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

1. Cervical and Vaginal Pathogens and Preterm Labor. A Cuban Experience. JOHN ESSIEN, MD JESSICA BARDALES MITAC, MD PROF. J. M. RODR�GUEZ FERN�NDEZ �

3. FACTS

4. 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

5. FACTS In our hospital and in the Province of Camag�ey 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 Camag�ey and in Cuba, a significant decrease in the perinatal morbidity and mortality indexes has been achieved. 1Colectivo de Autores - Manual de diagn�stico y Tratamiento en Obstetricia y Perinatolog�a. La Habana. Editorial Ciencias M�dicas, 1997; 329-36; 406-20. 2Ministerio de Salud P�blica, Direcci�n Nacional de Estad�stica � Anuario Estad�stico 1996.

8. PATHOPHISIOLOGY

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

16. Cervical and vaginal infections Have accelerating effects on delivery mediated by proinflammatory cytokines such as the Tumor Necrosis Factor (TNF)? and Interleukin-1� (IL-1�). 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?.

23. HOW DO THEY GET THERE?

24. 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.

25. 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.

26. 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 twin�s membranes to the cervix, thus favoring ascending infection.

27. RESULTS

28. TABLE No.1 Obstetrical antecedents in relation with age groups.Hospital Ginecobst�trico Docente Provincial�Ana Josefa Betancourt de Mora�January 1, 2000 � June 30, 2000.

29. TABLE No. 2 Distribution of the clinical entities.

30. TABLE No. 3 Cervicovaginal pathogens diagnosed at simple smear in relation to those found at culture.

31. TABLE No. 4 Gestational age at diagnosis of cervicovaginal pathogens in relation to the age at delivery.

32. TABLE No. 5 Form of comencement of labor and the typr of delivery performed.

33. TABLE No. 6 Relation of the status of the neonate with the gestational age at delivery and weight at birth.

34. TABLE No.7 Distribution of perinatal morbidity.

35. TABLE No.8  Distribution of maternal morbidity.

36. CONCLUSIONS

37. The mean age of the women studied was 25,6�6 a�os. 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.

38. 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.

39. The birth weight was between 2000 and 2499 grams in 59% of the neonates. The mean weight was 1082�672 grams. Low Apgar scores was presented by 7,6% of the neonates at the first minute of life; none continued at the fifth minute.

40. 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.

41. RECOMENDATIONS

42. 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.