Microbial associations in postpartum endometritis
T.E. Samoilova1, N.I. Kokhno1, Sh.A. Dokudaeva2
1 Department of Gynecopathy and Reproductive Health of Continuing Medical Education Institute, Pirogov National Medical and Surgical Center, Moscow
2 LLC “Znakomii Doctor”, Moscow
Aim: to study the microflora of the birth canal with postpartum endometritis and to determine the associative risk of developing infectious-inflammatory pathology of puerperium.
Patients and Methods: the main group included 27 puerperas with signs of inflammation in the uterine cavity, who were discharged from the obstetric institution 4–6 days after delivery, but sought medical help with complaints of pain in the pelvic area and an increase in body temperature at 7th–9th day after birth. The control group consisted of 30 women after natural term birth with physiological puerperium period. Both groups were age-matched. All patients underwent bimanual examination and examination of the birth canal, ultrasound procedure, comprehensive study of the microflora of the birth canal and uterine cavity by the method of polymerase chain reaction, bacteriological study of the microflora of the birth canal.
Results: postpartum endometritis can manifest at 6th–9th day after birth. In postpartum endometritis, Staphylococcus spp. was found in 100% of cases in the birth canal and uterine cavity; Streptococcus spp. was manifested in the birth canal in the group with postpartum endometritis 11.2 times more often than in the physiological puerperium period, the microbial association of Sneathia spp. + Leptotrichia spp. + Fusobacterium spp.– 4 times more often. In postpartum endometritis, lactoflora was detected only in 44.4% of patients. The highest score of predictive validity were found for Staphylococcus spp., Streptococcus spp. The risk of postpartum endometritis is high when the genital tract is contaminated by staphylococcal flora (100%), enterococci (85.2%), streptococci (74.1%) and Ureaplasma urealiticum (70.4%) in concentrations up to 107–1010 genome-equivalent/sample.
Conclusion: women with early discharge from the hospital, with the presence of microflora in the birth canal, causing not only the infectious-inflammatory process in the uterine cavity but also associated with dysbiotic conditions of the vagina, are at risk of developing postpartum endometritis.
Key words: postpartum endometritis, Enterobacterium, Streptococcus, Staphylococcus, Ureaplasma urealiticum, puerperium, ultrasound criteria for the diagnosis of postpartum endometritis.
For citation: Samoilova T.E., Kokhno N.I., Dokudaeva Sh.A. Microbial associations in postpartum endometritis // RMJ. Medical Review. 2018. № 10. P. 6–13.
References
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39. Watts D.H., Eschenbach D.A., Kenny G.E. Early postpartum endometritis: the role of bacteria, genital mycoplasmas, and Chlamydia trachomatis // Obstet Gynecol. 1989. Vol. 73 (1). Р. 52–60.
40. Hoyme U.B., Kiviat N., Eschenbach D.A. Microbiology and treatment of late postpartum endometritis // Obstet Gynecol. 1986. Vol. 68 (2). Р. 226–232.
41. Ahmadzia H.K., Patel E.M., Joshi D. et al. Obstetric Surgical Site Infections: 2 Grams Compared With 3 Grams of Cefazolin in Morbidly Obese Women //Obstetrics and Gynecology. 2015. Vol. 126 (4). P. 708–715.
42. Martingano D., Renson A., Rogoff S., et al. Daily gentamicin using ideal body weight demonstrates lower risk of postpartum endometritis and increased chance of successful outcome compared with traditional 8-hour dosing for the treatment of intrapartum chorioamnionitis // J Matern Fetal Neonatal Med. 2018. DOI: 10.1080/14767058.2018.
43. Tita A.T., Hauth J.C., Grimes A., et al. Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis // Obstet Gynecol. 2008. Vol. 111 (1). Р. 51–56.
44. Mackeen A.D., Packard R.E., Ota E. et al. Antibiotic regimens for postpartum endometritis // Cochrane Database Syst-Rev. 2015. CD001067. DOI: 10.1002/14651858.CD001067.pub3.
45. Bonet M., Ota E., Chibueze C.E., Oladapo O.T. Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity // Cochrane Database Syst Rev. 2017. CD012137. DOI: 10.1002/14651858.CD012137.pub2.
46. Cluver C., Novikova N., Eriksson D.O. et al. Interventions for treating genital Chlamydia trachomatis infection in pregnancy // Cochrane Database Syst Rev. 2017. CD010485. DOI: 10.1002/14651858.CD010485.pub2.
2. Heine R.P., Puopolo K.M., Beigi R. et al. Committee Opinion No. 712: Intrapartum Management of Intraamniotic Infection // Obstet Gynecol. 2017. Vol. 130 (2): e95-e101. DOI: 10.1097/AOG.0000000000002236.
3. Rwabizi D., Rulisa S., Findlater A., Small M. Maternal near miss and mortality due to postpartum infection: a cross-sectional analysis from Rwanda // BMC Pregnancy Childbirth. 2016. Vol. 16. (1) Р. 177. DOI: 10.1186/s12884–016–0951–7.
4. Демографический ежегодник России. 2017. Статистический сборник. М.: Росстат, 2017. 265 с. [Demograficheskiy yezhegodnik Rossii. 2017. Statisticheskiy sbornik. M.: Rosstat. 2017. 265 s. (in Russian)].
5. Duff P. Pathophysiology and management of postcesarean endomyometritis // Obstet Gynecol. 1986. Vol. 67 (2). Р. 269–276.
6. Barrett S., Taylor C. A review on pelvic inflammatory disease // Int. J. STD. AIDS. 2005. Vol. 16 (11). P. 715–720.
7. Donders G. Diagnosis and management of bacterial vaginosis and other types of abnormal vaginal bacterial flora: a review // Obstet Gynecol Surv. 2010. Vol. 65 (7). Р. 462–473.
8. Sobel J.D. What’s new in bacterial vaginosis and trichomoniasis? // Infect Dis Clin North Am. 2005. Vol. 19 (2) Р. 387–406.
9. Soper D.E. Pelvic inflammatory disease // Obstet Gynecol. 2010. Vol. 116 (2 Pt 1). Р. 419–28.
10. Axelsson D., Brynhildsen J., Blomberg M. Postpartum infection in relation to maternal characteristics, obstetric interventions and complications // J. Perinat. Med. 2018 Apr. Vol. 46 (3). P. 271–278.
11. Стрижаков А.Н., Давыдов А.И. Трансвагинальная эхография: 2Д и 3Д методы. М.: ОСЛН, 2006. 160 с. [Strizhakov A.N., Davydov A.I. Transvaginal’naya ekhografiya: 2D i 3D metody. M.: OSLN, 2006. 160 s. (in Russian)].
12. Савельева Г.М., Кулаков В.И., Стрижаков А.Н. и др. Акушерство: Учебник / под ред. Г.М. Савельевой. М.: Медицина, 2000. 816 c. [Savel’yeva G.M., Kulakov V.I., Strizhakov A.N.i dr. Akusherstvo: Uchebnik / pod red. G.M. Savel’yevoy. M.: Meditsina, 2000. 816 s. (in Russian)].
13. Filker R., Monif G.R. The significance of temperature during the first 24 hours postpartum // Obstet Gynecol. 1979. Vol. 53 (3). Р. 358–361.
14. Rosene K., Eschenbach D.A., Tompkins L.S. et al. Polymicrobial Early Postpartum Endometritis with Facultative and Anaerobic Bacteria, Genital Mycoplasmas, and Chlamydia trachomatis: Treatment with Piperacillin or Cefoxitin // The Journal of Infectious Diseases. 1986. Vol. 153 (6). P. 1028–1037.
15. Gibbs R.S., Blanco J.D. Streptococcal infections in pregnancy. A study of 48 bacteremias // Am J Obstet Gynecol. 1981. Vol. 140 (4). Р. 405–411.
16. Gibney R.T., Moore A., Muldowney F.P. Toxic-shock syndrome associated with post-partum staphylococcal endometritis // Ir Med J. 1983. Vol. 76 (2). Р. 90–91.
17. Jorup-Rönström C., Hofling M., Lundberg C., Holm S. Streptococcal toxic shock syndrome in a postpartum woman. Case report and review of the literature // Infection. 1996. Vol. 24 (2). Р. 164–167.
18. Enterobacteriaceae (Электронный ресурс) URL: https://en.wikipedia.org/wiki/Enterobacteriaceae (дата обращения: 25.10.2018).
19. Harrison H.R. Prospective studies of Mycoplasma hominis infection in pregnancy // Sex Transm Dis. 1983. Vol. 10 (4 Suppl). Р. 311–317.
20. Patai K., Szilágyi G., Hubay M. et al. Severe endometritis caused by genital mycoplasmas after Caesarean section / /J Med Microbiol. 2005. Vol. 54 (Pt 12) Р. 1249–125l.
21. Ismail M.A., Moawad A.H., Poon E., Henderson C. Role of Chlamydia trachomatis in postpartum endometritis // J Reprod Med. 1987. Vol. 32 (4). Р. 280–284.
22. Soper D.E. Bacterial vaginosis and postoperative infections // Am J Obstet Gynecol. 1993. Vol. 169 (2 Pt 2). Р. 467–469.
23. Fernandez H., Gagnepain A., Bourget P., et al. Antibiotic prophylaxis against postpartum endometritis after vaginal delivery: a prospective randomized comparison between Amox-CA (Augmentin) and abstention / /Eur J Obstet Gynecol Reprod Biol. 1993. Vol. 50 (3). Р. 169–175.
24. Newton E.R., Prihoda T.J., Gibbs R.S. A clinical and microbiologic analysis of risk factors for puerperal endometritis //Obstet Gynecol. 1990. Vol. 75 (3 Pt 1). Р. 402–406.
25. Spore W.W., Moskal P.A., Nakamura R.M., Mishell D.R. Jr. Bacteriology of postpartum oviducts and endometrium // Am J Obstet Gynecol. 1970. Vol. 107 (4). Р. 572–577.
26. Casey B.M., Cox S.M. Chorioamnionitis and endometritis // Infect Dis Clin North Am. 1997. Vol. 11 (1). Р. 203–211.
27. Duff P. Staphylococcal infections / In Gleicher N (eds): Principles and Practice of Medical Therapy in Pregnancy, 2nd ed. // New York: Appleton and Lange. 1992. Р. 518.
28. Gibbs R.S. and Duff P. Progress in pathogenesis and management of clinical intraamniotic infection // Am J Obstet Gynecol. 1991. Vol. 164 (5 Pt 1). P. 1317–1326.
29. Burrows L.J., Meyn L.A., Weber A.M. Maternal morbidity associated with vaginal versus cesarean delivery // Obstet Gynecol. 2004. Vol. 103 (5 Pt 1). Р. 907–912.
30. Declercq E., Barger M., Cabral H.J. et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births // Obstet Gynecol. 2007. Vol. 109 (3). P. 669–677.
31. Bobitt J.R., Ledger W.J. Amniotic fluid analysis. Its role in maternal neonatal infection // Obstet Gynecol. 1978. Vol. 51 (1) Р. 56–62.
32. D’Angelo L.J., Sokol R.J. Time-related peripartum determinants of postpartum morbidity // Obstet Gynecol. 1980. Vol. 55 (3). Р. 319–322.
33. Ely J.W., Rijhsinghani A., Bowdler N.C., Dawson J.D. The association between manual removal of the placenta and postpartum endometritis following vaginal delivery // Obstet Gynecol. 1995. Vol. 86 (6). Р. 1002–1006.
34. Wilkinson C., Enkin M.W. Manual removal of placenta at caesarean section // Cochrane Database Syst Rev. 2000: CD000130.
35. Jazayeri A., Jazayeri M.K., Sahinler M., Sincich T. Is meconium passage a risk factor for maternal infection in term pregnancies? // Obstet Gynecol. 2002. Vol. 99 (4). Р. 548–552.
36. Tran S.H., Caughey A.B., Musci T.J. Meconium-stained amniotic fluid is associated with puerperal infections // Am J Obstet Gynecol. 2003. Vol. 189 (3). Р. 746–750.
37. Louis J., Buhari M.A., Allen D., et al. Postpartum morbidity associated with advanced HIV disease // Infect Dis Obstet Gynecol. 2006. Vol. 2006. Article ID 79512. DOI: 10.1155/IDOG/2006/79512.
38. Palacios-Saucedo G.C., Hernández-Hernández T.I., Rivera-Morales L.G., et al. Group B streptococcal perinatal infection: A Global, Latin American and Mexican Overview // Gaceta Médica de México. 2017. Vol. 153 (3). Р. 361–370.
39. Watts D.H., Eschenbach D.A., Kenny G.E. Early postpartum endometritis: the role of bacteria, genital mycoplasmas, and Chlamydia trachomatis // Obstet Gynecol. 1989. Vol. 73 (1). Р. 52–60.
40. Hoyme U.B., Kiviat N., Eschenbach D.A. Microbiology and treatment of late postpartum endometritis // Obstet Gynecol. 1986. Vol. 68 (2). Р. 226–232.
41. Ahmadzia H.K., Patel E.M., Joshi D. et al. Obstetric Surgical Site Infections: 2 Grams Compared With 3 Grams of Cefazolin in Morbidly Obese Women //Obstetrics and Gynecology. 2015. Vol. 126 (4). P. 708–715.
42. Martingano D., Renson A., Rogoff S., et al. Daily gentamicin using ideal body weight demonstrates lower risk of postpartum endometritis and increased chance of successful outcome compared with traditional 8-hour dosing for the treatment of intrapartum chorioamnionitis // J Matern Fetal Neonatal Med. 2018. DOI: 10.1080/14767058.2018.
43. Tita A.T., Hauth J.C., Grimes A., et al. Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis // Obstet Gynecol. 2008. Vol. 111 (1). Р. 51–56.
44. Mackeen A.D., Packard R.E., Ota E. et al. Antibiotic regimens for postpartum endometritis // Cochrane Database Syst-Rev. 2015. CD001067. DOI: 10.1002/14651858.CD001067.pub3.
45. Bonet M., Ota E., Chibueze C.E., Oladapo O.T. Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity // Cochrane Database Syst Rev. 2017. CD012137. DOI: 10.1002/14651858.CD012137.pub2.
46. Cluver C., Novikova N., Eriksson D.O. et al. Interventions for treating genital Chlamydia trachomatis infection in pregnancy // Cochrane Database Syst Rev. 2017. CD010485. DOI: 10.1002/14651858.CD010485.pub2.
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