© 1990 S. Karger AG, Basel 0378-7346/90/0303-0155Î2.75/0
Gynecol Obstet Invest 1990;30:155-158
Serum-Specific Antibodies for Chlamydia trachomatis in Preterm Premature Rupture of the Membranes Ilan Cohena, Ella Tenenbauma, Moshe Fejgin3, Galia Michaeli*, Yoram Beytha, IsraelSarovb a Department of Obstetrics and Gynecology ‘A’, Meir General Hospital, Kfar Saba; bVirology Unit, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
Key Words. Antibodies • Chlamydia trachomatis
■
Membranes, preterm and premature rupture of
Abstract. A case control study was performed to examine possible morbidity associated with Chlamydia tracho matis in 15 pregnant women with idiopathic preterm premature rupture of the membranes (PROM; group A), and in two control groups, 35 healthy preterm pregnant women (group B), and 43 healthy pregnant women at term (group C). Serum C trachomatis IgG and IgA specific antibodies were determined using the single serovar (L2) inclusion immunoperoxidase assay. There were no significant differences in the prevalence rate of elevated levels of chlamydia IgG specific antibodies (titer >: 1:128) between pregnant women suffering from idiopathic preterm PROM, as compared to healthy preterm and term pregnant women (20, 28 and 26%, respectively). Nor were there any significant differences in the prevalence rate of elevated levels of chlamydia IgA specific antibodies (titer >: 1:16) between pregnant women with idiopathic preterm PROM, as compared to healthy preterm and term pregnant women (20, 20 and 17%, respectively). These findings do not support the assumption that C. trachomatis may play role in preterm PROM.
Preterm premature rupture of the membranes (pre term PROM) causes considerable perinatal morbidity and mortality, and is one of the most common and chal lenging problems in obstetrics and in public health. Sev eral observations indicate that there is a high incidence of pathogenic or potentially pathogenic bacteria in the uterine cervix that may cause preterm PROM [1], and that maternal genital tract infection may frequently play an etiologic role in preterm PROM [2, 3]. An increased prematurity rate has subsequently been associated with maternal infection by group B streptoccoci, Neisseria gonorrhoeae, herpes simplex virus and Chlamydia tra chomatis [4], Cervical infection with C. trachomatis has become an increasingly recognized problem in perinatal clinics [5]. The prevalence of chlamydial infection of the cervix in pregnant women has been reported to be between 2 and 37% [6]. However, the effect of maternal chlamydial infection on pregnancy outcome and perinatal complica
tions, such as preterm labor and birth, premature rup ture of the membranes, and low-birth weight infants, remains controversial. Although some studies have found an association between cervical C. trachomatis and an increased risk of adverse pregnancy outcome [7], others have questioned such an association [8-10]. Ele vated titers of IgA and IgG antichlamydial antibodies have been suggested as markers of active chlamydial infection [8, 11-19], In this study, we examined the prevalence of chlamy dia IgG and IgA specific antibodies in the serum of preg nant women suffering from preterm PROM of unknown etiology by using the single serovar (L2) inclusion immu noperoxidase assay (IPA).
Selection of Patients From April to August 1985, women admitted to the Department of Obstetrics and Gynecology ‘A’ at the Meir General Hospital in Kfar Saba, Israel, due to PROM, with a gestational age < 36 weeks, were asked to participate in the study. Women with urinary tract
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Introduction
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23-37 years (mean: 27.6 years), at 38-42 weeks gestation (mean: 40.5 weeks). All women in the control groups were from median socioeconomic backgrounds, and had uneventful pregnancies. Laboratory Methods Blood drawn from the patients was allowed to coagulate, and then was centrifuged. The detection of C. trachomatis IgG and IgA specific antibodies in human sera was processed and determined by using the single serovar (L2) IPA (Ipazyme Chlamydia, Savyon Diagnostics Ltd., Beer-Sheva, Israel) according to the manufactur er’s instructions. According to the manufacturer’s recommendations, IgG titers of >1:128 and IgA titers of > 1:16 indicate active C. trachomatis infection. Statistical Analysis Statistical analysis was evaluated by x2 test with Yate’s correc tion, and by Fisher’s exact test of continuation.
Results Table 1 shows that there were no statistical differ ences in the prevalence of elevated levels of chlamydia IgG specific antibodies between the pregnant women with preterm PROM of unknown etiology (group A), as compared to control groups B (healthy preterm pregnant women) and C (healthy pregnant women at term). Three of the 15 women of the study group, 8 of the 35 women in control group B, and 11 of the 43 women in control group C had elevated IgG antibodies. Table 2 demonstrates that there were no statistical differences in the prevalence rate of elevated levels of chlamydia IgA antibodies between the women in the study group, as compared to control groups B (preterm) and C (term). Three of the study group’s women, 7 of the
Table 1. Serum IgG specific antibodies for Chlamydiae in women with idiopathic preterm PROM (group A), in preterm con trols (group B), and in term controls (group C) as determined by IPA
Table 2. Serum IgA specific antibodies for Chlamydiae in women with idiopathic preterm PROM (group A), in preterm con trols (group B), and in term controls (group C) as determined by IPA
Group
Group
Study group A1 Control group B1 Control group C 1
Total n
15 35 43
Chlamydia IgG titers (IPA) -----------------------------------128 n
percent
n
percent
12 27 32
80.0 77.0 74.0
3 8 11
20.0 28.0 26.0
1 p value statistically not significant between the three groups.
Study group A1 Control group B1 Control group C 1
Total n
15 35 43
Chlamydia IgA titers (IPA) ----------------------------------16 n
percent
n
percent
12 28 36
80.0 80.0 83.0
3 7 7
20.0 20.0 17.0
1 p value statistically not significant between the three groups.
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infections, other infectious diseases, incompetence of cervix, or uterine contractions were excluded from the study. Thus, 15 healthy women, aged 20-39 years (mean: 29 years), at 26-36 weeks gesta tion (mean: 31.6 weeks) were included. Nine had uneventful obstet rical histories for their previous pregnancies, 2 had terminations of pregnancy in the first trimester twice previously, 4 had one previous second-trimester abortion. All had uneventful obstetrical histories for the present pregnancy. All patients in the study (group A) suffered from preterm PROM, which started 2-16 h (mean: 8.8 h) prior to their admission. Rupture of the membranes was diagnosed during speculum exami nation by direct visualization of amniotic fluid either exuding through the cervix or pooled in the vagina, and by a positive nitrazine test. On admission, 5 ml of peripheral blood was drawn, and a cervical culture was performed after the nature of the study had been fully explained. No patient had either cervical dilation of more than 2 cm, or cervical effacement of more than 50%. Maternal heart rate and temperature were measured 4 times daily, and white blood cell count was made twice a day. Nonstress tests, performed twice weekly, revealed normal fetal heart patterns. No patient in the study was treated with antibiotics, ritodrine hydrochloride or glucocorticosteroids. Ultrasound examinations were performed in all women in the study, in which a single, presumably healthy fetus with normal pla centa and placental implantation, no signs of placental abruption, and normal uterine shape was observed. Qualitative amniotic fluid volume was determined by a linear array ultrasound method, and was termed normal if at least one pocket of amniotic fluid, measur ing 1 cm at its broadest diameter, was identified [20]. Three women had mild to moderate oligohydramnion. The other 12 had normal amniotic fluid volume. All women in the study were from median socioeconomic backgrounds. These results were compared to those obtained from two differ ent control groups in the same population who were matched for age, marital status and socioeconomic background, and who at tended our antenatal outpatient clinic at the same time period of the study. All controls were evaluated in the same manner as the study group and were composed of: control group B, 35 healthy women aged 23-36 years (mean: 26.4 years), at 28-36 weeks gestation (mean: 32.2 weeks), and control group C, 43 healthy women aged
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Chlamydia trachomatis in Preterm PROM
Discussion The effect of cervical C. trachomatis during preg nancy on pregnancy outcome is still controversial. It has been claimed that the presence of cervical chlamydial infection in pregnant women does not increase the risk of preterm PROM [5, 9, 10, 21], and that only recent chlamydial infection during pregnancy, as evidenced by the presence of maternal IgM chlamydial antibodies, increases the risk of adverse pregnancy outcome, includ ing premature PROM [9, 10], In the above studies, the incidence of C. trachomatis infection was determined in a group of unselected preg nant women in order to identify the prevalence of the infection in the general pregnant population. In the present study, we examined a specific high-risk preg nancy group (i.e. pregnant women exhibiting idiopathic preterm PROM) for a possible correlation with C. tra chomatis infection, based on the supposition that C. tra chomatis infection may be a possible etiologic factor for preterm PROM. Furthermore, in most of the studies cited, the diagno sis was made by using the direct cervical colonization technique. But it would appear that chlamydial cervical cultures and smears are of little benefit in the diagnosis of chronic upper-tract chlamydial infections, which are mostly asymptomatic. These infections may persist for long periods, unless appropriate antibiotic therapy is
administered [22], Several studies have suggested that elevated titers of IgA and IgG antichlamydial antibodies may be markers of active chlamydial infection. IgG and IgA antibodies, at serum dilutions of >1:128 and >1:16, respectively, appear to indicate individuals with chlamydial infections [8, 11-19]. Since the half-life of IgA is very short, it is detectable for only a short period following removal of the antigen [14, 15, 23]; its pres ence in serum suggests an ongoing or very recent infec tion [24], Thus, by measuring IgG and IgA specific anti bodies, it was hoped that this method would prove to be more accurate and specific for the identification of active or persistent chlamydial infection. Moreover, in the present study, blood samples for chlamydial anti bodies were taken approximately simultaneously with the onset of preterm PROM, and would therefore more accurately reflect the true infectious status of the preg nant women in the study. For this reason, we used sero logical diagnostic methods and measured specific IgA and IgG antibodies seropositive for chlamydia. In the present study, we found that there were no sig nificant statistical differences in the prevalence of ele vated levels of chlamydial IgG specific antibodies for pregnant women suffering from preterm PROM of un known etiology, when compared to the two control groups (20, 28 and 26%, respectively, had high IgG anti body levels). Nor were there any statistically significant differences in the prevalence of elevated levels of chla mydial IgA specific antibodies for the study group, when compared to the two control groups (20, 20 and 17%, respectively, had high IgA antibody levels). At the same time, there were no statistical or numerical differences in the prevalence of chlamydial IgG and IgA specific anti bodies between the two control groups. Similar results were found by Cohen et al. [8] in their study on chlamydial IgG and IgA specific antibodies measured at the time of onset of premature contractions. It was also found that the occurrence rate of chlamydial IgA antibodies was significantly higher in the control groups, when compared to pregnant women who suf fered from premature contractions. In conclusion, our data provide additional support for the assumption that C. trachomatis is not a common etiologic factor in preterm PROM. Acknowledgments We wish to thank Savyon Diagnostic Ltd., Beer-Sheva, Israel, for supplying the Ipazyme kit and for their laboratory assistance, and Mrs. S. Esakov for preparing the manuscript.
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35 women in control group B, and 7 of the 43 women in control group C had elevated IgA antibodies. Tables 1 and 2 show that there were no statistical dif ferences in the prevalence of chlamydia IgG and IgA antibodies between the two control groups. The admission-administered cervical culture per formed in the study group was negative in 6 patients, while 4 patients had lactobacillus species, 1 had lactobacillus and peptococcocus species, 3 had Candida and 1 had Staphylococcus albus. All women in the study group developed spontaneous contractions and delivered between 4-20 days after oc currence of PROM (mean: 11.66 days). Ten delivered pre maturely, and 5 delivered at or above 37 weeks gestation. No woman showed any sign of infection before, during, or after delivery. All women in the two control groups de livered healthy infants at or above 37 weeks of gestation. All the infants, both those of the study group and of the two control groups, were free of clinical conjunctivi tis or pneumonitis.
Cohen/Tenenbaum/Fejgin/Michaeli/Bcyth/Sarov
References 1 Creatsas, G.; Paolatos, M.; Dalis, D.; Arvantinos, D.; Karkarelis, D.: Bacterial contamination of the cervix and premature rupture of the membranes. Am. J. Obstet. Gynec. 179: 522-525 (1981) . 2 Alger, L.S.; Pupkin, M.J.: Etiology of preterm premature rupture of the membranes. Clin. Obstet. Gynec. 29: 758-770 (1986). 3 Miller, J.M. Jr.; Patarek, J.G., II; The microbiology of premature rupture of the membranes. Clin. Obstet. Gynec. 29: 739-757 (1986). 4 Graven, M.G.; Holmes, K.K.: Pregnancy outcome and maternal infection. The need for comprehensive studies. JAMA 250: 1751-1752 (1983). 5 Fitzsimmons, J.; Callahan, C ; Shanahan, B.; Junkind, D.: Chla mydial infections in pregnancy. J. reprod. Med. 31: 19-22 (1986). 6 Schächter, J.; Grossman, M.; Sweet, R.L.; Halt, J.; Jordan, C.; Bishop, E.: Prospective study of perinatal transmission of Chla mydia trachomatis. JAMA 255: 3374-3377 (1986). 7 Martin, D.H.; Koutsky, L.; Eschenbach, D.A.; Doling, J.R.; Alexander, E.R.; Bendetti, J.K.; Holmes, K.K.: Prematurity and perinatal mortality in pregnancies complicated by maternal Chlamydia trachomatis infections. JAMA 247: 1585-1588 (1982) . 8 Cohen, I.; Tenenbaum, E.; Fejgin, M.; Altaras, M.; Ben-Aderet, N.; Sarov, I., et al.: Serum specific antibodies for Chlamydia trachomatis in premature contractions. Am. J. Obstet. Gynec. 158: 579-582 (1988). 9 Harrison, H.R.; Alexander, E.R.; Weinstein, L.; Lewis, M.; Nash, M.; Sim, D.A.: Cervical Chlamydia trachomatis and my coplasma infections in pregnancy. JAMA 250: 1721-1727 (1983) . 10 Sweet, G.L.; Landers, D.L.; Walker, C.; Schächter, J.: Chlamy dia trachomatis infection and pregnancy outcome. Am. J. Ob stet. Gynec. 156: 824-833 (1987). 11 Osborne, N.G.; Hecht, Y.; Grosline, J.; Forbes, B.A.; Morgenstem, F.; Winkelman, J.: Prevalence of IgA and IgG antichlamydial antibodies in women in the third trimester of pregnancy. J. natn. med. Ass. 80: 1201-1203 (1988). 12 Piura, B.; Sarov, I.; Sarov, B.; Kleinman, D.; Chaim, W.; Insler, V.: Serum IgG and IgA antibodies specific for Chlamydia tracho matis in salpingitis patients as determined by the immunoperox idase assay. Eur. J. Epidemiol. 1: 110-116 (1985). 13 Sarov, L; Kleinman, D.; Holchberg, G.; Cevenini, R.; Sarov, B.; Insler, V.: Specific IgG and IgA, and IgM antibodies to Chlamy dia trachomatis in patients with pelvic inflammatory disease as determined by immunoperoxidase assay. Israel J. med. Scis 20: 486-489 (1984). 14 Sarov, L; Insler, V.; Sarov, B.; Cevenini, R.; Rumianesi, F.; Donati, M.; Kleinman, D.; Piura, B.; Liberman, J.; Kimmei, N.; Freidman, M.; La Plaça, M.: Specific serum of IgA antibodies in the diagnosis of active viral and chlamydial infections; in Sanna, Morace, New Horizons in Microbiology, pp 157-168 (Elsevier, Amsterdam 1984).
15 Sarov, I.; Sarov, B.; Hanuka, N.; Cevenini, R.; Donati, M.; Piu ra, B.: The significance of serum specific IgA antibodies in the diagnosis of Chlamydia trachomatis infections; in Ariel, Ridge way, Schächter, Taylor-Robinson, Wort, Chlamydial Infection, pp. 566-569 (Cambridge University Press, Cambridge 1986). 16 Cevenini, R.; Rumpianesi, F.; Donati, M.; Sarov, L: A rapid immunoperoxidase assay for the detection of specific IgG anti bodies to Chlamydia trachomatis. J. clin. Path. 36: 353-356 (1983). 17 Cevenini, R.; Sarov, I.; Rumpianesi, F.; Donati, M.; Melega, C ; Varotti, C.; La Plaça, M.: Serum specific IgA antibodies to Chla mydia trachomatis in patients with Chlamydia trachomatis in fection detected by ELISA and an immunofluorescence test. J din. Path. 37: 686-691 (1984). 18 Hecht, Y.; Tomar, R.; Winkleman, J.W.: Evaluation of indirect immunoperoxidase assay for specific IgG and IgA antibodies for Chlamydia trachomatis. Lab. Med. 19: 22-24 (1988). 19 Osborne, N.G.; Hecht, Y.; Grosline, J.; Forbes, B.A.; Morgenstem, F.; Winkelman, J.: A comparison of culture, direct fluores cence antibody test, and a quantitative indirect immunoperoxi dase assay for detection of Chlamydia trachomatis in pregnant women. Obstet. Gynec. N.Y. 71: 412-415 (1988). 20 Manning, F.A.; Hill, L.M.; Platt, L.D.: Qualitative amniotic fluid volume determination by ultrasound. Antepartum detec tion of intrauterine growth retardation. Am. J. Obstet. Gynec. 139: 254-258 (1981). 21 Gravett, G.M.; Nelson, H.P.; DeRoven, T.; Critchlow, C.; Eschenbach, D.A.; Holmes, K.K.: Independent associations of bacterial vaginosis and Chlamydia trachomatis infections with pregnancy outcome. JAMA 256: 1899-1903 (1986). 22 Guderian, A.M.; Trobough, G.E.: Residues of pelvic inflamma tory disease in intrauterine device users: a result of the intrauter ine device or Chlamydia trachomatis infection? Am. J. Obstet. Gynec. 754: 497-503 (1986). 23 Tomasi, T.B.; Grey, H.M.: Structure and function of immuno globulin A. Prog. Allergy 16: 81 (1972). 24 Bienenstock, J.; Befus, A.D.: Some thought on the biological role of immunoglobulin A. Gastroenterology 84: 178-185 (1983).
Received: December 11,1989 Accepted after revision: May 10, 1990 Ilan Cohen, MD Department of Obstetrics and Gynecology ‘A’ Meir General Hospital Sapir Medical Center Kfar Saba 44281 (Israel)
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Gynecol Obstet Invest 1990;30:155-158
Serum-Specific Antibodies for Chlamydia trachomatis in Preterm Premature Rupture of the Membranes Ilan Cohena, Ella Tenenbauma, Moshe Fejgin3, Galia Michaeli*, Yoram Beytha, IsraelSarovb a Department of Obstetrics and Gynecology ‘A’, Meir General Hospital, Kfar Saba; bVirology Unit, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
Key Words. Antibodies • Chlamydia trachomatis
■
Membranes, preterm and premature rupture of
Abstract. A case control study was performed to examine possible morbidity associated with Chlamydia tracho matis in 15 pregnant women with idiopathic preterm premature rupture of the membranes (PROM; group A), and in two control groups, 35 healthy preterm pregnant women (group B), and 43 healthy pregnant women at term (group C). Serum C trachomatis IgG and IgA specific antibodies were determined using the single serovar (L2) inclusion immunoperoxidase assay. There were no significant differences in the prevalence rate of elevated levels of chlamydia IgG specific antibodies (titer >: 1:128) between pregnant women suffering from idiopathic preterm PROM, as compared to healthy preterm and term pregnant women (20, 28 and 26%, respectively). Nor were there any significant differences in the prevalence rate of elevated levels of chlamydia IgA specific antibodies (titer >: 1:16) between pregnant women with idiopathic preterm PROM, as compared to healthy preterm and term pregnant women (20, 20 and 17%, respectively). These findings do not support the assumption that C. trachomatis may play role in preterm PROM.
Preterm premature rupture of the membranes (pre term PROM) causes considerable perinatal morbidity and mortality, and is one of the most common and chal lenging problems in obstetrics and in public health. Sev eral observations indicate that there is a high incidence of pathogenic or potentially pathogenic bacteria in the uterine cervix that may cause preterm PROM [1], and that maternal genital tract infection may frequently play an etiologic role in preterm PROM [2, 3]. An increased prematurity rate has subsequently been associated with maternal infection by group B streptoccoci, Neisseria gonorrhoeae, herpes simplex virus and Chlamydia tra chomatis [4], Cervical infection with C. trachomatis has become an increasingly recognized problem in perinatal clinics [5]. The prevalence of chlamydial infection of the cervix in pregnant women has been reported to be between 2 and 37% [6]. However, the effect of maternal chlamydial infection on pregnancy outcome and perinatal complica
tions, such as preterm labor and birth, premature rup ture of the membranes, and low-birth weight infants, remains controversial. Although some studies have found an association between cervical C. trachomatis and an increased risk of adverse pregnancy outcome [7], others have questioned such an association [8-10]. Ele vated titers of IgA and IgG antichlamydial antibodies have been suggested as markers of active chlamydial infection [8, 11-19], In this study, we examined the prevalence of chlamy dia IgG and IgA specific antibodies in the serum of preg nant women suffering from preterm PROM of unknown etiology by using the single serovar (L2) inclusion immu noperoxidase assay (IPA).
Selection of Patients From April to August 1985, women admitted to the Department of Obstetrics and Gynecology ‘A’ at the Meir General Hospital in Kfar Saba, Israel, due to PROM, with a gestational age < 36 weeks, were asked to participate in the study. Women with urinary tract
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Introduction
Cohen/Tenenbaum/Fejgin/Michaeli/Beyth/Sarov
156
23-37 years (mean: 27.6 years), at 38-42 weeks gestation (mean: 40.5 weeks). All women in the control groups were from median socioeconomic backgrounds, and had uneventful pregnancies. Laboratory Methods Blood drawn from the patients was allowed to coagulate, and then was centrifuged. The detection of C. trachomatis IgG and IgA specific antibodies in human sera was processed and determined by using the single serovar (L2) IPA (Ipazyme Chlamydia, Savyon Diagnostics Ltd., Beer-Sheva, Israel) according to the manufactur er’s instructions. According to the manufacturer’s recommendations, IgG titers of >1:128 and IgA titers of > 1:16 indicate active C. trachomatis infection. Statistical Analysis Statistical analysis was evaluated by x2 test with Yate’s correc tion, and by Fisher’s exact test of continuation.
Results Table 1 shows that there were no statistical differ ences in the prevalence of elevated levels of chlamydia IgG specific antibodies between the pregnant women with preterm PROM of unknown etiology (group A), as compared to control groups B (healthy preterm pregnant women) and C (healthy pregnant women at term). Three of the 15 women of the study group, 8 of the 35 women in control group B, and 11 of the 43 women in control group C had elevated IgG antibodies. Table 2 demonstrates that there were no statistical differences in the prevalence rate of elevated levels of chlamydia IgA antibodies between the women in the study group, as compared to control groups B (preterm) and C (term). Three of the study group’s women, 7 of the
Table 1. Serum IgG specific antibodies for Chlamydiae in women with idiopathic preterm PROM (group A), in preterm con trols (group B), and in term controls (group C) as determined by IPA
Table 2. Serum IgA specific antibodies for Chlamydiae in women with idiopathic preterm PROM (group A), in preterm con trols (group B), and in term controls (group C) as determined by IPA
Group
Group
Study group A1 Control group B1 Control group C 1
Total n
15 35 43
Chlamydia IgG titers (IPA) -----------------------------------128 n
percent
n
percent
12 27 32
80.0 77.0 74.0
3 8 11
20.0 28.0 26.0
1 p value statistically not significant between the three groups.
Study group A1 Control group B1 Control group C 1
Total n
15 35 43
Chlamydia IgA titers (IPA) ----------------------------------16 n
percent
n
percent
12 28 36
80.0 80.0 83.0
3 7 7
20.0 20.0 17.0
1 p value statistically not significant between the three groups.
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infections, other infectious diseases, incompetence of cervix, or uterine contractions were excluded from the study. Thus, 15 healthy women, aged 20-39 years (mean: 29 years), at 26-36 weeks gesta tion (mean: 31.6 weeks) were included. Nine had uneventful obstet rical histories for their previous pregnancies, 2 had terminations of pregnancy in the first trimester twice previously, 4 had one previous second-trimester abortion. All had uneventful obstetrical histories for the present pregnancy. All patients in the study (group A) suffered from preterm PROM, which started 2-16 h (mean: 8.8 h) prior to their admission. Rupture of the membranes was diagnosed during speculum exami nation by direct visualization of amniotic fluid either exuding through the cervix or pooled in the vagina, and by a positive nitrazine test. On admission, 5 ml of peripheral blood was drawn, and a cervical culture was performed after the nature of the study had been fully explained. No patient had either cervical dilation of more than 2 cm, or cervical effacement of more than 50%. Maternal heart rate and temperature were measured 4 times daily, and white blood cell count was made twice a day. Nonstress tests, performed twice weekly, revealed normal fetal heart patterns. No patient in the study was treated with antibiotics, ritodrine hydrochloride or glucocorticosteroids. Ultrasound examinations were performed in all women in the study, in which a single, presumably healthy fetus with normal pla centa and placental implantation, no signs of placental abruption, and normal uterine shape was observed. Qualitative amniotic fluid volume was determined by a linear array ultrasound method, and was termed normal if at least one pocket of amniotic fluid, measur ing 1 cm at its broadest diameter, was identified [20]. Three women had mild to moderate oligohydramnion. The other 12 had normal amniotic fluid volume. All women in the study were from median socioeconomic backgrounds. These results were compared to those obtained from two differ ent control groups in the same population who were matched for age, marital status and socioeconomic background, and who at tended our antenatal outpatient clinic at the same time period of the study. All controls were evaluated in the same manner as the study group and were composed of: control group B, 35 healthy women aged 23-36 years (mean: 26.4 years), at 28-36 weeks gestation (mean: 32.2 weeks), and control group C, 43 healthy women aged
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Chlamydia trachomatis in Preterm PROM
Discussion The effect of cervical C. trachomatis during preg nancy on pregnancy outcome is still controversial. It has been claimed that the presence of cervical chlamydial infection in pregnant women does not increase the risk of preterm PROM [5, 9, 10, 21], and that only recent chlamydial infection during pregnancy, as evidenced by the presence of maternal IgM chlamydial antibodies, increases the risk of adverse pregnancy outcome, includ ing premature PROM [9, 10], In the above studies, the incidence of C. trachomatis infection was determined in a group of unselected preg nant women in order to identify the prevalence of the infection in the general pregnant population. In the present study, we examined a specific high-risk preg nancy group (i.e. pregnant women exhibiting idiopathic preterm PROM) for a possible correlation with C. tra chomatis infection, based on the supposition that C. tra chomatis infection may be a possible etiologic factor for preterm PROM. Furthermore, in most of the studies cited, the diagno sis was made by using the direct cervical colonization technique. But it would appear that chlamydial cervical cultures and smears are of little benefit in the diagnosis of chronic upper-tract chlamydial infections, which are mostly asymptomatic. These infections may persist for long periods, unless appropriate antibiotic therapy is
administered [22], Several studies have suggested that elevated titers of IgA and IgG antichlamydial antibodies may be markers of active chlamydial infection. IgG and IgA antibodies, at serum dilutions of >1:128 and >1:16, respectively, appear to indicate individuals with chlamydial infections [8, 11-19]. Since the half-life of IgA is very short, it is detectable for only a short period following removal of the antigen [14, 15, 23]; its pres ence in serum suggests an ongoing or very recent infec tion [24], Thus, by measuring IgG and IgA specific anti bodies, it was hoped that this method would prove to be more accurate and specific for the identification of active or persistent chlamydial infection. Moreover, in the present study, blood samples for chlamydial anti bodies were taken approximately simultaneously with the onset of preterm PROM, and would therefore more accurately reflect the true infectious status of the preg nant women in the study. For this reason, we used sero logical diagnostic methods and measured specific IgA and IgG antibodies seropositive for chlamydia. In the present study, we found that there were no sig nificant statistical differences in the prevalence of ele vated levels of chlamydial IgG specific antibodies for pregnant women suffering from preterm PROM of un known etiology, when compared to the two control groups (20, 28 and 26%, respectively, had high IgG anti body levels). Nor were there any statistically significant differences in the prevalence of elevated levels of chla mydial IgA specific antibodies for the study group, when compared to the two control groups (20, 20 and 17%, respectively, had high IgA antibody levels). At the same time, there were no statistical or numerical differences in the prevalence of chlamydial IgG and IgA specific anti bodies between the two control groups. Similar results were found by Cohen et al. [8] in their study on chlamydial IgG and IgA specific antibodies measured at the time of onset of premature contractions. It was also found that the occurrence rate of chlamydial IgA antibodies was significantly higher in the control groups, when compared to pregnant women who suf fered from premature contractions. In conclusion, our data provide additional support for the assumption that C. trachomatis is not a common etiologic factor in preterm PROM. Acknowledgments We wish to thank Savyon Diagnostic Ltd., Beer-Sheva, Israel, for supplying the Ipazyme kit and for their laboratory assistance, and Mrs. S. Esakov for preparing the manuscript.
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35 women in control group B, and 7 of the 43 women in control group C had elevated IgA antibodies. Tables 1 and 2 show that there were no statistical dif ferences in the prevalence of chlamydia IgG and IgA antibodies between the two control groups. The admission-administered cervical culture per formed in the study group was negative in 6 patients, while 4 patients had lactobacillus species, 1 had lactobacillus and peptococcocus species, 3 had Candida and 1 had Staphylococcus albus. All women in the study group developed spontaneous contractions and delivered between 4-20 days after oc currence of PROM (mean: 11.66 days). Ten delivered pre maturely, and 5 delivered at or above 37 weeks gestation. No woman showed any sign of infection before, during, or after delivery. All women in the two control groups de livered healthy infants at or above 37 weeks of gestation. All the infants, both those of the study group and of the two control groups, were free of clinical conjunctivi tis or pneumonitis.
Cohen/Tenenbaum/Fejgin/Michaeli/Bcyth/Sarov
References 1 Creatsas, G.; Paolatos, M.; Dalis, D.; Arvantinos, D.; Karkarelis, D.: Bacterial contamination of the cervix and premature rupture of the membranes. Am. J. Obstet. Gynec. 179: 522-525 (1981) . 2 Alger, L.S.; Pupkin, M.J.: Etiology of preterm premature rupture of the membranes. Clin. Obstet. Gynec. 29: 758-770 (1986). 3 Miller, J.M. Jr.; Patarek, J.G., II; The microbiology of premature rupture of the membranes. Clin. Obstet. Gynec. 29: 739-757 (1986). 4 Graven, M.G.; Holmes, K.K.: Pregnancy outcome and maternal infection. The need for comprehensive studies. JAMA 250: 1751-1752 (1983). 5 Fitzsimmons, J.; Callahan, C ; Shanahan, B.; Junkind, D.: Chla mydial infections in pregnancy. J. reprod. Med. 31: 19-22 (1986). 6 Schächter, J.; Grossman, M.; Sweet, R.L.; Halt, J.; Jordan, C.; Bishop, E.: Prospective study of perinatal transmission of Chla mydia trachomatis. JAMA 255: 3374-3377 (1986). 7 Martin, D.H.; Koutsky, L.; Eschenbach, D.A.; Doling, J.R.; Alexander, E.R.; Bendetti, J.K.; Holmes, K.K.: Prematurity and perinatal mortality in pregnancies complicated by maternal Chlamydia trachomatis infections. JAMA 247: 1585-1588 (1982) . 8 Cohen, I.; Tenenbaum, E.; Fejgin, M.; Altaras, M.; Ben-Aderet, N.; Sarov, I., et al.: Serum specific antibodies for Chlamydia trachomatis in premature contractions. Am. J. Obstet. Gynec. 158: 579-582 (1988). 9 Harrison, H.R.; Alexander, E.R.; Weinstein, L.; Lewis, M.; Nash, M.; Sim, D.A.: Cervical Chlamydia trachomatis and my coplasma infections in pregnancy. JAMA 250: 1721-1727 (1983) . 10 Sweet, G.L.; Landers, D.L.; Walker, C.; Schächter, J.: Chlamy dia trachomatis infection and pregnancy outcome. Am. J. Ob stet. Gynec. 156: 824-833 (1987). 11 Osborne, N.G.; Hecht, Y.; Grosline, J.; Forbes, B.A.; Morgenstem, F.; Winkelman, J.: Prevalence of IgA and IgG antichlamydial antibodies in women in the third trimester of pregnancy. J. natn. med. Ass. 80: 1201-1203 (1988). 12 Piura, B.; Sarov, I.; Sarov, B.; Kleinman, D.; Chaim, W.; Insler, V.: Serum IgG and IgA antibodies specific for Chlamydia tracho matis in salpingitis patients as determined by the immunoperox idase assay. Eur. J. Epidemiol. 1: 110-116 (1985). 13 Sarov, L; Kleinman, D.; Holchberg, G.; Cevenini, R.; Sarov, B.; Insler, V.: Specific IgG and IgA, and IgM antibodies to Chlamy dia trachomatis in patients with pelvic inflammatory disease as determined by immunoperoxidase assay. Israel J. med. Scis 20: 486-489 (1984). 14 Sarov, L; Insler, V.; Sarov, B.; Cevenini, R.; Rumianesi, F.; Donati, M.; Kleinman, D.; Piura, B.; Liberman, J.; Kimmei, N.; Freidman, M.; La Plaça, M.: Specific serum of IgA antibodies in the diagnosis of active viral and chlamydial infections; in Sanna, Morace, New Horizons in Microbiology, pp 157-168 (Elsevier, Amsterdam 1984).
15 Sarov, I.; Sarov, B.; Hanuka, N.; Cevenini, R.; Donati, M.; Piu ra, B.: The significance of serum specific IgA antibodies in the diagnosis of Chlamydia trachomatis infections; in Ariel, Ridge way, Schächter, Taylor-Robinson, Wort, Chlamydial Infection, pp. 566-569 (Cambridge University Press, Cambridge 1986). 16 Cevenini, R.; Rumpianesi, F.; Donati, M.; Sarov, L: A rapid immunoperoxidase assay for the detection of specific IgG anti bodies to Chlamydia trachomatis. J. clin. Path. 36: 353-356 (1983). 17 Cevenini, R.; Sarov, I.; Rumpianesi, F.; Donati, M.; Melega, C ; Varotti, C.; La Plaça, M.: Serum specific IgA antibodies to Chla mydia trachomatis in patients with Chlamydia trachomatis in fection detected by ELISA and an immunofluorescence test. J din. Path. 37: 686-691 (1984). 18 Hecht, Y.; Tomar, R.; Winkleman, J.W.: Evaluation of indirect immunoperoxidase assay for specific IgG and IgA antibodies for Chlamydia trachomatis. Lab. Med. 19: 22-24 (1988). 19 Osborne, N.G.; Hecht, Y.; Grosline, J.; Forbes, B.A.; Morgenstem, F.; Winkelman, J.: A comparison of culture, direct fluores cence antibody test, and a quantitative indirect immunoperoxi dase assay for detection of Chlamydia trachomatis in pregnant women. Obstet. Gynec. N.Y. 71: 412-415 (1988). 20 Manning, F.A.; Hill, L.M.; Platt, L.D.: Qualitative amniotic fluid volume determination by ultrasound. Antepartum detec tion of intrauterine growth retardation. Am. J. Obstet. Gynec. 139: 254-258 (1981). 21 Gravett, G.M.; Nelson, H.P.; DeRoven, T.; Critchlow, C.; Eschenbach, D.A.; Holmes, K.K.: Independent associations of bacterial vaginosis and Chlamydia trachomatis infections with pregnancy outcome. JAMA 256: 1899-1903 (1986). 22 Guderian, A.M.; Trobough, G.E.: Residues of pelvic inflamma tory disease in intrauterine device users: a result of the intrauter ine device or Chlamydia trachomatis infection? Am. J. Obstet. Gynec. 754: 497-503 (1986). 23 Tomasi, T.B.; Grey, H.M.: Structure and function of immuno globulin A. Prog. Allergy 16: 81 (1972). 24 Bienenstock, J.; Befus, A.D.: Some thought on the biological role of immunoglobulin A. Gastroenterology 84: 178-185 (1983).
Received: December 11,1989 Accepted after revision: May 10, 1990 Ilan Cohen, MD Department of Obstetrics and Gynecology ‘A’ Meir General Hospital Sapir Medical Center Kfar Saba 44281 (Israel)
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