IJCRR

IJCRR - 4(10), May, 2012

Pages: 67-72

Date of Publication: 25-May-2012

CORRELATION OF MATERNAL BACTERIAL VAGINOSIS WITH NEONATAL SEPSIS

Author: Deepti Shrivastava, Indradip Bandyopadhyay, N. S. Tankhiwale, Swati Chavan

Category: Healthcare

Abstract:Bacterial vaginosis is a common disease found in pregnant women. Patients presented with white
discharge per vaginum are often victims of preterm labor. Babies of mother with excessive white
discharge mostly needed ICU admissions. Correlation of maternal infections, with neonatal sepsis was
suspected.

Full Text:

INTRODUCTION
The birth of a healthy child is a well orchestrated event that encompasses several facets including prenatal and perinatal factors. However it is not a rare event that the entire gestational period of 280 days is often confronted with innumerable risk factors that affect the birth of a healthy neonate. These factors could be maternal, fetal, placental or of idiopathic origin, of which maternal infection in the form of bacterial vaginosis (BV) is well documented (1). BV is a polymicrobial syndrome caused due to altered pH conditions of the vaginal niche. As a result the normal vaginal flora is replaced by anaerobic organisms. Commonly, the predominant lactobacillus gets replaced by a mixed population of Gardnerella vaginalis, Peptostreptococci, anaerobic gram negative bacilli, Mobiluncus, Provotella and Mycoplasma sp. causing chronic infection and vaginal discharges (2, 3).

BV during pregnancy has been associated with increasing risks of spontaneous abortion, preterm labor, premature birth, preterm premature rupture of the membranes, amniotic fluid infection, postpartum endometritis, and post-cesarean wound infections making the scenario alarming (4, 5). Furthermore increasing association of BV with preterm labor makes antenatal diagnosis of BV mandatory in pregnant women (6). Hence, considering the dreading sequel of events of BV, its association with the pregnancy/gestation is a matter of deep concern. Neonatal septicemia is a syndrome diagnosed by systemic signs of infection during the first month of life (7, 8). Sepsis is the leading cause of neonatal morbidity and mortality (30-70%) in India (9). Infection is usually acquired intrapartum or from the maternal birth canal and is transmitted before or during the birth process. Hence imbalance of the normal vaginal flora due to altered biochemical characteristics of the vaginal niche could serve as a potent risk factor causing neonatal infection. So the prospective study was undertaken to determine a probable correlation between BV in pregnancy and the fate of the neonate using sepsis as a monitoring index MATERIALS AND METHODS Study population A total of 100 pregnant women with different gestational stages of pregnancy positive for BV infection were selected as subjects. In parallel, 100 suitable healthy pregnant women without BV served as controls. The study was done in between the period from March 2010 to December 2011. The subjects were selected for the study at carried out in the department of Obstetrics and Gynecology and Department of Microbiology of Jawaharlal Nehru Medical College, AVBRH Sawangi (M), Wardha, as per the following selection criteria mentioned below: Inclusion criteria 1. Singleton pregnancy 2. Gestational age: two groups, between 28-36 weeks (preterm) and 36-40 weeks (full term). 3. Painful uterine contractions >2 in 10 minutes each lasting > 45 seconds. 4. Cervical dilatation 1 to 4 cm. 5. Cervical effacement >25% Exclusion criteria 1. Gestational age 4.5: vaginal pH was determined using pH indicator paper (range 2-10.5) with color scale. ii. Color and consistency: Thin grayish white homogenous iii. Whiff test (or Amine test): A few drops of 10 % KOH solution was added to the vaginal discharge, mixed and the emission of a strong fishy odor indicated a positive test. iv. Detection of clue cells in smear preparation: A wet smear preparation was done, stained with Gram stain and presence of more than 20 % clue cells was considered positive. Light microscopy of immediate wet mounts was done to identify different microbes. Nugent?s score is based on the gram staining of different vaginal morphotypes (11). Their number was enumerated based on the number visualized in oil immersion under 1000X magnification. The Nugent criteria score vaginal flora as normal (0- 3), intermediate (4-6) and BV (7-10) Detection of neonatal septicemia The study was performed in babies aged 0-28 days delivered from women diagnosed of BV during pregnancy (12, 13). In parallel, babies from healthy women served as control. A detailed history including the age, sex, birth weight, gestational age and manifestations of clinical septicemia was noted. Subsequently, routine blood culture investigations for diagnosis of infection were performed (14, 15). In brief, blood (4 mL) was drawn in sterile syringe after skin preparation by 2 step process. The organisms were isolated and identified by standard microbiological methods. Culture was monitored for 1-7 days respectively and the observation was correlated with BV, the associated maternal risk factor of the study. Statistical analysis Values show the means ± SD of triplicate results from single representative experiments. Three independent experiments were routinely carried out for each assay. Student's t test was used to determine the level of statistical significance. P<0.05 was considered significant. RESULTS We enrolled 100 pregnant women, who were further categorized as preterm and full term pregnancy. The study and the control groups were comparable as per age, weight, gestational age, haemoglobin content, parity and socioeconomic status as shown in Table 1. The diagnosis of BV was done by performing the tests defining Amsel?s criteria. The mean pH of the vaginal discharge of women in the study group was significantly higher (4.72 ± 0.35) as compared to that in the control (BV-) group (3.72 ± 0.55, p<0.01, Table 2) indicating their positivity for bacterial vaginosis (hence referred as BV +). Interestingly, the mean pH of the vaginal discharge of BV + women in preterm and full term pregnancy was almost similar, the values being (4.72 ± 0.31 and 4.73 ± 0.28). Additionally, 52 % of pregnant women showed thin white homogenous vaginal discharge that signified presence of BV in them. Similarly, Whiff test or amine test was positive in increased number (56 ± 2 %) of BV+ pregnant women in the study. In contrast only 15% of BV-ve pregnant women comprising the control group showed positive amine test. The fourth test of Amsel?s criteria to estimate the percent of clue cells was performed with samples taken from the BV+ pregnant women and the results were compared with that of the control group. The study group revealed significantly higher number of pregnant women with clue cells as compared to the control group indicating the occurrence of BV during pregnancy. Nugent?s scoring system based on the identification of the different bacterial morphotypes from individual smear preparation confirmed that 45 % pregnant women were positive for BV. The results corroborating the presence of BV by whiff?s test showed a good correlation (r = 0.98) with that observed by scoring method. Clinical symptoms of neonatal sepsis The aim of this study was to investigate the probable correlation between the outcomes of neonatal sepsis in the babies delivered from women positive for BV during pregnancy. Primarily to assess the indications of neonatal sepsis, the behavioral attributes of the babies were monitored and as to the babies delivered from the control group. The babies showed refusal of feed, lethargy, hypothermia, irritability, respiratory distress, jaundice, abdominal distension, seizures, and cyanosis. In most of the cases the babies showed an incidence of several features. The blood culture from the babies showed the growth of microorganisms. The microbial flora depicted the profile of neonatal sepsis mostly comprised of Gram negative bacilli. Some of the predominantly occurring culture positive organisms were Klebsiella sp., Staphylococcus aureus, E.coli, Pseudomonas aeruginosa, Enterobacter sp., Acinetoacter sps. Candida sp. Time of culture positivity was significantly observed within 4 days, which saved time for initiation of the required treatment. The incidence of neonate sepsis showed a good correlation (0.99) with the presence of bacterial vaginosis in pregnant subjects. DISCUSSION Neonatal sepsis is one of the important factors causing neonatal deaths. It is commonly described as a clinical syndrome of bacteremia manifested with symptoms within the first 4 weeks of life (7, 16). Neonatal sepsis has a wide range of risk factors involving frequent vaginal checkups during pregnancy, premature birth, infected maternal birth canal and infected placenta. However if diagnosed and treated with proper antibiotic therapy sepsis can be cured. BV is the most common cause of vaginitis. The prospective study demonstrated the presence of BV, as evidenced by Nugent?s scoring system and postivity in Amsel?s criteria. Amine test which is both highly sensitive and specific was positive in patients with BV. Our study detected 45 % cases by smear examination. The presence of clue cells also predicted BV. Previously, reports have documented the incidence of BV with preterm delivery and the complications associated with it (17-19). In this study we have corroborated the presence of BV in patients all throughout their pregnancy (preterm and full term). Interestingly, since BV culminates in the alteration of the microbial population in the vagina, we observed a good correlation of the incidence of neonatal sepsis in patients positive for BV. The study demonstrated that the neonates from mothers? positive for BV demonstrated signs and symptoms of sepsis which was further confirmed through blood culture studies.

CONCLUSION
Thus we conclude that of the many factors influencing neonatal sepsis, the incidence of bacterial vaginosis poses preponderance for its outcome. Moreover the presence of BV at any phase of pregnancy shows a good correlation with neonatal sepsis. Mothers with bacterial vaginosis invariably had some detrimental effects on their babies.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

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