A midtrimester pregnancy loss, due to B. fragilis is described. We hypothesize that in early pregnancy anaerobic bacterial vaginosis has the greatest pathogenicity, while an intermediate (mixed) flora is most dangerous in midtrimester miscarriages, and that aerobic vaginitis is more dangerous than anaerobes towards the second half of the pregnancy. Unfortunately, no screen and treat policy has yet been proven to be sufficiently powerful to prevent the vast majority of infection-related prematurity. © 2005 Taylor & Francis.status: publishe

Baekelandt, J

Bosteels, J

Crombach, M

Donders, G

English

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J. Baekelandt

M. Crombach

G. Donders

J. Bosteels

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Infectious Diseases in Obstetrics and Gynecology

Spontaneous Midgestation Abortion Associated With Bacteroides Fragilis: A Case Report

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CASE REPORTSpontaneous midgestation abortion associated with Bacteroidesfragilis: A case reportJ. BAEKELANDT1, M. CROMBACH1, G. DONDERS2, & J. BOSTEELS11Department of Obstetrics and Gynecology, AZ Imeldaziekenhuis, Bonheiden, Belgium, and 2Department of Obstetrics andGynecology, Heilig Hartziekenhuis, Tienen, BelgiumIntroductionIntrauterine infection underlies many spontaneousmid-gestation abortions. We present a case of mid-trimester abortion, where Bacteroides fragilis was thesole pathogen that could be cultured.Case reportA 31-year-old primigravida consulted her gynaecol-ogist in the casualty department of a private hospitalin Belgium (Imeldaziekenhuis Bonheiden) withintermittent contractions presenting as lower backpain, vague hypogastric cramps and vaginal dis-charge of blood and mucus. She was 19 weeks and 3days pregnant according to dates of conception andan ultrasound at 7 weeks. Her medical history wasunremarkable. Serology for CMV IgG, Hepatitis AIgG, Hepatitis B surface antigen and Hepatitis C IgGwas negative and there was no immunity forToxoplasmosis. Routine ultrasound at 18 weekswas unremarkable.A few days prior to her admission in the hospitalshe recalled vague flu-like symptoms and diarrhoea.Before these symptoms started she had eaten cheese,made with non-pasteurised milk.On admission she had no fever, her abdomen anduterus were soft, non-tender and adequately sized for19 weeks gestation. A sterile speculum examinationrevealed bulging membranes and a bloody discharge.Fetal membranes were intact.An ultrasound showed an anatomically normal,very active fetus, with biometry compatible with 19weeks gestation, normal amount of amniotic fluid,and normal placenta. On abdominal ultrasound thecervix appeared to be 3 cm dilated and fully effaced.The C-reactive protein (CRP) was normal(0.92 mg/dl) and the leucocytosis was up to 19300/mm with 85% neutrofils. Urinary culture wasnegative.Based on the patient’s history, chorioamnionitis,possibly due to Listeria monocytogenes from thecheese, was assumed. Because of the infectious risk,the decision was made not to administer tocolysis,nor to perform a cervical cerclage. Amoxycilline-clavulanic acid was administered IV 1 g every6 hours. Despite this treatment the patient devel-oped 38.48C fever and uterine contractions within12 hours. The CRP had risen to 2.78 mg/dl with aleucocytosis of 20500/mm (80% neutrofil count).Vaginal GBS swab cultured on a GBS selectivemedium was negative and aerobe and anaerobeblood cultures remained negative as well.A male fetus with Apgar 0 was promptly delivered.Anatomopathological examination showed an im-mature placenta with intervillous microabcessescontaining necrotic debris. The membranes showedsevere signs of chorioamnionitis. The fetus showedno congenital abnormalities and no signs of pneu-monitis.Cultures taken from the placenta and the fetusboth showed infection with B. fragilis.The patient recovered quickly and was dischargedfrom the hospital on day 4 on oral antibiotictreatment, without a fever.DiscussionThe role of ascending genital infection, leading toamniotic fluid infection and preterm labor is wellrecognized in midtrimester miscarriages [1–10].Prior rupture of membranes is not necessary forCorrespondence: Dr J Baekelandt, Neckersbeemd 3, 2540 Hove, Belgium. Tel: 32495638983. Fax: 3234558732. E-mail: janbaekelandt@hotmail.comInfectious Diseases in Obstetrics and Gynecology, December 2005; 13(4): 241–243ISSN 1064-7449 print/ISSN 1098-0997 online ª 2005 Taylor & FrancisDOI: 10.1080/10647440500148347development of ascending amniotic infection [11]. Ithas been established that subclinical intrauterineinfection may occur, even with intact membranes,leading to the absence of clinical signs of infection,despite clear histological signs of chorioamnionitis[12]. Micro-organisms can be recovered from theretro-chorioamniotic space in cases with pretermlabor at early gestational age and histologicalchorioamnionitis can usually be demonstrated [6].Furthermore, the earlier the gestational age, thehigher is the rate of histological chorioamnionitis andamniotic fluid infection [11].There are two likely mechanisms of fetal lossassociated with infection in midgestation and bothare similar to those operating later in pregnancy.First, there may be bacterial invasion of the amnioticcavity or fetoplacental membranes, stimulating laborand delivery of a previable fetus, and second, theremay be intrauterine infection of the fetus presumablyfrom swallowed and inhaled infected amniotic fluid,leading to fetal pneumonitis and/or septicaemia [12].McDonald (1991) demonstrated preterm labor tobe associated with the recovery of bacterial micro-organisms in the vagina during labor. Bothmicroorganisms linked to bacterial vaginosis (G.vaginalis, Bacteroides) and aerobic organisms (E. coli,group B streptococci) were involved [5]. Bacteroidessp. were shown to be significantly associated withPROM, whereas no such relationship was presentwith G. vaginalis. [5]. Minkoff et al. (1984) demon-strated that women colonised with Bacteroides had arelative risk of 2.8 for PROM compared with non-carriers [13].The role of vaginal microorganisms in latemiscarriage was also demonstrated in a study of783 women screened in early pregnancy, showing a 7fold increased risk of preterm birth and latemiscarriage (16–24 weeks of gestation) in womenwith abnormal vaginal flora compared to normalflora [14]. As most of these midtrimester abortioncases had rather intermediate flora (mixed anaero-bic-aerobic flora) than full blown bacterial vaginosis,it led our group to propose a revision of the currentopinion of the pathogenesis of infection-relatedpreterm birth [15]. Indeed numerous studies nowrelate anaerobic [8,14] bacterial vaginosis and notaerobic vaginitis to early pregnancy losses, whereas inthe second half of pregnancy, preterm birth is ratherassociated with aerobic vaginitis than with uncom-plicated anaerobic bacterial vaginosis [12,16,17].Later in pregnancy, at 24–32 weeks, not infre-quently the aerobic group, B streptococci, with orwithout Candida albicans are the sole organismsfound, and in a recent study on the preterm birth riskearly in pregnancy, it could be confirmed that not theanaerobic bacterial vaginosis at first prenatal visitmatters so much for a preterm delivery between 20and 34 weeks, but rather aerobic vaginitis due togroup B strep, E. coli and other aerobes [16].SummaryA midtrimester pregnancy loss, due to B. fragilis isdescribed. We hypothesize that in early pregnancyanaerobic bacterial vaginosis has the greatest patho-genicity, while an intermediate (mixed) flora is mostdangerous in midtrimester miscarriages, and thataerobic vaginitis is more dangerous than anaerobestowards the second half of the pregnancy. Unfortu-nately, no screen and treat policy has yet been provento be sufficiently powerful to prevent the vastmajority of infection-related prematurity.References1. Gravett MG, Hummel D, Eschenbach DA, Holmes KK.Preterm labor associated with subclinical amniotic fluidinfection and with bacterial vaginosis. Obstet Gynecol1986;67:229–237.2. Lamont RF, Taylor-Robinson D, Wigglesworth JS, Furr PM,Evans RT, Elder MG. The role of mycoplasmas, ureaplasmasand chlamydiae in the genital tract of women presenting inspontaneous early premature labor. Med Microbiol1987;24:253–257.3. Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK,Eschenbach DA. A case-control study of chorioamnioniticinfection and histological chorioamnionitis in prematurity. NEngl J Med 1988;319:972–978.4. Romero R, Sirtori M, Oyarzun E, Avila C, Mazor M,Callahan R, Sabo V, Athanassiadis AP, Hobbins JC. Infectionand labor: Prevalence, microbiology and clinical significanceof intraamniotic infection in women with preterm labor andintact membranes. Am J Obstet Gynecol 1989;161:817–824.5. McDonald HM, O’Loughlin JA, Jolley P, Vigneswaran R,McDonald PJ: Vaginal infection and preterm labor. Br JObstet Gynaecol 1991;99:427–435.6. Hillier SL, Krohn MA, Kiviat NB, Watts DH, EschenbachDA. Microbiologic causes and neonatal outcomes associatedwith chorioamnion infection. Am J Obstet Gynecol1991;165:955–961.7. Donders GGG, Odds A, Vereecken A, Van Bulck B, CaudronJ, Londers L, Salembier G, Spitz B. Abnormal vaginal flora inthe first trimester, but not full-blown bacterial vaginosis isassociated with premature birth. Prenat Neonat Med1998;3:588–593.8. Donders GGG, Van Bulck B, Caudron J, Londers L,Vereecken A, Spitz B. Bacterial vaginosis and mycoplasmataincrease the risk of spontaneous abortion. Am J ObstetGynecol 2000;183:431–437.9. Andersen LF, Svare J, Madsen H, Langhoff-Roos J, JensenET, Bruun BB. Group B streptococcal chorioamnionitis andneonatal septicemia following 8 days pivampicillin andmetronidazol prophylaxis after premature rupture of mem-branes; a case report: Eur J Obstet Gynecol Reprod Biol1991;38:157–160.10. Krohn MA, Thwinn SS, Rabe LK, Brown Z, Hillier S.Vaginal colonization by E. coli as a risk factor for very low birthweight delivery and other perinatal complications. J Infect Dis1997;175:606–610.242 J. Baekelandt et al.11. Naeye RL, Peters EC. Causes and consequences of prematurerupture of fetal membranes. Lancet 1980;1:192–194.12. McDonald HM, Chambers HM. Intrauterine infection andspontaneous midgestation abortion: is the spectrum ofmicroorganisms similar to that in preterm labor? Infect DisObstet Gynecol 2000;8(5–6):220–227.13. Minkoff H, Grunebaum AN, Schwarz RH, Feldman J,Cummings M, Crombleholme W, Clark L, Pringle G,McCormack WM. Risk factors for prematurity and prematurerupture of membranes : a prospective study of the vaginal florain pregnancy. Am J Obstet Gynecol 1984;150:965–972.14. Hay PE, Lamont RF, Taylor-Robinson D, Morgan DJ, IsonC, Pearson J. Abnormal bacterial colonization of the genitaltract and subsequent preterm delivery and late miscarriage. BrMed J 1994;308:295–298.15. Donders GGG. Bacterial vaginosis in pregnancy: screen andtreat? (Editorial) Eur J Obstet Gynecol Reprod Biol 1999;83:1–4.16. Donders GGG, Vereecken A, Bosmans E, Dekeersmaecker A,Salembier G, Spitz B. Definition of a type of abnormal vaginalflora that is distinct from bacterial vaginosis: aerobic vaginitis.Br J Obstet Gynecol 2002;109:1–10.17. Carey JC, Klebanoff MA, Hauth JC, Hillier SL, Thom EA,Ernest JM, Heine P, Nugent RP, Fischer ML, Leven KJ,Metronidazole to prevent preterm delivery in pregnant womenwith asymptomatic bacterial vaginosis. N Engl J Med 2000;342:534–540.Spontaneous midgestation abortion 243Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Lirias

Spontaneous midgestation abortion associated with Bacteroides fragilis: a case report.

J.  Bosteels

G.  Donders

M.  Crombach

J.  Baekelandt

A case-control study of chorioamnionitic infection and histological chorioamnionitis in prematurity.

Abnormal bacterial colonization of the genital tract and subsequent preterm delivery and late miscarriage.

Abnormal vaginal ﬂora in the ﬁrst trimester, but not full-blown bacterial vaginosis is associated with premature birth.

Bacterial vaginosis and mycoplasmata increase the risk of spontaneous abortion.

Bacterial vaginosis in pregnancy: screen and treat?

Deﬁnition of a type of abnormal vaginal ﬂora that is distinct from bacterial vaginosis: aerobic vaginitis.

Group B streptococcal chorioamnionitis and neonatal septicemia following 8 days pivampicillin and metronidazol prophylaxis after premature rupture of membranes; a case report:

Infection and labor: Prevalence, microbiology and clinical signiﬁcance of intraamniotic infection in women with preterm labor and intact membranes.

Intrauterine infection and spontaneous midgestation abortion: is the spectrum of microorganisms similar to that in preterm labor? Infect Dis Obstet Gynecol

Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis.

Microbiologic causes and neonatal outcomes associated with chorioamnion infection.

PJ: Vaginal infection and preterm labor.

Preterm labor associated with subclinical amniotic ﬂuid infection and with bacterial vaginosis. Obstet Gynecol

Risk factors for prematurity and premature rupture of membranes:a prospective study of the vaginal ﬂora in pregnancy.

The role of mycoplasmas, ureaplasmas and chlamydiae in the genital tract of women presenting in spontaneous early premature labor. Med Microbiol

Vaginal colonization by E. coli as a risk factor for very low birth weight delivery and other perinatal complications.

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Spontaneous midgestation abortion associated with Bacteroides fragilis: a case report.

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