The course of labor in term patients with concomitant acute intestinal infections

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BACKGROUND

Complications in the course of pregnancy, childbirth, postpartum period, and newborn conditions in the presence of acute intestinal infections (AII) in the mother represent an urgent but poorly investigated problem. Depending on the gestational age, AIIs can cause spontaneous abortion, chorioamnionitis, and premature rupture of membranes, and, thus, preterm birth of a premature baby. Infectious processes in the body of a pregnant woman, affecting the fetus, can lead to antenatal death, neonatal sepsis, and meningitis [1–13].

Until now, no studies were conducted detailing the features of the delivery of female patients with AII at full-term pregnancy. Some reports are presented, which mainly describe the effect of certain pathogens that cause AII on the course of pregnancy, childbirth, and the postpartum period. In published studies, childbirth occurred at different gestational ages and in different ways.

A very small number of cases of AII associated with Campylobacter jejuni and Campylobacter fetus in pregnant women are known to date; however, these pathogens are considered proven to cause septic abortion, preterm labor, and maternal sepsis [5–8]. No data was found on the effect of AII caused by Campylobacter jejuni and Campylobacter fetus at full-term pregnancy on the course of labor and perinatal outcomes.

Salmonellosis in pregnant women can cause septic abortions, antenatal fetal death, chorioamnionitis, postpartum sepsis, neonatal sepsis, and meningitis [7, 11, 14]. A.R. Scialli, T.L. Rarick, L. Coughlin, and J. McGuigan described that the gestational age was 15 and 16 weeks in clinical cases of salmonellosis during pregnancy that ended in spontaneous abortions [7, 15]. M. Seoud et al. reported 14 cases of typhoid fever in pregnancy. This disease, diagnosed after 20 weeks, with adequate treatment, did not affect the pregnancy outcome and the condition of newborns. One of the two cases of typhoid fever, established before 20 weeks of gestation, ended in septic abortion at week 16, whereas the other case ended in full-term delivery. At birth, the child was diagnosed with neonatal sepsis caused by K. pneumonia [11]. S. Mohanty reported 5 pregnant women with salmonellosis caused by S. typhi and S. paratyphi A strains, who had a vaginal delivery. One case had preterm birth at 28 weeks of gestational age, whereas the other four cases were delivered at term. Two newborns were diagnosed with severe asphyxia at birth and three children were diagnosed with neonatal sepsis [16].

Evidence on the effect of shigellosis on pregnancy outcomes is inconsistent. According to some reports, pregnant women with dysentery caused by Shigella flexneri are characterized by the threat of pregnancy termination, but the incidence of preterm birth remains within the population values [17]. N.S. Cherkasova obtained no data on the negative impact of dysentery on the course of pregnancy and childbirth [18]. Research by M. Makhmudova indicates that with dysentery, the frequency of not only spontaneous abortion but also abnormalities of uterine contractile activity increases, as well as the average labor duration and volume of blood loss [19].

Pregnancy with Shigella sonnei dysentery can be complicated by the threat of preterm delivery. Thus, a clinical case of surgical abdominal delivery of a patient with a gestational age of 25/26 weeks was presented. In presence of Shigella sonnei, a premature rupture of membranes stained with meconium occurred; the patient started labor, which was completed by cesarean section due to acute fetal hypoxia [12]. M. Parosot revealed that 28 pregnant women at different gestational stages had various pregnancy complications, and the course of labor was noted in the presence of dysentery caused by Shigella sonnei. In the third trimester of pregnancy, 15 out of 22 pregnant women registered the threat of preterm delivery, which was implemented in three cases. In addition, childbirth was typical in one case and ended with abdominal delivery due to acute fetal hypoxia in another. Woman 3 had an antenatal death of one fetus from twins, and the second fetus was born alive at 32/33 weeks of gestation [13].

Therefore, the literature best describes the effect of AII on the course of pregnancy, but rarely at full-term. Practically, no data are available on the effect of AII on the course of labor at full-term pregnancy.

This study aimed to evaluate the course of labor in patients with AII in the third trimester of pregnancy.

MATERIALS AND METHODS

The childbirth of 120 patients at S.P. Botkin Clinical Hospital for Infectious Diseases in 2017–2019 was retrospectively analyzed. The patients included in the study were distributed into two groups. The main group consisted of 60 patients who gave birth with the presence of AII. Inclusion criteria were childbirth at a gestational age of 37–41 6/7 weeks and clinical manifestations of AII upon admission. Exclusion criteria were multifetal pregnancy, fetal malformations, and severe preeclampsia. The comparison group consisted of 60 conditionally healthy women. The inclusion criterion was childbirth at a gestational age of 37–41 6/7 weeks. Exclusion criteria were signs of any infectious diseases upon admission, multifetal pregnancy, fetal malformations, and severe preeclampsia.

The average age of patients included in the main group was 27.4±4.2 years and 30.4±4.5 years in the comparison group (F=14.2; p<0.001). The gestational age at the time of delivery in the main group was 39.3±1.1 weeks and 39.3±1.1 weeks in the comparison group.

Table 1 presents the reproductive history of patients from the main and comparison groups.

 

Table 1. Characteristics of patients in the studied groups

Параметры	Main group (n=60)	Comparison group (n=60)	Significance of differences, p
Primigravidae	26 (43.3±6.4)	17 (28.3±5.8)	N/S
History of abortion	18 (30.0±5.9)	16 (26.7±5.7)	N/S
History of childbirth	25 (41.7±6.4)	38 (63.3±6.2)	<0.05
History of cesarean section	3 (5.0±2.8)	0	N/S

Note: N/S — not significant.

 

Upon hospital admission, all patients underwent a clinical blood test, biochemical blood test, general urine test, and fecal bacteriological examination. In the case of the growth of microorganisms, automatic mass spectrometry was performed on a Vitek MS bacteriological analyzer. Automatic isolation of nucleic acids for the polymerase chain reaction (PCR) of feces for diagnostics of AII pathogens was performed at the Neon-100 (Xiril) station. PCR diagnostics of viral and bacterial pathogens in feces was performed using the test systems of the company InterLabService “AmpliSens OKI screen-FL” on a Rotor-Gene Q device. All patients underwent fetal ultrasound examination, Doppler blood flow test in the mother–placenta–fetus system, and cardiotocography. For morphological examination of the placenta after delivery, its 1–2 cm³ fragment was fixed in 10% neutral buffered formalin (pH 7.2), dehydrated using the Sakura Tissue-Tek VIP 5 Jr automatic station, and embedded in paraffin according to the standard histological scheme. The material was stained with hematoxylin and eosin for microscopic examination.

 

Table 2. Etiological structure of acute intestinal infections in pregnant women

Microorganisms causing AII	Number of patients, n	Incidence, %
Enterobacter spp.	19	32
Klebsiella spp.	12	20
Citrobacter spp.	12	20
Hafnia spp.	5	8
Proteus spp.	4	7
Norovirus	4	7
Enterococcus spp.	2	3
Shigella Sonne	1	2
Rotavirus	1	2
Total	60	100

Note. AII — acute intestinal infections.

 

The average age of patients was calculated using a one-way analysis of variance (ANOVA). The Pearson Chi-square test was used to analyze the characteristics of delivery and complications arising during childbirth. The multivariate ANOVA was used to compare the duration of the mothers’ stay in the postpartum ward.

Statistical processing of the research results was performed using International Business Machines Corporation Statistical Package for the Social Sciences Statistics 24. The critical level of significance for all statistical tests was equal to 0.05.

RESULTS AND DISCUSSION

Analysis of the range of AII pathogens in the main group showed that opportunistic flora prevailed in the etiological structure of AII. Table 2 presents data on the range of microorganisms detected in the main group.

Table 3 presents data on the gestational age at which the disease started to develop and delivery occurred, depending on the identified pathogen.

Table 3 shows that childbirth occurred soon after the onset of AII symptoms and hospitalization. No differences were found depending on the pathogen.

 

Table 3. Terms of hospitalization and delivery, depending on the pathogens identified in the main group

Pathogens	n	Gestational age at the onset of the disease, weeks	Gestational age at delivery, weeks
		M±m	M±m
Enterobacter spp.	19	39.2±1.04	39.3±1.1
Klebsiella spp.	12	39.4±0.9	39.5±1.08
Citrobacter spp.	12	39.08±1.08	39.1±1.2
Hafnia spp.	5	37.6±0.9	38.0±1.4
Proteus spp.	4	39.6±0.8	39.6±0.8
Norovirus	4	39.2±0.9	39.7±1.2
Enterococcus spp.	2	40	40.5±0.7
Shigella Sonne	1	40	40
Rotavirus	1	39	40

 

In the main group, 73.3% (44 patients) of pregnancies resulted in vaginal delivery, wherein 4.5% (2 patients) ended in vacuum extraction of the fetus due to acute hypoxia. Five patients of the main group resulted in a planned cesarean section, whereas an emergency cesarean section was performed in 11 puerperas with AII. Cesarean section was performed in 62.5% of patients with AIIs caused by Enterobacter spp., Citrobacter spp., and Klebsiella spp. All women of the comparison group had a vaginal delivery.

Table 4 presents the indications for surgical abdominal delivery in female patients with AII. Half of all cesarean sections were performed due to acute fetal hypoxia.

 

Table 4. Indications for surgical abdominal delivery in female patients with acute intestinal infections

Indications for surgical delivery	Number of patients, n	Incidence, %
Acute fetal hypoxia	8	50
Uterine scar inconsistency after cesarean section	2	13
Acute genital herpes	2	13
Drug-resistant primary poor uterine contraction strength	1	6
Foot presentation of the fetus	1	6
Threatening uterine rupture	1
Thrombosis of hemorrhoids	1	6

 

Premature rupture of membranes was more common in patients with AII (X²=14.594; p < 0.0001), whereas timely rupture of membranes was more common in patients in the comparison group (X²=14.594; p=0.01). The frequency of early rupture of membranes was equal in women of both groups (Table 5).

 

Table 5. Estimation of the time of discharge of amniotic fluid in the studied groups

Nature of the amniotic fluid discharge	Main group (n=54)		Comparison group (n=58)
	number of patients, n	incidence, %	number of patients, n	incidence, %
Preterm discharge	21	38.9*	6	10.3
Early discharge	8	14.8	10	17.3
Timely discharge	25	46.3	42	72.4**

* р < 0.0001; ** р=0.01.

 

Abnormalities of labor activity were registered in patients of both groups; they did not differ in frequency of  occurrence and were represented by primary and se condary poor uterine contraction strength. Primary poor uterine contraction strength in patients with AII was revealed in 1 case of childbirth (1.9%), and in 2 cases in the comparison group (3.3%). Secondary poor uterine contraction strength was found in 2 patients of the main group (3.8%), whereas secondary poor uterine contraction strength was not noted in patients of the comparison group. In both groups, puerperas with secondary poor  uterine contraction strength were given oxytocin stimulatory therapy with a positive effect. Labor induction with oxytocin in a puerpera of the main group with primary poor uterine contraction strength was ineffective. The patient had delivered by emergency cesarean section.

The duration of labor in patients of both groups did not significantly differ. Puerperas of the main group lasted for 7.1±2.2 h, whereas 6.8±2.4 h in the comparison group.

Acute and chronic fetal hypoxia was more common during labor in the main group (X²=15.393; p=0.002 and X²=15.393; p=0.028, respectively). Table 6 presents the incidence of acute and chronic fetal hypoxia in patients of both groups.

 

Table 6. Incidence and structure of fetal hypoxia in the studied groups

Type of hypoxia	Main group		Comparison group
	number of patients, n	incidence, %	number of patients, n	incidence, %
Острая гипоксия плода	11	20*	1	1.6
Хроническая гипоксия плода	7	12.7*	1	1.6

* p=0.002; ** р=0.028.

 

The Apgar score of newborns from patients with AII 1 min after delivery was 7.6±0.4 points and 7.9±0.1 points in the comparison group. The Apgar score of newborns from patients of the main group was 8.7±0.4 points and 8.9±0.2 points in the comparison group 5 min after delivery. Moderate asphyxia at birth (7 points on the Apgar scale 1 min after birth) was diagnosed in 31.6% (19 children) of newborns from mothers with AII and in 3.3% (2 children) in the comparison group (X²=36.109; p < 0.0001). No difference was found in the condition of children on the Apgar scale 5 min after childbirth.

The volume of blood loss in puerperas with AII during vaginal delivery was 272.7±65.9 ml, 656.2±89.2 ml in cesarean section, and 272.5±85 ml in the comparison group.

Episiotomy in female patients of the main group was performed in 56.8% of cases (25 patients), whereas 28.3% of cases (17 patients) in the comparison group (X²=9.233; p=0.01). The main indication for episiotomy was the incipient perineal rupture.

No differences were found in the incidence of maternal injuries in both groups (Table 7).

 

Table 7. Maternal injuries in the studied groups

Type of maternal injury	Main group		Comparison group
	number of patients, n	incidence, %	number of patients, n	incidence, %
Hysterocervicorrhexis grade I	7	15.9	6	10
Hysterocervicorrhexis grade II	1	2.2	1	1.6
Rupture of the mucous membrane of the vaginal walls	2	4.4	0	0
Perineal rupture grade I	1	2.2	4	6.6
Perineal rupture grade II	1	2.2	3	5
Perineal rupture grade III	1	2.2	0	0

 

In the postpartum period, the duration of stay in the ward was 5.1±1.2 days for postpartum women with AII and 4.0±1.0 days for patients in the comparison group (F=25.634; p < 0.0001).

No differences were found in the incidence of complications in the postpartum period between the postpartum women of both groups. Complications in the postpartum period were represented by hypotonic bleeding in the early postpartum period, placenta segment retention in the uterus, and uterine subinvolution. Hypotonic bleeding in the early postpartum period was noted in only 1 (1.6%) patient with AII, due to which a manual examination of the uterine cavity was performed. The placenta segment retention in the uterus was registered only in patients of the comparison group and in 1 case of childbirth. This patient underwent a manual examination of the uterine cavity, and the retained segment of the placenta was removed. Uterine subinvolution was diagnosed in both groups, wherein 3.3% (2 patients) of patients in the main group and 5% (3 patients) in the comparison group. These patients underwent vacuum aspiration of the contents of the uterine cavity.

CONCLUSION

Study results revealed that at present, the etiological structure of patients with AII with full-term pregnancy is represented mainly by opportunistic flora. Female patients with AII at full-term pregnancy more often had a complicated course of labor. In this group, preterm discharge of amniotic fluid was noted more often than in the comparison group. The frequency of acute and chronic fetal hypoxia was significantly higher in patients with AII, as well as the presence of moderate asphyxia 1 min after delivery. The data obtained confirm the study results by K.B. Markham, G. Mor, and M. Makhmudova on the risk of acute fetal hypoxia in puerperas with AII [12, 13, 19]. No differences were found in the incidence of labor anomalies, labor duration, and volume of blood loss in patients with AII, which was confirmed by the data of T.V. Belyaeva and N.S. Cherkasova [17, 18]. However, patients with AII have an increased incidence of episiotomy during labor and a longer stay in the postpartum unit.

Therefore, childbirth must be performed in patients with AII with continuous monitoring of the condition of the fetus during labor, and timely medical care to the newborn is necessary.

ADDITIONAL INFORMATION

Conflict of interest. The authors declare no conflict of interest.

Funding. The study had no external funding.

Author contributions. The authors of the article were equally involved in preparing its manuscript for publication in accordance with the Vancouver Guidelines for Authorship of Articles.

About the authors

Alexey S. Kovalchuk

Clinical Infectious Hospital named after S.P. Botkin

Email: babai_jo@bk.ru
ORCID iD: 0000-0001-8206-6561
SPIN-code: 2784-3503

MD, obstetrician-gynecologist

Russian Federation, 195067, Saint-Petersburg, Piskarevsky avenue 49

Eduard N. Popov

AVA-PETER Ltd.

Email: edwardpopov@mail.ru
ORCID iD: 0000-0001-8671-3551
ResearcherId: K-2802-2018

MD, Dr. Sci. (Med.), Assistant Professor, Head of the Department of Operative Gynecology

Russian Federation, 191014, Saint-Petersburg, 55a, letter A, office. 3-N, 31

Dmitry A. Lioznov

Smorodintsev Research Institute of Influenza; the First Pavlov State Medical University of St. Petersburg

Email: dlioznov@yandex.ru
ORCID iD: 0000-0003-3643-7354
SPIN-code: 3321-6532

MD, Dr. Sci. (Med.), Professor

Russian Federation, 197022, St. Petersburg, Professor Popov Street, 15/17; 41 Kirochnaya Str., Saint Petersburg, 191015

Dmitry S. Sudakov

North-Western State Medical University named after I.I. Mechnikov; The Research Institute of Obstetrics, Gynecology, and Reproductology named after D.O. Ott

Author for correspondence.
Email: suddakovv@yandex.ru
ORCID iD: 0000-0002-5270-0397
SPIN-code: 6189-8705

MD, Cand. Sci. (Med.), Assistant of the Department of Obstetrics and Gynecology of the University, Head of the Educational and Methodological Department of the Research Institute

Russian Federation, 41 Kirochnaya Str., Saint Petersburg, 191015; 3 Mendeleevskaya Line, Saint Petersburg, 199034

References

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