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Abstract
The purpose of this work was to study bacterial endotoxin in menstrual effluent, preterm labor and spontaneous abortion.
Preterm delivery is defined as delivery before 37 completed weeks ,it represent approximately 12% of births, 28 of preterm births are the result of a physicians decision to bring about delivery for maternal or fetal indications. The remaining 72% were due to spontaneous preterm labor with or without prematurely ruptured membranes [Meis et al., 1998].
Infection of the membranes and amniotic fluid caused by a variety or microorganisms has emerged as possible explanation of some cases of ruptured membranes, preterm labor, or birth.
Bacteria are recovered by transabdominal amniocentesis, 20% of women in preterm labor without overt clinical infection and with intact fetal membranes [Cox et al., 1996].
The earlier on the onset of preterm labor is the like hood of documented amniotic fluid infection [Goldenberg et al 2000] Preterm labor is associated with approximately 12-20% of neonatal mortality. Neonatal morbidity and mortality are primary influenced by gestational age and thus maturity and less so by birth weight [Ginsbrg et al., 1990].
E.Coli release endotoxins, which activates the deciduas and fetal membranes to produce a number of cytokines [Tanaka et al., 1998]. Further, more cytokines and endotoxin stimulates prostaglandin synthesis and release, initiate Neutrophil Chemotaxis infiltration and activators, culminating in the synthesis and release of metalloproteases substances. Prostaglandin stimulates uterine contractions while metallo-proteases attack the chorioamniotic membrane leading to rupture, the metalloproteases also remodel the collagen in cervix [Vanmeir et al., 1997].
Two thirds of pregnant women who have spontaneous or threatened abortion may be more likely to have an abnormality response to Gram negative bacteria, these women often have low levels antibodies serum Lipopolysaccharide (LPS) [Romorek et al., 2003].
Bacterial infections are a recognized cause of fetal loss in animals and man [Mcduffle 1992]. Lipopolysaccharide has been known to cause fetal death or abortion; it induces a marked inflammatory response [Michalek et al., 1980].
The limulus Amebocyte Lysate (LAL) Test is recommended for the quantitation of Gram-negative bacterial endotoxin.
Limulus Amebocyte Lysate is an aqueous extract of blood cells (amebocytes) from the horseshoe crab, limulus polyphemus. Bang, [1953] discovered that, Gram-negative bacteria cause limulus blood to clot. Levin and Bang, [1964] later determined that, the reaction is enzymatic and that the enzymes are located in granules in amebocytes. They showed that clotting is initiated by a unique structural component of the bacterial cell wall called endotoxin or Lipopolysaccharide, the reaction can be determined by kinetic turbidimetric method is based on the development of turbidity of the lysate in the presence of endotoxins. The sensitivity of the assay to endotoxin was 0.005Eu/ml.
This study include 128 non pregnant women had a history of preterm labor or spontaneous abortion or both, fulfilling inclusion and exclusion criteria, all were subjected to full history, examination, laboratories studies, day 21 serum progesterone, Gram stain for detection of bacterial vaginosis and measurement of bacterial endotoxin in menstrual effluent using the limulus Amoebocyte Lysate (LAL) test.
After one year, 68 women became pregnant, follow up of these women to assess the outcome of pregnancy, correlation between endotoxin level in menstrual blood and spontaneous preterm labor or abortion was done. Bacterial endotoxin was detectable with a range 5.2 to >1000 pg/ml. in 123 samples and was not detected in 5 samples with the mean endotoxin level of 242, 88±337.79 pg/ml.
The pregnancy rate among the studied subject was 53% follow up of the pregnant women revealed that 57.4% of pregnant women had full term pregnancy. While preterm pregnancy and spontaneous abortion were 19.1% and 23.5% respectively.
The mean endotoxin level in menstrual blood for pregnant women was 178.49±256.31pg/ml. and it was 61.14±97.37 pg/ml with full term pregnancy while in preterm labor, the mean endotoxin was 268.72±251.35 and increased in spontaneous abortion to 391.23±356.01 pg/ml.
We studied the relation between endotoxin level in menstrual effluent and the preterm labor, and spontaneous abortion the result was statistically significant.
This study revealed significant correlation between endotoxin level in menstrual blood and spontaneous abortions and preterm labor. There was a good negative correlation between mean endotoxin and weeks of gestation among the pregnant women. r = - 0.654 for and p < 0.01.
Correlating endotoxin level in menstrual effluent (pg/ml), with the outcome of pregnancy in the present study, we found the cut off value of endotoxin to be > 150pg/ml, this gives an overall accuracy of 85.3%, a sensitivity of 80% and the specificity of 89.62%