Syntax Literate: Jurnal Ilmiah Indonesia p�ISSN: 2541-0849 e-ISSN: 2548-1398

Vol. 7, No. 5, Mei 2022

 

BACTERIAL VAGINOSIS ASSOCIATED WITH PRETERM PREMATURE RUPTURE OF MEMBRANES: A CASE REPORT

 

Aliffudin Nuur1, Indrahani Alwi 2 Aprilia Arifianti 3

Pacitan general hospital, East Java 1, Department of Obstetrics and Gynecology, Pacitan general hospital 2, PKU Muhammadiyah Wonosari Hospital 3

Email: [email protected], [email protected], [email protected]

 

Abstract

Bacterial vaginosis is condition which caused by increasing production of vaginal mucus. Nearly one of five women in Indonesia are affected by bacterial vaginosis. More than thirty percent symptom recurrent in 1 years. A i23 iyears iold iwoman, ifirst itime ipregnant icoming ito iemergency idepartment iin iour ihospital. iShe icomplained iabout i32 iweeks igestational iage icame iout iblood ispot iand ifluid ifrom ibirth icanal isince i10 ihours iago. iShe iis igenerally iwell icondition, iwith ino iabdominal ipain ior ibirth icanal ipain. iPatient icomplains iitchy iand ireddish ivagina. iShe ialso ihave irecurrent iwhitish ihistory ipreviously iuntil inow. iShe ialso isays iwhitish iputrid ismells iand igrey icolored isomewhat. iSpeculum isterile iexamination, ilooked iwhite ito igray imucus iwith iPH i5, iWhiff itest i(+), iamin ites i(+), iNugent iscore i= i7. iFetal iultrasonography iexamination ishows ithe iamnion iare iwithin inormal iAFI i10 icm. iNitrazine itest i(+).We present a women with preterm premature rupture of membranes that caused by bacterial vaginosis. The mechanism of preterm labor are breakdown iof imembrane iintegrity icausing irupture i(due ito iinflammation iand ithe iaction iof ithe iprotease ienzymes), iand iinclude ithe irelease iof iendotoxin, iexotoxin iand iprostaglandin ithat istimulating icytokines. iThe iTwo ihypotheses iput iforward ifor ibacterial ivaginosis ion ipreterm ilabor, ifirst; iorganisms ithat imove iascending ito ithe iuterus iand isecondly, ibacterial ivaginosis iis ia imarker iof iintrauterine icolonization iby isimilar iorganisms. Eventhough bacterial vaginosis did not included sexually transmitted infection, but the impact to preterm pregnancy as well as sexually transmitted infection.

 

Keywords: Bacterial, Vaginosis, Premature Rupture

 

Introduction

The whitish plea often attacks women with no-look age. Whitish (Fluor Albus) is the symptom of a discharge from the vagina and did not accompany by blood, which happened in the activity of flora normal which lived in the vagina. The normal flora of the vagina has many types, such as corynebacterium, Bacteroides, peptostreptoccocus, Gardnerella, mobilunucuc, mycoplasma, and Candida spp. In this case, vagina mucus is a natural mechanism to defense against and clean up the various infections. Whitish can occur either normally (physiological) or pathological. One of causing whitish in women is bacterial vaginosis (Bautista et al., 2016).

For the two last decade, some in vitro and in vivo research have been reported that bacterial vaginosis (BV), was the condition of vagina which common in reproductive age women. It have a biological risk factor that related to sexually transmitted infection (IMS), including chlamydia and gonorrhea. Although the etiology of vaginosis bacterial still unknown, we have been believed that happened when lactobacillus spp, which is the main species of healthy normal flora replaced by anaerobic bacteria, especially Gardnerella Vaginalis. It is causes decrease of H2O2 concentration that marked with increasing production of vaginal mucus, and become grey colored, thin, homogenous, smelling putrid and there are increase vagina PH. BV gives chief complain� fishy smells, itchy and redness. But 50 % patients did not give any symptoms. 7. High Incidence of BV founded in woman with pelvic inflammatory disease (PID). But there is no research shows that treatment to BV lower the risk of PID later. Microbial change that causes increase BV, still not all known, so is possibility by sexually transmission still unable to enforce. BV patients have a higher risk against other sexually transmitted infection (IMS). Bv In pregnant women could caused complications such as abortus, premature delivery, premature rupture of membrane and endometriosis postpartum (Clinton, Newell, Downey, & Ferreira, 2017).

A systematic review in 2013 reported that prevalence of BV vary widely across the world. Southern and eastern Africa women have BV (68% higher in Mozambique, 51% in Lesotho, 44% in Kenya, 37 % in Gambia). Women in southeastern Asia, Australia, New Zealand, and Indonesia usually have BV > 30%. Latin and Caribbean woman have lower prevalence of BV. In USA, BV become common condition in women, with prevalence of varying according to race / ethnic African-American (51%), Hispanic (32%), and white (23%). Aboriginal and Canadian women have high native BV (33%) (Pirotta, Fethers, & Bradshaw, 2009).

Preterm premature rupture of membranes (PPROM) is defined as rupture of membranes before the onset of labor. The most significant maternal risk of PPROM is intrauterine infection which increases with the duration of membrane rupture. Fetal risks include umbilical cord compression and ascending infection (Ecker et al., 2016).

Preterm premature rupture of membranes (PPROM) is a common clinical condition with significant impacts on obstetric outcome and is considered one of the �great obstetrical syndromes� responsible for spontaneous preterm birth (Lee et al., 2016). The amniotic cavity is a sac made of amnion and chorion known as chorioamnionitis membrane. The product of conception in the amniotic cavity is kept safe and sealed by ithis imembrane. Any ibreach in the integrity of the membrane is rupture of the membrane and the subsequent closer of the breech is considered resealing of ithe imembrane (Fortner et al., 2014). There have been several techniques developed inan attempt to artificially reseal the fetal membranes and prevent leakage of amniotic fluid, iincluding among others: intra-amniotic injection of platelets and cryoprecipitate (amniopatch), isealing ithe icervical icanal, iand ifetoscopic laser coagulation. However, there is as yet no effective and safe technique readily available to achieve this goal (Akolekar, Beta, Picciarelli, Ogilvie, & D�Antonio, 2015).It is very rare that resealing occurs spontaneously with rewarding outcome.

 

CASE

A i23 iyears iold iwoman, ifirst itime ipregnant icoming ito iemergency idepartment iin iour ihospital. iShe icomplained iabout i32 iweeks igestational iage icame iout iblood ispot iand ifluid ifrom ibirth icanal isince i10 ihours iago. iShe iis igenerally iwell icondition, iwith ino iabdominal ipain ior ibirth icanal ipain. iPatient icomplains iitchy iand ireddish ivagina. iShe ialso ihave irecurrent iwhitish ihistory ipreviously iuntil inow. iShe ialso isays iwhitish iputrid ismells iand igrey icolored isomewhat. iSpeculum isterile iexamination, ilooked iwhite ito igray imucus iwith iPH i5, iWhiff itest i(+), iamin ites i(+), iNugent iscore i= i7. iFetal iultrasonography iexamination ishows ithe iamnion iare iwithin inormal iAFI i10 icm. iNitrazine itest i(+), iconfirmed iPROM. iUrinalysis itest iresults ilooked imurky iurin iyellow icolor, iph i4, ispecific igravity i1,010. iMicroscopic iexamination, ileukosit iesterase i7/LP, iepithelial i6/LP iand ibacteria icoccus i(+)

 

Result and Discussion

LAND SUBSIDENCE MODEL

�� Bacterial iVaginosis i(BV), ipreviously iknown ias ivaginitis inonspecific, ibecause iit iis iassociated iby ibacteria iand iinflammation iprocess. iBV iis ithe imost icommon icause iof ivaginitis iand iinfection iwhich ioccurred i ito ithe imost icommon igynecological ioutpatient ipoly. iThe icharacteristics iof iBV iare iwhitish iand ifishy ismell icaused iby ichanges iin ithe inormal iflora ivagina. i iWhitish iBV iis itypically idescribed ias ia ihomogeneous igrey ipristine iliquid ithat iattached ito ithe ivaginal imucosa. iMany iresearch ishows ithat ithere iwere irelations ibetween iGardnerella ivaginalis iand ianother ibacteria ithat icaused iBV. i(Bautista et al., 2016). iBV iis iknown ias ipolymicrobial isynergistic iinfection. iSome iof ispecies ithat iare iassociated isuch ias ilactobacillus, iprevotella iand ianaerobic ibacteria iincluding iMobiluncus, iBacteroides, iPeptostreptococcus, iFusobacterium, iVeillonella iand iEubacterium ispecies. iMycoplasma ihominis, iUreaplasma iUrealitycum iand istreptococcus imay ibe iinvolved iin iBV. i(Pirotta et al., 2009)

�� Bacterial ivaginosis iis iconnected iwith ithe iincidence iof ipreterm ilabor. iThese ifindings iare iin iline iwith iprevious icohort istudies. iA icohort istudy iwith ia isample iof i234 ipregnant iwomen ipresenting iwith ithe ithreat iof ipreterm ilabor, ibacterial ivaginosis iand isexually itransmitted iinfections iwere ithe imost icommon icauses iidentified iin ithe istudy iand icaused ipreterm ilabor ibetween i24 ito i32 iweeks' igestation (McPheeters et al., 2005).

�� In iBV, ithe ivaginal iflora ichange ithrough itheir imechanism iof iknown iand iunknown, ithat icausing ian iincrease iof ilocal iPH. iThis ihappens idue ito ireduced ilactobacilli iwhich iproduce ihydrogen iperoxide. iLactobacilli iare iorganisms ithat iformed ia ilarge itrunk iwhich ihelps imaintain ithe ihealthy iacidic iPH iof ivagina iand iinhibit iother ianaerobic imicroorganism ithrough ithe ielaboration iof ihydrogen iperoxide. iMostly, ilactobacilli iare ifounded ihigh iconcentrations iin ihealthy ivagina. iIn iBV, ithe ipopulation iis igreatly ireduced, iwhile ivarious itypes iof ianaerobic ibacteria iand iG ivaginalis iare iincreasing, iwhere iG ivaginalis iforms ibiofilms iin ithe ivagina. iSome iresearch isuggests ithat ithis ibiofilm imay ibe iresistant ito isome idrugs. iDominant iBiofilm iof iG iVaginalis ihas ibeen iproven ito isurvive iin ihydrogen iperoxide i(H202), ilactic iacid, iand ihigh ilevels iof iantibiotics.

Although iBV iis inot iallowed ias ia isexually itransmitted idisease, isexual iactivity ihas ibeen iassociated iwith ithe idevelopment iof ithis iinfection. iThe iobservation ithat isupports ithis ithing iinclude i: i(1) ithe iincidence iof iBV iincrease iwith ian iincrease iin ithe inumber iof inew isexual ipartner, i(2) inew isexual ipartner ican ibe iassociated iwith iBV, iand i(3) ithe imale ipartners iof iwoman iwith iBV imay ihave icolonization iof iurethra iby ithe isame iorganism, ibut imale iis inot ishowing iany isymptoms. iMore irecent istudies ishow ithat iBV iis iassociated iwith ichanges iin imediators iof iimmune idissolved iparticular, iincreased itarget icell iof iHIV, iand idecrease iof iendogenous iantimicrobial iactivity, iwhich imay icontribute ito iincreasing irisk iof iHIV itransmission

�� The ichief icomplaint iare ioften iobtained iof iBV isuch ias ivaginal iodor ithat�s itypical iof ifishy ismell i(fishy iodor) iand iitching. i iMalodor icomplaint iare ioften icauses iby iincreasing iamin, iespecially iTrimethylalamina ithat iis iproduced iby iG. iVaginalis, iM.Hominis, iand iMobiluncus ispp. iAmin ievaporates iwhen ivaginal ifluid ibecomes ialkaline. iAlkaline ifluid icement i(ph i7,2) icauses irelease iamin ifrom ithe iattachment iin iprotein, iand ievaporate iof iamin icaused ia icharacteristic iof iodor. i

Irritation iof ithe ivaginal iarea ior iaround ivagina ican icause ipain. iIn ithis icase, ithe ipatient icomplained ia ihistory iof irepeated iwhiteness iwith iitching isymptoms iand iincreasing iof iabnormal ivaginal idischarge. iThis idischarge ismells ifishy iand igrey-colored. iOn ispeculum isterile iexamination, iit iappears iwhite ito igray isecret. i iShades iof igray iin ivaginal idischarge iare ia itypical ipictures iof ibacterial ivaginosis.

�� The iexamination ishows iWhiff itest i(+), iamen itest i(+), iNugent iscore i=7 i. iWhiff itest iis ione iof ithe itests iare itypically iin iBV icases. iWhiff itest ior iAmen iis idone iby idripping iKOH i10% ion ivaginal idischarge. iA ipositive iresults ion iwhiff itest ithat ifishy ismells ior ifishy iodor.

 

AMSEL iCRITERIA i(3 iDARI i4) i

Homogen imucus, igrey, i(1 idari i3 ikekuningan, iencer) i

pH ivagina i>4,5 i(spesifikasi irendah)

Whiff itest ipositif i(amine itest-sensitifitas irendah) i

>20% iclue icells ipada ipreparat ibasah i(NaCL)/ imikroskopis i(>>90% isensitifitas) i

����������� This ipastient icase iusing icriteria iof inugent iget iscore i=7. iNugent icriteria iis ithe igold istandar iin ienforcement idiagnosis iof iBV, ibecause iit ihave iexcess ion iobjectivity ivalue, isensitivity iand ispecificity. iThe inugent iciteria ihas i7 iscore. i0-3 iis iconsidered inormal, i4-6 iis iconsidered ias iintermediate iand i7 ior imore iis ian iinfection iof iBV

Skor i

Lactobacillus

(Paralel-sided, iGram-positive irods) i

Gardnella/Bacteriodes i(Tiny, iGram-variable icoccobacilli iand irounded, ipleomorphic, iGram-Negative irods iwith ivacuoles) i

Mobiluncus i( iCurved, iGram-negative irods)

0

>30

0

0

1

5-30

<1

1-5

2

1-4

1-4

>5

3

<1

5-30

 

4

0

>30

 

 

�� On ithis icase, ithe ipresence iof ivaginitis icaused iweakness ion iamniotic imembranes ithat iinduced ipreterm ipremature irupture iof imembranes. iBacterial ivaginosis i(BV) iin ipregnant iwoman iis ia irisk ifactor ifor ivarious itypes iof icomplications iin ipregnancy, iincluding ipreterm ipremature irupture iof imembranes. i iMechanisms iof ipreterm ilabor idue ito iinfection iare ipart iof ithe ibreakdown iof imembrane iintegrity icausing irupture i(due ito iinflammation iand ithe iaction iof ithe iprotease ienzymes), iand iinclude ithe irelease iof iendotoxin, iexotoxin iand iprostaglandin ithat istimulating icytokines. i iThe iTwo ihypotheses iput iforward ifor ibacterial ivaginosis ion ipreterm ilabor, ifirst; iorganisms ithat imove iascending ito ithe iuterus iand isecondly, ibacterial ivaginosis iis ia imarker iof iintrauterine icolonization iby isimilar iorganisms (Goffinet et al., 2003).

�� Bacterial ivaginosis iin isome iresearch ican iincrease iinterleukin-1 ibeta ilevels iin iwomen, iwhich iin iturn ican ilead ito iactivation iof iMatrix iMetalloproteinases i(MMP) isuch ias iMMP-1 iand iMMP-9. iMetalloproteinase imatrix iwill iact ias ian ienzyme ithat idegrades ithe iextracellular imatrix iin ithe icervix iand icauses icervical iweakness idue ito iinflammatory iprocesses. iApart ifrom iIL-1B, iIl- i6 iand iIL-8 ilevels iwere ialso iincreased iwhich iinduced ia itissue iinflammatory iresponse. 15 iIn itheory, ipathogenic ibacteria ican imove iascending iinto ithe iuterus iand icause iinflammation ithat ileads ito ipremature irupture iof imembranes, ipremature ilabor iand ifetal iinfection (Verma, Avasthi, & Berry, 2014). i iIn ia iprevious icase icontrol istudy, iit iwas ifound ithat i36.54% iof ipregnant iwomen iwith iurinary itract iinfections iin ithe ipopulation iof ipatients ipresenting iwith ipreterm ilabor (Granda Velasco, 2020).iThis iis ianalogous iwith ia istudy iof i272 ipatients iin iwhich i35.6% ihad ipositive iurine icultures iand i32.9% ihad ipreterm ilabor (Lim et al., 2011). iSignificant iassociations iwere ialso ireported iby iprevious iinvestigators, i34% iof iurogenital iinfections iwere iobserved ias ia isignificant icause iof ipreterm ilabor.

�� The iinflammatory iresponse icauses ithe irelease iof iproinflammatory icytokines isuch ias iIL-1 ibeta, iIL-6, iIL-8 iand iTNF-α iin ibacterial ivaginosis. iThis iproinflammatory icytokine iwill istimulate ithe irelease iof iMMP, iespecially iMP-8. iNeutrophils iproduce iMMP-8 iand icause idegradation iof ithe imembrane. iMMP-8 ican idegrade ia ilarge inumber iof iextracellular imatrix iproteins isuch ias icollagen i1 iand iIII. iThe iprocess iof iinfection ishowed iincreased ilevels iof iMMP8 iand idegradation iof iproteoglycans ithat icompose ithe imembranei(McPheeters et al., 2005). i iConcerning ito icytokines, iamniotic ifluid icytokines isuch ias iinterleukin-1 i(IL-1), iinterleukin-6 i(IL-6), iinterleukin-8 i(IL-8), itumor inecrosis ifactor-alpha i(TNF-α), iand igranulocyte icolony-stimulating ifactor i(G- iCSF) iis ifirmly iassociated iwith iinfection, ipremature irupture iof imembranes iand ipreterm ilabor iwhich icannot ibe istopped iwith itocolytic itherapy. iThe icytokines iin iconcert iwith iprostaglandins iwill istimulate ipremature ilabor (Caughey, Robinson, & Norwitz, 2008).

�� Degradation iof iamniotic ifluid icauses preterm premature irupture iof imembranes. iPPROM iin ipremature ipregnancy icauses imaternal iand ineonatal icomplications. iSome iof icomplications ithat icaused iby iPPROM isuch ias iPremature idelivery, ichorioamnionitis, iplacental iabruption, ipostpartum ihemorrhage, iendometriosis, ipreterm iinfants, ineonatal isepsis iand ieven ideath iof ifetus. iIn ithis icase, ithe ipatient iis i23 iyears iold iwhich iis ithe iproductive iage iof ihigh isexual iactivity. i iHormonal icanges ilikes idecreasing iestrogen ilevel, icauses iincrease iof ivagina iPH. iThis ienvironment iis inot ioptimal ifor ilactobacillus ispp igrowth, ihowever iconducive ito iother imicroorganism ithat icauses iBV. iThis isituations ialso ihappen iin ipregnant iwoman (Caughey et al., 2008).

�� A Systematic review by Mehta SD on 80 patients with diagnosis of BV showed Whiff test sensitivity was 87% and specificity 96%. The diagnosis of BV is enforced based on Amsel criteria.�

Women who suffer from BV are associated with increased risk of STI (sexually transmitted infection) such as HIV, Gonorrhea, Chlamydia, and herpes simplex. Susceptibility of STI transmission is associated with decreasing protection of Lactobacillus, increasing abnormal flora, and decreased secretion of leukocyte protease inhibitor vagina (Pirotta et al., 2009).

 

Conclusion

����������� The prevalence rate of bacterial vaginosis among pregnant women is high, that significantly associated with preterm delivery. Awareness of the condition and treatment may help to reduce the adverse outcome

 

 

 

 

 

 

 

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Copyright holder:

Aliffudin Nuur, Indrahani Alwi, Aprilia Arifianti (2022)

 

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