Syntax Literate: Jurnal Ilmiah Indonesia p�ISSN:
2541-0849
e-ISSN:
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Vol.
7, No. 5, Mei 2022
RELATIONS OF VAGINAL BACTERIAL INFECTION TYPES
BASED ON GRAM STAINING WITH PREMATURE RUPTURE OF MEMBRANES
Bayu Permana1, Ariadi2, Joserizal Serudji2
1 Obstetrics and Gynecology Department, Dr. M. Djamil Central General Hospital Padang, West Sumatera,
Indonesia
2 Sub Division of Fetomaternal Medicine, Obstetrics and Gynecology Department, Faculty of Medicine, Andalas University, Dr. M. Djamil Central General Hospital Padang, West Sumatera, Indonesia
Email: bayupermanapiliang@gmail.com,
[email protected], [email protected]
Abstract
Introduction: Premature rupture of membranes (PROM) is defined as rupture
of the membranes before delivery (<37 weeks is called preterm premature
rupture of membranes-PPROM, >37 weeks is called premature rupture of
membranes-PROM). PPROM complicates 3-8% of pregnancies and is responsible for
20-30% of all preterm births and perinatal morbidity. Bacterial infection in
the third trimester of pregnancy is a risk factor for PROM. Vaginal infections
originate from pathogenic microorganisms that interfere with the normal vaginal
flora. The microorganism causing the infection can usually be found by Gram
stain and/or vaginal swab culture. Objective: To determine the relationship between vaginal bacterial infection based
on Gram stain and the incidence of preterm premature rupture of membranes. Methods: This study is observational with a cross-sectional comparative
study design. Sampling was conducted from Mei 2020 hingga April
2021. A total of 60 pasien preterm who met the criteria were investigated, with 30 samples experiencing PROM and 30 samples not experiencing PROM. Every sample was performed vaginal swab to examine
the existence of bacterial infection based on Gram stain. The chi-square test was used for statistical analysis. Results: The most recent education level was SMA (PPROM 57%, non-PPROM 63%). Most
were multiparous (PPROM 73%, non-PPROM 67%) and delivered by cesarean section
(PPROM 70%, non-PPROM 90%). 63.3% of patients had vaginal infections (PPROM
90%, non PPROM 63.3%). Most infections are caused by gram negative bacteria.
The results of statistical tests showed that there was a significant relationship
between bacterial infection and the incidence of preterm premature rupture of
membranes (p<0.05) but there was no significant relationship between
bacterial species based on vaginal Gram staining and the incidence of preterm
premature rupture of membranes (p >0.05).
Conclusion: Gram stain examination should
be carried out routinely as an initial procedure for treating PROM patients so
that it can be a guide for selecting the right antibiotic therapy in future
studies.
Keywords: pprom; infection in pregnancy; bacterial
Introduction
Premature rupture of membranes (PROM)
is defined as the rupture of the membranes before delivery. If the rupture of
the membranes occurs before 37 weeks of gestation, it is called preterm
premature rupture of membranes (PPROM), whereas if it occurs after 37 weeks of
gestation, it is called premature rupture of membranes (PROM). PPROM
complicates 3%-8% of pregnancies and is responsible for 20%-30% of all preterm
births and perinatal morbidity (Adewumi et al., 2017),
(El-Messidi & Cameron, 2010).
One of the currently recognized risk
factors for PROM in the literature is the presence of bacterial infection in
the third trimester of pregnancy. Contamination of pathogenic microorganisms in
the vaginal environment can spread to the cervix and reach the amniotic cavity
so that it can trigger local inflammation and/or proteolytic processes
resulting in lesions of the membranes.4 The prevalence of genital infection in
women with preterm labor was 16.1% and 21.6% in PPROM.4 A study in India by Taralekar et al, stated that infections were 2-3 times more
common in patients with PPROM compared to PROM (Shivaraju, Purra, Bheemagani, & Lingegowda, 2015).
Vaginal infections are characterized
not only by the presence of pathogenic microorganisms, but also by changes in
normal vaginal microorganisms resulting in reduced Lactobacillus counts.
Several organisms have been associated with PPROM in various parts of the
world. Vaginal swab culture performed on women with PROM revealed Escherichia coli, Streptococcus, Staphylococcus,
Bacteroides and Klebsiella bacteria which are the types of bacteria that can be
detected quickly by Gram staining. These bacteria can be classified into Gram
positive or Gram negative which can be a reference in the administration of
specific antibiotics (P A, A.G G, 2018).
Another study conducted by Asrat et al. regarding Gram examination on amniocentesis in
PPROM patients found that 77 patients out of 108 patients had Gram negative
bacteria and only 31 patients had Gram positive bacteria. Both of these studies
showed the same results, namely more Gram-negative bacteria were found on Gram staining (Asrat, Nageotte, Garite, Gocke, & Dorchester, 1990).
A study conducted by Rani et al. found that the most bacteria found in vaginal
swabs were Gram negative bacteria in the PPROM group. Groups of bacteria E.
coli I and Staphylococcus aereus are the most common
types of bacteria found in this group (Rani, Mehra, Gupta, Huria, & Chander, 2014).
Prolonged anhydramnios
after PPROM is associated with a fourfold risk of adverse complications such as
fetal death, severe neurologic impairment and severe retinopathy (Tchirikov et al., 2018).
The most significant risk to the fetus after delivery with PPROM is the
complication of prematurity. Airway obstruction was reported as the most
frequent complication of labor. In addition, several complications such as
sepsis, intraventricular hemorrhage and necrotizing enterocolitis are also
closely associated with prematurity, but they do not occur frequently (Ehsanipoor & Major, 2012).
The diagnosis of PROM must be carried
out thoroughly through anamnesis, physical examination and investigations. To
determine one of the causes of preterm premature rupture of membranes, it must
go through various examinations such as vaginal inspection, ultrasound to
identify the causative bacteria by Gram staining to vaginal swab culture (P A, A.G G, 2018).
The researcher wanted to know the relationship between vaginal bacterial
infection based on Gram stain and the incidence of preterm premature rupture of
membranes.
Research Methods
This study is a cross-sectional
comparative study with an observational study design The
research was carried out at Dr. M. Djamil Padang's
Department of Obstetrics and Gynecology. Sampling was conducted from May 2020 to April 2021. Inclusion criteria
were 24-34 weeks of gestation, single live fetus as evidenced by ultrasound;
the state of the amniotic membrane as evidenced by the litmus test; and willing
to be a sample. Exclusion criteria were multiple fetuses, medical abnormalities
in pregnant women (diabetes mellitus, hypertension in pregnancy,
preeclampsia/eclampsia), and polyhydramnios. A total of 60 preterm patients who
met the criteria were investigated, with 30 samples having PPROM and 30 samples non-PPROM. Every sample
was performed vaginal swab to examine the existence of bacterial infection
based on Gram stain. The chi-square test was used for statistical analysis.
Results and Discussion
A. Results
Characteristics
of research respondents consisted of maternal age, education, parity before
pregnancy and vaginal bacterial infection (Table 1). Level The most recent
education level was senior high schoold (PPROM 57%, non-PPROM 63%). Most were
multiparous (PPROM 73%, non-PPROM 67%) and delivered by cesarean section (PPROM
70%, non-PPROM 90%). 63.3% of patients had vaginal infections (PPROM 90%, non
PPROM 63.3%). Most infections were caused by gram-negative bacteria (PPROM
46.7%, non-PPROM 36.7%).
Table 1
Characteristics of Respondents
|
Characteristics |
PPROM |
Non-PPROM |
|
Education levels |
|
|
|
Elementary school |
1 (3%) |
0 (0%) |
|
Junior high school |
8 (27%) |
6 (20%) |
|
Senior high school |
17 (57%) |
19 (63%) |
|
Bachelor degree |
4 (13%) |
5 (17%) |
|
Parity |
|
|
|
Primipara |
8 (27%) |
10 (33%) |
|
Multipara |
22 (73%) |
20 (67%) |
|
Treatment |
|
|
|
Vaginal birth |
9 (30%) |
3 (10%) |
|
cesarean section |
21 (70%) |
27 (90%) |
|
Vaginal infection |
|
|
|
Yes |
27 (90%) |
19 (63,3%) |
|
No |
3 (10%) |
11 (36,7%) |
|
Gram staining |
|
|
|
Positif |
13 (43,3%) |
9 (30%) |
|
Negatif |
14 (46,7%) |
10 (33,3%) |
|
No bacterial |
3 (10%) |
11 (36,7%) |
The relationship of vaginal
bacterial infections based on Gram staining with the incidence of preterm
premature rupture of membranes is presented in Table 2. Most infections are
caused by gram-negative bacteria. The results of statistical tests showed that
there was a significant relationship between bacterial infection and the
incidence of preterm premature rupture of membranes (p<0,05) but there is no significant
relationship between bacterial species based on vaginal Gram staining with the
incidence of preterm premature rupture of membranes (p>0,05).
Table 2
The Relationship Between Vaginal Bacterial Infections
And Their Types Based On Gram Staining With
The Incidence Of Preterm Premature Rupture Of Membranes
|
|
PPROM
|
Non-PPROM
|
P value
|
||
|
|
N
|
%
|
N
|
%
|
|
Vaginal infection
Yes
No
Gram staining
Positif
Negatif
No bacterial
|
27
3
13
14
3
|
90
10
43,3
46,7
10
|
19
11
9
10
11
|
63,3
36,7
36,7
40
23,3
|
0,015
0,051
|
B.
Discussion
Maternal education plays
an important role in the development of PROM. Mothers with higher levels of
education tend to be more aware of the health conditions of themselves and
their families apart from nutrition and health control during pregnancy. So
that mothers with higher levels of education are able to identify changes in
their pregnancy quickly (Maryuni & Kurniasih, 2017).
This is in line with Nafis' research in 2020 where
most of the samples were multipara, as many as 80 percent. Research conducted
in Semarang in 2002 showed that there was no relationship between parity and
the incidence of premature rupture of membranes (Ayu, Winarsih, & Nooryanto, 2016).
From this study, it was found
that the distribution of this study was in accordance with the research of Beevi et al, which showed that the distribution of
gram-negative bacteria was the most common bacterial pathogen in cases of
preterm premature rupture of membranes. The overall composition of
microorganisms before tearing of the membranes and the delivery process in
preterm cases from mild to extreme was comparable which gave an increased
incidence of chorioamnionitis at preterm gestation. This similarity was caused
by the reduction of Lactobacillus spp.
from the observations after the membrane tear occurred. The latent condition
between PROM and labor tends to be long in early pregnancy, allowing sufficient
time for remodeling of the bacterial group in the vagina with pathogenic infiltration
associated with ascending infection and chorioamnionitis. The mean latency time
after PROM was lower and the rate of chorioamnionitis was higher in women with Lactobacillus spp. decreased before
PROM. This suggests that vaginal microorganisms with an increase in bacteria
before PROM result in early labor as a result of inflammatory activation and
stimulation of the preterm labor pathway or as a result of a vaginal pathogenic
reaction causing ascending infection and chorioamnionitis when the membrane
defenses fail (Brown et al., 2019).
A study conducted by Rani
et al. found that the most bacteria found in vaginal swabs were Gram negative
bacteria in the PPROM group. Groups of bacteria E. coli and Staphylococcus aereus are the most common types of bacteria found in
this group. While in the control group, the most bacteria found were Gram
positive bacteria with the culture results mostly sensitive to gentamicin. This
research is in line with the research that has been done by the author by
finding the most bacteria are Gram negative bacteria (Saghafi et al., 2018).
A study conducted by Nikolaitchouk found that from 37 research samples, 42
species of bacteria were found from the results of vaginal secretion
examinations. In women with bacterial vaginosis, several species were found,
including Atopobium vaginale, Peptoniphilus harei, and Actinomyces urogenitalis. The bacterial
species found in lesser numbers was Lactobacillus
coleohominis (Nikolaitchouk, 2009).
A study conducted by Feld
et al. who conducted a study using Gram staining in patients with preterm
premature rupture of membranes immediately upon admission to the hospital. From
a total of 70 samples, 41.7 percent of them were found to be Gram-positive
cocci bacteria, 30 percent of which were positive for the results of Streptococcus haemolyticus culture. The results of
this study indicate that the administration of selective antibiotics according
to vaginal Gram swab staining is very useful in administering a suitable
antibiotic while waiting for the culture results (Feld & Harrigan, 1987).
In a study by Beevi et al, an analysis of 105 vaginal swabs was
performed. The results of the examination showed 31 samples in preterm labor
without PROM and 74 samples in those with PROM. The results of further
examination showed bacterial culture with 80% negative culture results and 20%
positive culture results. In this study, the prevalence of genital infections
in women with preterm labor was 16.1% and 21.6% in PPROM (P A, A.G G, 2018).
An Indian study by Taralekar et al, stated that there
were 2-3 times more frequent infections in patients with PPROM compared to PROM (Shivaraju et al., 2015).
From another study in
China, it was stated that broadly speaking, Gram-positive bacteria were
cultured in 18.4% of PPROM patients, and the most common was Group B Streptococcus and Gram-negative
bacteria were also cultured in 12.8% of PPROM patients, and the most frequent
was Group B Streptococcus. E. coli. Both Gram positive and negative
had an equally significant relationship between the occurrence of neonatal
sepsis with rapid onset (p=0.036 and p=0.001, respectively) (Li, Kong, & To, 2019).
Adewumi et al. obtained the
results of his study that Gardnerella vaginalis presented microscopically and
with a positive whiff test in 3 (5.3%) cases of preterm PROM but 1 (1.8%) in
the control group. Trichomonas vaginalis
was seen under the microscope in 3 (5.3%) cases of preterm PROM but 2 (3.6%) in
the control group. Candida albicans
was seen in 2 (3.6%) of the cases but 7 (12.5%) in the control group (Adewumi et al., 2017).
The results of a study
conducted by Saghafi et al found that 136 patients
with PROM had positive endocervical cultures which consisted mainly of
Gram-negative (31%) and 29% Gram-positive and 8% fungal species. The most
common pathogens found in endocervical culture were E. coli (24.2%) and epidermal
Staphylococci (14.7%), Staphylococci sapraphitices (12.5%), Enterococci (11.7%) and Candida
(11.7%).57 Other studies were conducted. by Asrat et
al. regarding Gram examination on amniocentesis in PPROM patients found that 77
patients out of 108 patients had Gram negative bacteria and only 31 patients
had Gram negative bacteria. Both of these studies showed the same results,
namely more Gram-negative bacteria were found on Gram staining (Asrat et al., 1990).
In a case-control study, Saremi et al examined maternal risk factors which included
vaginal culture, history of abortion and cervical length in 121 control
subjects (without PROM) and 121 subjects with PROM. The results of this study
stated that there was no significant relationship between the number of
pregnancies, cerclage procedures, and vaginal cultures with preterm PROM (Dars, Malik, Samreen, & Kazi, 2014).
In another study by Al Riyami et al., 44 women with preterm PROM were surveyed to
find out the association of risk factors and their side effects in Omani women.
The results of this study indicated that the most important risk factor was a
history of infection in 24 study subjects. In addition, there was no
significant relationship between gestational age, parity, maternal age and
caesarean section. Infection had a significant role both as a risk factor and a
cause of PROM in 27% of the study subjects. In conclusion, the researchers
stated that infection is still a high risk factor in patients with preterm PROM
(Al Riyami, Al-Ruheili, Al-Shezaw, & Al-Khabori, 2013).
In this study, the Odd
Ratio value was found to be 5.2. With the Odd Ratio assessment, it can be
interpreted that patients with infection have a 5.2-fold risk of developing
PROM. Based on the table above, it can also be seen that the overall p value in
this study was 0.02, so it can be concluded that there is a significant
relationship between the relationship between gram vaginal bacteria
infection and the incidence of preterm premature rupture of membranes. The
weakness in this study is that researchers are limited to carrying out Gram
staining on the results of vaginal swab examinations, further research should
be carried out with bacterial culture examination to determine the pattern of
bacterial infection in PROM.
Conclusion
There was no significant difference
between the sample characteristics in the PROM and Non-PROM groups. Most cases
of PROM were found to be infected with the most bacteria being Gram-negative
bacterial species. There is a relationship between bacterial infection and the
incidence of early PROM. Gram stain examination should be performed routinely
as an initial procedure in treating PROM patients in determining appropriate
antibiotic therapy while waiting for culture results and preventing resistance
to broad-spectrum antibiotics. Further research needs to be done by examining bacteria
through culture to find out more about the pattern of bacterial infection in
PROM and test resistance to these bacteria.
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Copyright holder: Bayu Permana, Ariadi, Joserizal Serudji (2022) |
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