31 October 2016 from http://cid.oxfordjournals.org/content/23/4/671 Verdicts & Settlements: Failure to Prevent Early Labor. (2016) Michigan Cerebral Palsy Attorneys. Retrieved October 31 2016 from https://www.michigancerebralpalsyattorneys.com/legal-help-from-michigan-cerebral-palsy-attorneys/verdicts-and-settlements/failure-prevent-early-labor/ illustration Viscardi, RM. Ureaplasma species: role in neonatal morbidities and outcomes. Arch Dis Child Fetal Neonatal Ed;99(1):F87-92. doi: 10.1136/archdischild-2012-303351. (2014 Jan) Retrieved October 31 2016 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239122/ Waites KB, Katz B, Schelonka RL. Mycoplasmas and ureaplasmas as neonatal pathogens. Clin Microbiol Rev. 2005 Oct. 18(4):757-89. http://reference.medscape.com/medline/abstract/16223956 Waites, Ken B and Bronze, Michael Stuart Chief Editor. Ureaplasma Infection: Background, Pathophysiology, Epidemiology (October 24, 2016) Retrieved 31 October2016 from http://emedicine.medscape.com/article/231470-overview#a5 What are the treatments for bacterial vaginosis (BV)? National Institute of Child Health and Human Development. 2013-07-15. Retrieved November 4 March 2016 from https://www.nichd.nih.gov/health/topics/bacterialvag/conditioninfo/Pages/treatments.aspx Workowski, Kimberly A., Bolan, Gail. Sexually Transmitted Diseases Treatment Guidelines, 2015. Centers for Disease Control and Prevention, Morbitity and Mortality Weekly Report. (June 5, 2015) Vol 64 3. Print. Zheng, Jia; Xiao, Xinhua; Zhang, Qian; Mao, Lili; Yu, Miao; Xu, Jianping. The Placental Microbiome Varies in Association with Low Birth Weight in Full-Term Neonates (2015) Nutrients. 7 (8): 6924–6937. doi:10.3390/nu7085315. Retrieved October 31 2016 from http://www.mdpi.com/2072-6643/7/8/5315