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Research Article| Volume 19, ISSUE 8, P835-852, July 1997

Evidence-based Prevention of Preterm Birth and Rupture of Membranes: Infection and Inflammation

DOI:https://doi.org/10.1016/S0849-5831(97)80007-9
Evidence-based Prevention of Preterm Birth and Rupture of Membranes: Infection and Inflammation
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      Abstract

      Prevention of preterm birth and subsequent newborn immaturity is a primary goal of health care in Canada and throughout North America. Much accumulated evidence shows that (I) as many as 30 to 50 percent of preterm births are caused by common genital tract infections and subsequent maternal/fetal inflammatory responses; (2) microbial and maternal host factors (phospholipases, proteases) play roles in preterm labour and preterm premature rupture of membranes (pPROM); (3) identification and systemic treatment of common genitourinary infections, most importantly bacterial vaginosis (BV), reduces risks of preterm delivery and PROM; and, (4) antimicrobial treatment with erythromycin, clindamycin or other antibiotics can significantly delay delivery and reduce the risks of maternal and neonatal morbidity as well as reduce the risk of early onset group B streptococcal sepsis in women with pPROM or preterm labour prior to 34 completed weeks gestation.
      Diagnosis of EV can be made inexpensively and accurately by using Amsel’s clinical criteria: homogeneous discharge, pH ≥4.5, positive amine test, and “clue” cell identification (3 of 4). Optimal treatment for BV during pregnancy is either prompt administration of oral metronidazole or clindamycin followed by a “test of cure” evaluation and retreatment as necessary. Screening and treatment for BV and other prevalent reproductive tract infections and bacteriuria are most easily and effectively performed during the initial antepartum visit. Screening and treatment can be repeated at 20 or 28 weeks gestation in patients judged at risk for repeated infection. Partners of women with sexually transmitted diseases should be treated; both patients and partners should have “tests of cure.” Both asymptomatic and symptomatic infections should be treated. Potentially powerful interactions of reproductive tract infection and inflammation with other obstetric factors, including a prior history of preterm birth, first trimester bleeding, and possibly, short cervix and multiple gestation can be mitigated by effective treatment of reproductive tract infections. Medical care providers now have the opportunity and the obligation to reduce infection-mediated preterm birth by expeditiously identifying and treating prevalent reproductive tract infections in their pregnant patients.

      Résumé

      La prévention de la naissance avant terme et de l’immaturité qui s’ensuit chez le nouveau-né constitue un des principaux objectifs en matière de soins de santé au Canada et partout en Amérique du Nord. Une accumulation importante de données démontre (1) qu entre 30 et 50 pour cent des naissances avant terme sont causées par des infections banales de l’appareil génital et par les réactions inflammatoires qui s’ensuivent chez la mère et le foetus; (2) que les facteurs microbiens et propres à l’hôte maternel (phospholipases, protéases, etc.) jouent un rôle dans le travail avant terme et la rupture prématurée des membranes avant terme (RPMAT); (3) que l’identification et le traitement général des infections génito-urinaires banales, surtout la vaginite bactérienne (VB), réduisent les risques d’accouchement avant terme et de RPMAT; (4) et qu’un traitement antimicrobien à l’érythromycine, la clindamycine ou un autre antibiotique peut différer considérablement l’accouchement et réduire les risques de morbidité maternelle et néonatale, ainsi que le risque de septicémie à streptocoques du groupe B d’installation précoce en cas de RPMAT ou de travail avant terme avant 34 semaines complètes de gestation.
      La VB peut être diagnostiquée à peu de frais et avec précision grâce aux critères cliniques d’Amsel : écoulement homogène, pH < 4,5, analyse des aminés et identification des « bâtonnets courts » (3 sur 4). Pendant la grossesse, le traitement optimal dela VB consiste à administrer rapidement du métronizadole ou de la clindamycine par voie orale, à vérifier l’efficacité du traitement et à reprendre le traitement au besoin. Il est plus facile et efficace de dépister et de traiter la VB, les autres infections courantes de l’appareil reproducteur et la bactériurie pendant la première consultation antepartum. On peut reprendre le dépistage et le traitement à la 20e ou à la 28e semaine de gestation chez les patientes jugées à risque de réinfection. Il faut traiter les partenaires des femmes atteintes de maladies transmises sexuellement et vérifier l’efficacité du traitement chez les patientes et les partenaires. Il faut traiter à la fois les infections asymptomatiques et les infections sympto-manques. Des interactions potentiellement puissantes entre l’infection et l’inflammation de l’appareil reproducteur et d’autres facteurs obstétricaux, y compris des antécédents de naissance avant terme, d’hémorragie du premier trimestre et, éventuellement, de col court et de gestation multiple peuvent être atténuées par un traitement efficace des infections de l’appareil reproducteur. Les dispensateurs de soins médicaux ont maintenant la possibilité et l’obligation de réduire les naissances avant terme d’origine infectieuse en identifiant et en traitant sans délai les infections courantes de l’appareil reproducteur chez leurs patientes enceintes.

      Key Words

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      Article info

      Publication history

      Accepted: February 10, 1997
      Received in revised form: February 10, 1997
      Received: December 9, 1996

      Identification

      DOI: https://doi.org/10.1016/S0849-5831(97)80007-9

      Copyright

      © 1997 Published by Elsevier Inc.

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