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Sexually transmitted diseases among women with habitual abortion

N.K. Mahdi and M.M. Al-Hamdani

ABSTRACT Sexually transmitted disease as a risk factor for habitual abortion was investigated in a case-control study in Basra between October 1994 and May 1995. Of 81 women with habitual abortion, 41 (50.6%) had a sexually transmitted disease. In the normal pregnancy group, 64 of 119 women (53.8%) had a sexually transmitted disease (c² = 0.712, P > 0.05). The isolation rates of Candida spp., Trichomonas vaginalis, Gardnerella vaginalis and Neisseria gonorrhoeae in women with habitual abortion were not significantly different from those in normal pregnant women. No association was found between the presence of a sexually transmitted disease and habitual abortion (odds ratio = 0.9). No positive case of syphilis was diagnosed using VDRL and TPHA tests. There was a significant relation between the presence of a sexually transmitted disease and the presence of vaginal discharge, vaginal pH > 4.5 and the frequency of sexual activity/week > 2.

Les maladies sexuellement transmissibles chez les femmes ayant eu des avortements à répétition

RESUME Les maladies sexuellement transmissibles en tant que facteur de risque d'avortement à répétition ont fait l'objet d'une analyse dans le cadre d'une étude cas-témoin réalisée à Bassora d'octobre 1994 à mai 1995. Sur les 81 femmes ayant eu des avortements à répétition, 41 (50,6%) avaient une maladie sexuellement transmissible. Dans le groupe des femmes ayant une grossesse normale, 64 femmes sur 119 (53,8%) avaient une maladie sexuellement transmissible (c²=0,712, P>0,05). Les taux relatifs à l'isolation de Candida spp., Trichomonas vaginalis, Gardnerella vaginalis et Neisseria gonorrhoeae chez les femmes ayant eu des avortements à répétition n'étaient pas significativement différents de ceux des femmes ayant une grossesse normale. Aucune association n'a été établie entre la présence d'une maladie sexuellement transmissible et des avortements à répétition (risque relatif approché =0,9). Aucun cas positif de syphilis n'a été diagnostiqué à l'aide des tests VDRL et TPHA. Il n'y avait pas de relation significative entre la présence d'une maladie sexuellement transmissible et la présence d'un écoulement vaginal, un pH vaginal supérieur à 4,5 et la fréquence d'une activité sexuelle hebdomadaire supérieure à deux rapports.

Introduction

The causes of habitual abortion can be fetal and maternal [1]. It is likely that transplacental infection leads to chorioamnionitis, release of prostaglandins and preterm uterine activity [2]. Failure to give adequate and prompt care to these cases may result in considerable human loss.

There are several sexually transmitted diseases (STD), but gonorrhoea and syphilis are particularly important because of their high prevalence and morbidity. They are well recognized causes of fetal death in utero, low birth weight and severe diseases in neonates [3,4]. Many other infectious agents, particularly Gardnerella vaginalis, Trichomonas vaginalis and Candida spp., have been recognized as causes of STD. Chlamydia trachomatis infection is acquired through sexual contact, and recovery rates of 18%-37% have been reported from women attending sexually transmitted disease clinics [5]. The highest isolation rates (64%-72%) have been found in women harbouring gonococcus or who are known contacts of men with chlamydial urethritis [2,6]. Since chlamydial agents may cause abortion in several animal species, it may [2,5] or may not [7] have a role to play in spontaneous human abortion.

The population at risk of STD has risen and, therefore, public concern about these diseases has greatly increased and has provided momentum to STD research. To the best of our knowledge, this study is the first attempt in Iraq to assess the possible role of maternal infection with sexually transmitted agents among women with habitual abortion.

Subjects and methods

Subjects

This case-control study was carried out on 200 women attending the outpatient gynaecological clinic of Basra Maternity Hospital and antenatal care clinic in Hay Al-Shuhada health centre between October 1994 and May 1995. They comprised 81 women with habitual abortion and 119 pregnant women who did not have any history of abortion. Their ages ranged from 15 years to 45 years.

Clinical examination of the vulva and vagina was carried out and two vaginal swabs were obtained from each woman.

Laboratory diagnosis

One swab was used to recover T. vaginalis by wet preparation and culture methods. Cultures were carried out on Trichomonas broth, incubated at 37 °C and examined at 48 hours, then daily for 5 days.

Vaginal pH measurement was made by dipping a piece of Whatman pH paper into the vaginal discharge on the speculum. The amine or sniff test was carried out by adding a drop of 10% potassium hydroxide to the discharge.

The other vaginal swab was collected in Stuart medium and inoculated directly onto chocolate agar, Thayer-Martin medium and Sabouraud dextrose agar. The inoculated culture plates were incubated at 37°C for 48 hours. The Sabouraud agar plate was incubated aerobically. Chocolate and Thayer-Martin plates were incubated anaerobically. Also, a Gram-stain smear was prepared from the swab and examined for Gram-positive and Gram-negative organisms and yeast.

Serological test for syphilis

Sera were separated by blood centrifugation at 3000 rpm for 5 minutes. Samples were stored at -20 °C until needed. They were screened for syphilis using the VDRL test and confirmed by TPHA test.

Statistical analysis

The chi-squared (c²) test or, where appropriate, the SND test was used as a test of significance. Differences were recorded as significant whenever probability (P) was less than 0.05. In addition, the odds ratio and 95% confidence intervals of odds ratio were estimated for a single 2 ´ 2 table (to determine whether there was a crude disease-exposure association).

Results

The main characteristics of the group with habitual abortion and the normal pregnancy group are compared in Table 1. Of the 81 patients with habitual abortion, 41 (50.6%) had an STD. In the normal pregnancy group, 64 of 119 women (53.8%) had an STD. This relationship was not statistically significant (c² = 0.712, P > 0.05) (Table 2). The distribution of sexually transmitted microorganisms in both groups as well as the non-sexually transmitted microorganisms from the vaginal swabs is shown in Table 3.

There was no positive case of syphilis diagnosed among the 200 sera samples examined from both groups.

The prevalence of STD among women in this study was not statistically significant in relation to age, occupation and economic status (Table 4). However, 76% of women who presented with vaginal discharge had an STD, while 20.9% of women with no vaginal discharge (asymptomatic) had an STD (c² = 52.6, P < 0.01). The relationship was also significant in relation to vaginal
pH and the frequency of sexual activity/week (Table 4).

Discussion

This study indicates that, despite the progress made in methods of diagnosis and treatment, STDs are now among the most common communicable diseases and constitute an important public health problem among aborted as well as normal pregnancy women in the country.

Although the overall prevalence of Candida spp. in our study was 30.3%, there was no significant association between vaginal candidiasis and habitual abortion. C. albicans is the most common cause of vulvovaginitis in pregnancy. The presence of a glycogen-rich vaginal epithelium, because of increased estrogen production, or alterations in carbohydrate metabolism and reduction in cell-mediated immunity associated with pregnancy may play a role in the transition of the organism from a saprophyte to a pathogen [8,9].

Although the rate of T. vaginalis infection observed in this study had no association with habitual abortion, it still represents a high level from the public health point of view. Also some cases of T. vaginalis infection can be acquired through non-sexual means, such as toilet facilities, medical instruments or by sharing towels or underwear [10,11]. T. vaginalis is not implicated as a factor in abortion, premature labour and intrauterine growth retardation in many studies [12-14]. On the other hand, some researchers have reported a considerable association with premature rupture of membranes, preterm labour and low birth weight [3,15].

It has been reported that bacterial vaginosis may stimulate the premature rupture of membranes and preterm labour by inducing the synthesis and release of prostaglandins [16-18]. However, we found no association between bacterial vaginosis and habitual abortion.

There was no significant relationship observed between maternal Neisseria gonorrhoeae infection and habitual abortion. Similar observations have also been made in relation to spontaneous abortion [19]. However, some researchers have found that maternal gonococcal infection in the last trimester of pregnancy is associated with an increased incidence of premature rupture of the fetal membranes [20,21]. As almost all patients with gonococcal infection are asymptomatic, these researchers recommend that routine cultures should be obtained at the initial prenatal visit as well as during the later weeks of pregnancy [21].

Untreated syphilis contracted 6-12 months prior to pregnancy usually results in midtrimester abortion or death of the fetus [22]. Therefore, routine serological screening for syphilis is an important aspect of antenatal care and as such should always be performed in early pregnancy. Higher seroreactivity rate to syphilis was reported among women with spontaneous abortion in Zambia [23] and Nairobi, Kenya [19]. In our study, the role of syphilis could not be determined because no sera were reactive to the VDRL and TPHA tests.

We found a highly significant increase in the prevalence of STD in the presence of vaginal discharge, vaginal pH > 4.5 and the
frequency of sexual activity/week > 2. These results suggest that the frequency of STD is greater among sexually active women and among women with vaginal discharge, which is more likely to harbour infectious microorganisms. It has been reported that women with a vaginal pH ³ 4.4 were significantly more likely to carry T. vaginalis, Bacteroides spp. and non-specific vaginitis [15]. They were also more likely to have premature rupture of the membranes.

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