CHLORHEXIDINE

Fetal Risk Summary

Chlorhexidine, a bisbiguanide antiseptic and disinfectant, is effective against most bacteria, and some fungi and viruses (including HIV). In addition to its topical use on the skin and intravaginally, it has been used for gingivitis and the prevention of dental plaque. Chlorhexidine has also been used as a spermicide (1). No adverse fetal effects were observed in pregnant rats administered chlorhexidine by gastric intubation on days 6 through 15 of gestation (2).

A number of studies have documented the safety and possible effectiveness of vaginal disinfection with chlorhexidine prior to delivery, primarily to prevent colonization of newborns with group B streptococci (3,4,5,6,7,8,9,10,11,12,13,14 and 15). Application to the groin and perineum, to the abdomen prior to cesarean section, and whole body washing has also been effective in preventing fetal and maternal infection (3,16,17,18 and 19). However, two double-blinded, placebo-controlled, randomized studies published in 1997, one utilizing a single intravaginal wash with 20 mL of a 0.4% chlorhexidine solution (20) and the other a 200 mL vaginal irrigation with a 0.2% solution (21), both groups in active labor, did not find a significant reduction in maternal infection rates compared with sterile water or saline. No adverse effects in the newborns were observed.

One author, hypothesizing an etiological connection between sudden infant death syndrome (SIDS) and toxigenic Escherichia coli or Chlamydia species, has suggested that decontamination of the birth canal with chlorhexidine during labor might reduce infant mortality from this disease (22), but a temporal relationship is speculative. In contrast to the real and theoretical benefits realized by the newborn from maternal chlorhexidine use, a single vaginal washing with a 0.4% chlorhexidine solution was not effective in decreasing the incidence of intra-amniotic infection or endometritis (23).

In one study involving nonpregnant women, swabbing of the entire vagina for 1 minute with gauze sponges soaked in 4% chlorhexidine gluconate did not result in detectable blood concentrations (sensitivity 0.1 µmg/mL) of the agent (24). A second study, utilizing a method ten times more sensitive (sensitivity 0.01 µmg/mL), was able to detect chlorhexidine in maternal blood from 34 of 96 women following vaginal washing with a 0.2% solution (25). Mean blood chlorhexidine concentrations obtained using two different methods of washing were 0.0146 µmg/mL and 0.0104 µmg/mL, respectively (range 0.01–0.083 µmg/mL). No accumulation of chlorhexidine in maternal blood was observed after a second vaginal washing at 6 hours in 14 patients or after a third washing, 6 hours later, in 3. The disinfectant was not detected in 62 of the women.

One writer has cautioned that the potential long-term effects (not specified) in the newborn from exposure to respiratory and other epithelial surfaces following vaginal use of chlorhexidine during labor have not been investigated (26). However, no reports of adverse effects in newborns have been reported even though chlorhexidine is used commonly during labor and in the neonate. Moreover, only very small amounts of disinfectant reach the maternal circulation and, presumably, the fetus. Although the agent is an effective disinfectant, single vaginal applications of chlorhexidine solutions do not appear to offer any advantage over sterile water or saline in the prevention of maternal infections during labor or in the postpartum period.

Breast Feeding Summary

No reports describing the excretion of chlorhexidine into milk have been located. The presence of the drug in breast milk is probably clinically insignificant because of the very small amounts absorbed into the maternal circulation following vaginal washing. As a general precaution, the mother's nipples should be rinsed thoroughly with water if chlorhexidine is used on them as a disinfectant, even though absorption of the agent from the gastrointestinal tract is poor.

References

1. Editorial. Multipurpose spermicides. Lancet 1992;340:211–3.
2. Gilman MR, De Salva SJ. Teratology studies of benzethonium chloride, cetyl pyridinium chloride and chlorhexidine in rats (Abstract). Toxicol Appl Pharmacol 1979;48:A35.
3. Vorherr H, Ulrich JA, Messer RH, Hurwitz EB. Antimicrobial effect of chlorhexidine on bacteria of groin, perineum and vagina. J Reprod Med 1980;24:153–7.
4. Christensen KK, Christensen P, Dykes AK, Kahlmeter G, Kurl DN, Linden V. Chlorhexidine for prevention of neonatal colonization with group B streptococci. I. In vitro effect of chlorhexidine on group B streptococci. Eur J Obstet Gynecol Reprod Biol 1983;16:157–65.
5. Dykes AK, Christensen KK, Christensen P, Kahlmeter G. Chlorhexidine for prevention of neonatal colonization with group B streptococci. II. Chlorhexidine concentrations and recovery of group B streptococci following vaginal washing in pregnant women. Eur J Obstet Gynecol Reprod Biol 1983;16:167–72.
6. Christensen KK, Christensen P. Chlorhexidine for prevention of neonatal colonization with GBS. Antibiot Chemother 1985;35:296–302.
7. Christensen KK, Christensen P, Dykes AK, Kahlmeter G. Chlorhexidine for prevention of neonatal colonization with group B streptococci. III. Effect of vaginal washing with chlorhexidine before rupture of the membranes. Eur J Obstet Gynecol Reprod Biol 1985;19:231–6.
8. Christensen KK, Dykes AK, Christensen P. Reduced colonization of newborns with group B streptococci following washing of the birth canal with chlorhexidine. J Perinat Med 1985;13:239–43.
9. Easmon CSF. Group B streptococcus. Infect Control 1986;7(Suppl 2):135–7.
10. Dykes AK, Christensen KK, Christensen P. Chlorhexidine for prevention of neonatal colonization with group B streptococci. IV. Depressed puerperal carriage following vaginal washing with chlorhexidine during labour. Eur J Obstet Gynecol Reprod Biol 1987;24:293–7.
11. Burman LG, Christensen P, Christensen K, Fryklund B, Helgesson AM, Svenningsen NW, Tullus K, and the Swedish Chlorhexidene Study Group. Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labour. Lancet 1992;340:65–9.
12. Burman LG, Tullus K. Vaginal chlorhexidine disinfection during labour. Lancet 1992;340:791–2.
13. Lindemann R, Henrichsen T, Svenningsen L, Hjelle K. Vaginal chlorhexidine disinfection during labour. Lancet 1992;340:792.
14. Henrichsen T, Lindemann R, Svenningsen L, Hjelle K. Prevention of neonatal infections by vaginal chlorhexidine disinfection during labour. Acta Paediatr 1994;83:923–6.
15. Kollée LAA, Speyer I, van Kuijck MAP, Koopman R, Dony JM, Bakker JH, Wintermans RGF. Prevention of group B streptococci transmission during delivery by vaginal application of chlorhexidine gel. Eur J Obstet Gynecol Reprod Biol 1989;31:47–51.
16. Vorherr H, Vorherr UF, Moss JC. Comparative effectiveness of chlorhexidine, povidone-iodine, and hexachlorophene on the bacteria of the perineum and groin of pregnant women. Am J Infect Control 1988;16:178–81.
17. Brown TR, Ehrlich CE, Stehman FB, Golichowski AM, Madura JA, Eitzen HE. A clinical evaluation of chlorhexidine gluconate spray as compared with iodophor scrub for preoperative skin preparation. Surg Gynecol Obstet 1984;158:363–6.
18. Sanderson PJ, Haji TC. Transfer of group B streptococci from mothers to neonates: effect of whole body washing of mothers with chlorhexidine. J Hosp Infect 1985;6:257–64.
19. Frost L, Pedersen M, Seiersen E. Changes in hygienic procedures reduce infection following caesarean section. J Hosp Infect 1989;13:143–8.
20. Sweeten KM, Ericksen NL, Blanco JD. Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection. Am J Obstet Gynecol 1997;176:426–30.
21. Rouse DJ, Hauth JC, Andrews WW, Mills BB, Maher JE. Chlorhexidine vaginal irrigation for the prevention of peripartal infection: a placebo-controlled randomized clinical trial. Am J Obstet Gynecol 1997;176:617–22.
22. Elfast RA. Chlorhexidine prophylaxis at labor. Prevention of sudden infant death? Lakartidningen 1993;90:3771–2.
23. Eriksen NL, Blanco JD. Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection (Abstract). Am J Obstet Gynecol 1995;172:304.
24. Vorherr H, Vorherr UF, Mehta P, Ulrich JA, Messer RH. Antimicrobial effect of chlorhexidine and povidone-iodine on vaginal bacteria. J Infect 1984;8:195–9.
25. Nilsson G, Larsson L, Christensen KK, Christensen P, Dykes AK. Chlorhexidine for prevention of neonatal colonization with group B streptococci. V. Chlorhexidine concentrations in blood following vaginal washing during delivery. Eur J Obstet Gynecol Reprod Biol 1989;31:221–6.
26. Feldman R, van Oppen C, Noorduyn A. Vaginal chlorhexidine disinfection during labour. Lancet 1992;340:791.