Cervical and Vaginal Pathogens and Preterm Labor. A Cuban Experience.

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Cervical and Vaginal Pathogens and Preterm Labor.
A Cuban Experience.

• JOHN ESSIEN, MD
• JESSICA BARDALES MITAC, MD
• PROF. J. M. RODRÍGUEZ FERNÁNDEZ
•  

Hospital Ginecobstétrico Docente Provincial
Camagüey, Cuba.
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Preterm labor is that which occurs before 37
weeks of gestation(less than 259 days from the
first day of the last menstrual period) defined
by the World Health Organization(1970-1977).1
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FACTS
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FACTS

• Preterm labor constitutes one of the principal
  obstetrical and neonatological problems in Cuba
  today.
• It is present in 8 to 9 of births, nevertheless,
  it is associated to more than 75 of the
  perinatal mortality nationwide.1,2

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FACTS

• In our hospital and in the Province of Camagüey
  similar rates were found, with a prematurity
  index of 6 to 7 , related to 45.5 of the
  perinatal mortality between January and June,
  2000.
• In the last decade in the Province of Camagüey
  and in Cuba, a significant decrease in the
  perinatal morbidity and mortality indexes has
  been achieved.
• 1Colectivo de Autores - Manual de
  diagnóstico y Tratamiento en Obstetricia y
  Perinatología. La Habana. Editorial Ciencias
  Médicas, 1997 329-36 406-20. 2Ministerio de
  Salud Pública, Dirección Nacional de Estadística
  Anuario Estadístico 1996.

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PATHOPHISIOLOGY
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ETIOLOGY
PRETERM LABOR
IATROGENY -MATERNAL CAUSES - FETAL CAUSES
IDIOPATHIC
PREMATURE RUPTURE OF MEMBRANES
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CAUSES
EVIDENCES

• Intramniotic Infection

• Clínical

• Utero-Placental Isquemia

• Pathologic

• Fetal Malformations

• Microbiological

• Immunologic Factors

• Experimental

• Stress

• Biochemical

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Predisposing Factors

• Maternal

General
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Gynecological
Uterine

• Over distension.
• Infections (TORCH, Listeriosis, Salmonelosis)
• Malformations.
• Foreign body (IUD)
• Uterine fibroids.
• Cervical trauma.
• Cervical incompetence.
• Haemorrrhage before 20 weeks.
• Genital infections
• - Sexually transmitted (vulvovaginitis-urethr
  itis)
• - Bacteriuria

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• Fetal

• Congenital abnormalties.
• Multiple pregnancy.

• Ovular

•  Placental
• -Abruption
• -Placenta praevia.
• Tumors of the umbilical cord.
• Ruptur of the ovular membranes.

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The most frequent causes in our environment.

• Cervical and Vaginal infections.

• Maternal age Adolescence.

• Maternal malnutrition.

• Rupture of the ovular membranes.

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Cervical and vaginal infections

• Are associated to increased concentrations of
  bacterial endotoxins, proteases, mucinases,
  sialidases and phospholipases in the lower
  reproductive tract.

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Cervical and vaginal infections

• Have accelerating effects on delivery mediated by
  proinflammatory cytokines such as the Tumor
  Necrosis Factor (TNF)? and Interleukin-1ß
  (IL-1ß). These bioactive products, among others,
  act on cells promoting the synthesis of other
  cytokines and other inflammation mediators in
  the ovular membranes and decidua such as
  prostaglandins,especially PGE2 and PGF2?.

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Vagina Protective Mechanisms Dynamic Ecosystem
THE WOMANS NATIVE FLORA MICROBIAL VAGINAL IS
GOVERNED BY

• Variations due to the presence of newly
  discovered microorganisms.

• Changing life styles and social habits.

• Therapeutic Advances.

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Vaginal homeostasis is maintained by
Döderlein Bacilli
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NATIVE VAGINAL FLORA OF THE ADULT WOMAN
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• CERVICOVAGINAL INFECTIONS
• ARE CAUSED BY
• Abnormal pathogen.
• Pathologic increase of the native flora.
• Originating from the digestive tract.
• Iatrogenic manipulations.

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• BACTERIAL VAGINOSIS
•   Prevotella
• Porfiromonas
• Peptostreptococcus
• Mobiluncus
• Micoplasma hominis
• Gardnerella
• Bacteroides
• Veillonella

• Other associated pathogens
• Trichomonas vaginalis
• Streptococcus
• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Escherichia coli
• Candida albicans

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VAGINOSIS. OBSTETRICAL AND GYNECOLOGICAL
DISORDERS. 
Obstetrical

•   Chorioamnionitis
• Preterm labor
• Rupture of the membranes
• Postpartum endometritis
• Postpartum infections

Gynecological

• Abnormal vaginal secretions
• Mucupurulent cervicitis
• Recurrent urinary tract infection
• Postoperative infections
• Post hysterectomy cellulitis of the vaginal
  vault
• Endometritis
• Pelvic Inflammatory Disease

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HOW DO THEY GET THERE?
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• The most commonly known routes of access to the
  uterine cavity and the ovular membranes are
• Ascending from the vagina and cervix.
• Haematic disemination through the placenta, known
  as transplacental infection.
• Retrograde disemination through the fallopian
  tube towards the peritoneal cavity.
• Iatrogenic introduction germens placed through
  invasive intrauterine diagnostic procedures, such
  as Amniocentesis, amnioscopy, chorial villi
  biopsy and cordocentesis.

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• The ascending route has been identified as the
  most frequent access route of infection. This
  hypothesis has been demonstrated by
• The presence of germs of the normal flora of the
  female lower genital tract in congenital neonatal
  infections.
• The presence of antepartum chorioamnionitis
  associated to congenital pneumonia.

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• Histologically proven chorioamnionitis is more
  commonly located at the site of rupture of the
  membranes than in other sites such as the
  umbilical cord or the placenta as these sites are
  further away from the cervix.
• In biamniotic twin gestations chorioamnionitis is
  more frequent in the first twin than in the
  second due to the proximity of the first twins
  membranes to the cervix, thus favoring ascending
  infection.

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RESULTS
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TABLE No.1 Obstetrical antecedents in relation
with age groups.Hospital Ginecobstétrico Docente
ProvincialAna Josefa Betancourt de
MoraJanuary 1, 2000 June 30, 2000.
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TABLE No. 2 Distribution of the clinical
entities.
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TABLE No. 3 Cervicovaginal pathogens diagnosed
at simple smear in relation to those found at
culture.
   
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TABLE No. 4 Gestational age at diagnosis of
cervicovaginal pathogens in relation to the age
at delivery.
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TABLE No. 5 Form of comencement of labor and the
typr of delivery performed.
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TABLE No. 6 Relation of the status of the
neonate with the gestational age at delivery and
weight at birth.
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TABLE No.7 Distribution of perinatal morbidity.
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TABLE No.8 Distribution of maternal morbidity.
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CONCLUSIONS
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• The mean age of the women studied was 25,66
  años. 52,4 were nulliparous. Preterm labor and
  induced abortion were the most relevant
  antecedents in the gynecologic and obstetric
  history of these women.
• The most frequent diseases associated to
  gestation were ferropenic anemia, urinary
  infection and bronchial asma. Among the diseases
  dependent on pregnancy the most frequent were
  cervical incompetence, PROM and threatened
  preterm labor.

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• 87,1 of the population studied presented
  cervical and vaginal pathogens.
• Anaerobes responsable for Bacterial Vaginosis and
  Enterococcus spp. were the most frequently found
  pathogens.
• In 39,5 of the women were diagnosed with
  cervical and vaginal pathogen prior to the 25th
  week of gestation. 78,9 presented delivery
  between 33 and 36.6 weeks of gestation. The mean
  gestational age at diagnosis was 28,6 weeks and
  at delivery was 33,6 3 weeks.

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• The birth weight was between 2000 and 2499 grams
  in 59 of the neonates. The mean weight was
  1082672 grams. Low Apgar scores was presented by
  7,6 of the neonates at the first minute of life
  none continued at the fifth minute.

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• Perinatal morbidity was represented by low birth
  weight, repiratory depression and the hyaline
  membrane disease. 5 perinatal deaths were
  reported.
• Ferropenic anemia and postpartum endometritis
  were the most frequent maternal morbidity.

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RECOMENDATIONS
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• Judging from the powerful relationship between
  the presence of cervical and vaginal pathogens
  and pretem labor, it is worth emphazising on the
  identification of gravidae at risk, as well as
  the early detection of the presence of these
  microorganisms in these women.
• The use of readily available and simple tests,
  such as the simple vaginal smear, as well as the
  prompt and precise treatment of cervical and
  vaginal infections will help, in no little
  measure, to reduce the high perinatal morbidity
  and mortality that the association between
  pathogens and preterm labor produces.

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MUCHAS GRACIAS !