Egyptian Journal of Medical Microbiology, October 2008 Vol. 17, No. 4

Correlation Between Female Genital Tract Levels of Interleukin-6 and Interleukin-8 in Recurrent Miscarriage Associated with Bacterial Vaginosis

Sahar Taher 1 and Mohamed El-Negeri 2

(1)Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University. (2) Department of Obstetric and Gynecology, Faculty of Medicine, Mansoura University. ABSTRACT: Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge among women in childbearing period. It develops when vaginal lactobacilli are replaced by an overgrowth of Gardnerella vaginalis, anaerobes, and mycoplasma. BV is associated with subclinical endometritis and may be correlated with recurrent miscarriages. Miscarriage refers to the loss a pregnancy before 24 weeks. It was reported that there is a relation between IL-6 and IL-8 in cervical and amniotic fluid and microbial invasion of chorioamniotic membranes. Our aim is to determine the value of genital tract levels of IL-6 and IL-8 in women with recurrent miscarriages in the presence or absence of BV. The present study included 94 women, 54 of them had history of recurrent miscarriage (patients group) and 40 females with normal pregnancy (control group). Samples were collected by vaginal swabs and cervicovaginal lavages(CVL) and examined physically, microscopically and were graded by Gram stain for BV, cytokine levels measured by ELISA kits. There was an increase in frequency of miscarriage with age. BV was detected in 37% of patients group and in 20% of control group. Gardnerella vaginalis was found in 33% and 15% of patients and control group respectively. When comparing patients group versus control group both cytokines levels were elevated, the mean (± SD) of IL-6 was 66.88±60.00 vs 11.14 ±13.69 pg/ml and that of IL-8 was 2265.47 ±3328.92 vs 195.12 ±203.59 pg/ml, P-value was highly significant <0.0001. The risk estimates of IL-6 for further miscarriage was 5 times, OR was 5.19, 95%CI ranged from 2.45- 10.99 and the risk estimates of IL-8 was 3 times, OR was3.08, 95% CI ranged from 1.74-5.30. From the present study, we can conclude that BV constitutes a factor that may lead to miscarriage especially in recurrent unexplained cases and this is reflected by the elevation of genital tract cytokines which cause subclinical endometritis. We recommend the initiation of systemic antibiotic therapy in cases of BV aiming for reduction of miscarriage incidence.

INTRODUCTION women having in-vitro fertilization (IVF) treatment.(4) Bacterial vaginosis is associated Bacterial vaginosis (BV) is a common with complications of pregnancy ,including clinical syndrome characterized by an miscarriage, preterm birth post-partum overgrowth of vaginal anaerobes and depletion endometeritis. It is though that infection ascends of the normal lactobacilli population.(1) It is the from the lower genital tract through the cervix most common cause of abnormal vaginal leading to deciduitis, chorioamnionitis and discharge among women in childbearing period (5) amniotic fluid and fetal infection. . Bacterial vaginosis develops when vaginal lactobacilli are replaced by an overgrowth of Miscarriage refers to the loss of a pregnancy Gardnerella vaginalis , anaerobes and before 24 weeks. It is a common complication of mycoplasma.(2) Bacterial vaginosis has been pregnancy, occurring in 12-30% of all clinical associated with change of sex partner, vaginal pregnancies. (6) douching, and the use of an intrauterine (1) Miscarriage is a common event that causes contraceptive device. considerable morbidity for the mother. The Women with BV have an elevated vaginal second trimester loss is less common, occurring pH (> 4.5) and can experience a vaginal in 1-2% of pregnancies. (1) homogenous discharge which oven has a Bacterial vaginosis is associated with distinctive fishy odor. The addition of potassium subclinical endometritis, (7) which may create an hydroxide to a drop of vaginal secretion on a adverse endometrial milieu for developing slide may produce or accentuate the odor and embryo or fetus .This link might partially these three signs in addition to the presence of account for the reported association between "Clue cells" on a wet mount smear comprise the st (3) bacterial vaginosis or intermediate flora and 1 criteria. trimester miscarriage. (2) The prevalence varies widely from 5 to 51% in different populations and about 24.6% of

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Many women are asymptomatic, but some It is well known that the frequency of pre- experience frequent symptomatic episodes of the term birth is high in successfully treated patients condition. Current antibiotic treatments restore suffering recurrent spontaneous miscarriage the normal lactobacillus dominated flora in the .This means that these might be a group of short term, but approximately 30% relapse heterogeneous unexplained recurrent within one month. (8) miscarriages whose miscarriages are caused by inflammation.(18) Bacterial vaginosis or disrupted Bacterial vaginosis is so named because it is vaginal flora may alter the local mucosal not a vaginitis as some studies reported that there immune environment and the concentration of is no polymorph nuclear leucocytes (PMNL). A cytokines present in genital secretions. BV was proteinacious toxin was isolated from found to be associated with increased levels of Gardnerella vaginalis with activity against various cytokines.(19) neutrophils, human erythrocytes and endothelial cells, preventing the purulent response in BV In humans, the immune system is deviated infection. (9) towards the Th2 immune response during normal pregnancy, while women with recurrent Gardnerella vaginalis an important organism spontaneous abortions(RSA) have a bias toward of BV, was found to interfere with adherence of Th1 immune response.(20) Failure to unable the lactobacilli to vaginal epithelial cells in vitro. shifting from a pro-inflammatory(Th1) to an Anaerobes play a synergistic role in flourishing anti-inflammatory(Th2) pattern, as evidenced by of Gardnerella vaginalis by raising vaginal pH a persisting or dominant Th1 immune response, through amines production. (10) is associated with complication such as multiple Established causes of recurrent miscarriage implantation failure, RSA(21),pre-eclampsia, are abnormal chromosomes in either partner, pre-term delivery, and intra-uterine growth particularly translocations, anti-phospholipid restriction.(22) antibodies, however half of all cases are The aim of the present work was to unexplained.(11) Women experiencing recurrent determine the genital tract levels of anti- miscarriage show evidence of excessive type 1 inflammatory cytokines IL-6 and IL-8 in women immune parameters and reduced type 2 and T with recurrent miscarriage in the presence or regulatory immune parameters, both absence of BV. systematically and in endometrial tissues.(12) Immunohistochemical and flow cytometric PATIENTS, MATERIALS, AND analysis suggest that, in non- pregnant state, METHODS: predisposition to miscarriage is characterized by changes in the balance between endometrial Patients with two or more consecutive first lymphocyte populations. (13) or second trimester miscarriages were enrolled to the present study. All were managed at Infection of intrauterine tissue, the decidua Mansoura University Hospital Obstetrics and/or amnion, results in macrophage activation Clinics. Hesterosalpingoraphy, chromosome and secretory production of inflammatory analysis for both parents, immunologic tests cytokines, including interleukin-1 (IL-1), tumour parameters such as β2glycoprotein I-dependent (14) necrosis factor (TNF), and IL-6. Elevated anticardiolipin antibodies and lupus amniotic fluid IL-6 has been found to be anticoagulant, blood tests for hyperthyroidism, associated with acute inflammatory lesions, diabetes mellitus, hyperprolactinemia and luteal (15) histologic chorioamnionitis, pre-term labor. In phase defects were performed before the next addition the cervical IL-8 concentrations have pregnancy. All the above investigations were been reported to be associated with vaginal done as a routine to exclude all these factors bacteria in pregnancy and intrauterine infections from the study group. in patients with pre-term labor, providing an indication for treatment to prevent pre-term After getting approval consent from ethical birth.(16) research committee of Ob/Gyn Department, Mansoura University Hospital. A total of 94 Recently, a relationship between IL-6 and women joined the present study. Fifty four IL-8 in cervical and amniotic fluid and microbial women with history of recurrent abortion served invasion of chorioamniotic membranes was as patients group and 40 women with no history (17) reported. of abortion attending the clinic for follow up

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were served as control group, from the period of supernatants were harvested. The resulting January 2007 to January 2008. All of them were supernatant was divided in two aliquots, and pregnant at the time of the study. All women cytokine concentrations were measured using gave informed written consent to undergo commercial quantitative sandwich enzyme speculum examination. immunoassay (Quantikine, R&D systems, Minneapolis, MN). All samples run in duplicate Samples collection and results were reported in pg/ ml. Samples 1.Vaginal swab specimens were collected by were diluted 1:4 for IL-6 and 1:10 for IL-8 using Dacron swabs and immediately processed according to manufacturer’s directions. Briefly, for routine laboratory testing. immunoplates coated with monoclonal 2.Cervicovaginal lavage(CVL) specimens: were antibodies to the studied cytokines were obtained by instilling 10 ml of sterile saline into incubated with samples and standards. After the vaginal vault directing the steam of fluid at washing, a biotin-cojugated polycolonal the cervical os. The fluid was left for about 30 antiserum to each cytokine was added, the plates seconds and then aspirated. The fluid was then were then incubated and washed. Next, avidin- transferred to a sterile 15 ml conical test tube peroxidase was added. Following washing, the and stored at -70C◦. color reaction was developed with tetramethyle bencidine. SO4H2 was added a stopper and Laboratory methods absorbencies were measured at 450 nm by A macroscopic examination of the vaginal means of an ELISA plate reader. Values were swab was performed to record the aspect, smell, calculated from standard curves based on abundance, pH of secretions. Yeast, Tricomonas prepared dilutions of recombinant cytokines. vaginalis, and clue cells were identified, and Statistical analysis epithelial cells, red blood cells, and leucocytes were counted by direct microscopic examination It was performed using SPSS version 11 (×400 amplification) of vaginal secretion wet using windows XP. Qualitative data were mount smears. A Gram’s stain of the vaginal presented as frequency and percentage. smear then was done to identify G. vaginalis, Quantitative data were presented as mean and Mobiluncus species, and lactobacilli and for standard deviation. Kolmogorov-Smirnov test scoring of the vaginal flora. was used to determine the distribution of data. All data were non-normally distributed. X- Vaginal flora typing and bacterial vaginosis square and Fisher exact test were used to diagnosis determine significance among qualitative data Vaginal flora was scored by a Gramed while Mann-Whitney test determine significance stained smear according to the following among quantitative data. Odds ratio determines classification scheme; exclusively lactobacilli the relation between genital tract levels of IL-6 (type I), predominantly lactobacilli (type II), and IL-8 and development of further presence of lactobacilli but predominance of miscarriage. P-value is significant when < 0.05. other gram- positive and gram-negative bacteria RESULTS (type III), and absence of lactobacilli and presence of a mono-or polybacterial flora (type Of the total 94 women undergoing the IV). Both type III and IV classifications present study, 54 patients experienced 2 or more represent flora in which non lactobacilli consecutive miscarriages and 40 women with morphotypes exceed lactobacilli. (23) Therefore, normal pregnancy attending Obstetric Clinic for BV was determined by (1) the presence of clue follow up. The median age of the participants cells in a vaginal smear confirmed by the was 26 years (range, from 19-42 years), all identification of G.vaginalis in a Gram stained women were pregnant at the time of the study. smear,(2) an increased vaginal pH (pH >4.5) and Table (1) describes age distribution and (3) a lacto deficient vaginal flora (types III- IV). miscarriage frequency in patients group, the frequency of miscarriage increases with age Cytokine assays while table (2) demonstrates characteristics of Frozen CVL samples were thawed and BV among studied groups, BV was detected in centrifuged at 500X g to remove debris; they 37.03% and 20% of patients and control group were then centrifuged at 2000Xg and respectively. Gardnerella vaginalis was found in 33.33% of patients and 15% of control group.

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Table (3) illustrates the correlation between BV significant for IL-6, p=0.004 and significant for status and genital tract levels of IL-6 and IL-8 in IL-8 p=0.037. Table (4) shows the diagnostic the studied groups. When comparing the efficiency of the combination of IL-6 and IL-8 cytokine levels between the patients group and levels in the genital tract for the risk of further control group, p- value was highly significant miscarriages. For IL-6 Odds ratio (OR) was 5.19 less than 0.0001. On the other hand, BV positive and 95% confidence interval (CI) ranged from patients versus BV negative patients, for IL-6 p- 2.45-10.99 and that of IL-8 OR was 3.08 and CI value was non significant =0.069 and for IL-8 ranged from 1.74-5.30. The risk estimate of IL-6 was moderately significant =0.004. On for further miscarriage is 5 and that of IL-8 is 3 comparison of patients group BV positive versus times. control group negative, p-value was moderately Table (1): Age distribution and miscarriage frequency in patients group Miscarriage frequency (n.) Patients (n.) % Age ( Mean ± SD) 2 18 33.33% 26 ± 5.1 3 26 48.15% 28 ± 3.8 4 2 3.70% 30 ± 6.3 More than 4 8 14.81% 37 ± 5.0 Table (2): Characteristic of BV in participating women. Characteristic Patient (No.) % Control (No.) % (1) Bacterial flora : -Type I 9 16.67 18 45 -Type II 11 20.37 9 22.5 -Type III 20 37.04 7 17.5 -Type IV 14 25.92 6 15 (2)Vaginal pH: <4.5 33 61.11 32 80 >4.5 21 38.89 8 20 (3) Bacterial vaginosis: Positive 20 37.03 8 20 Negative 34 62.97 32 80 (4) Gardnerella Vaginalis: Positive 18 33.33 6 15 Negative 36 66.67 34 85 Type I, exclusively lactobacilli; type II, predominantly lactobacilli; type III, presence of lactobacilli but predominance of other gram positive and gram negative bacteria; type VI, absence of lactobacilli and presence of a mono- or polymicrobial flora. Table (3): Correlation between BV status and genital tract levels of IL-6 and IL-8 in studied groups

Cytokine levels in cervico-vaginal lavage (mean ± SD ) Bacterial vaginosis status IL-6 (pg / ml) IL-8 (pg / ml)

(1) Patients (54): 66.88 (±60.000) 2265.47 (±3328.92) BV positive (20) 86.81 (± 68.75) 4056.75 (±4327.01) BV negative (34) 55.75 (± 52.15) 1211.78 (±1982.27) (2) Control (40): 11.14 (±13.69) 195.12 (±203.59) BV positive (8) 21.97 (±26.15) 123.62 (±111.06) BV negative (32) 8.49(±6.64) 481.15 (±293.83) • Patients group vs. control P <0.0001*** highly significant. • Patients group BV positive vs. BV negative :

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-IL-6 P = 0.069 non significant -IL-8 P = 0.004** • Patients group BV positive vs. control group negative : -IL-6 P = 0.004** -IL-8 P = 0.037* Table (4):Diagnostic efficiency of the combination of IL-6 and IL-8 levels in genital for the risk of further miscarriages.

Cytokine Patient(No.) Control (No.) P-value Odds ratio 95% CI level (pg/ml) IL-6: >18 42 6 0.0001*** 5.19 2.45-10.99 <18 12 34 0.0001*** 0.26 0.16-0.44

IL-8: >296.6 41 10 0.0001*** 3.08 1.74-5.30 <296.6 13 30 0.0001*** 0.32 0.19-0.53 - The risk estimate of IL-6 for further miscarriage is 5 times and that of IL-8 is 3 times . - The cutoff level was equal to mean plus 0.5 standard deviation among healthy control . - CI : Confidence interval . - P value : * significant ** moderately significant *** highly significant

DISCUSSION affecting implantation of the embryo and placenta, rather than the vaginosis itself. A study Abnormal vaginal flora and bacterial which used sheathed endometrial samplers to vaginosis are associated with amplified risks of minimize contamination from vaginal material late miscarriage and spontaneous preterm (24) reported plasma cell endometritis in 10 of 22 delivery. Bacterial vaginosis is associated endometrial biopsies from symptomatic with complications of pregnancy, including bacterial vaginosis positive women compared miscarriage, preterm birth and post-partum (7) with one out of 19 uninfected women. endomertitis. It is thought that infection ascends from the lower genital tract, through the cervix, In the present work bacterial flora type I was leading to deciduitis, chorioamnionitis and detected in 16.67 % , type II in 20.37%, type III amniotic fluid and fetal infection.(5) Therefore, in 37.04 % and type IV in 25.92% in patients initiation of systemic antibiotic treatment early group while in control group type I flora was might offer the best chance of modifying the detected in 45%, type II in 22.5% ,type III in risks associated with abnormal vaginal flora and 17.5% and type IV in15%. Bacterial vaginosis bacterial vaginosis.(25) was detected in 37.03% and 20% in patients and control group respectively. Gardnerella vaginalis Austin et al., (24) showed that treatment of was found in 33.33% in patients group and 15% asymptomatic intermediate abnormal vaginal of control group. flora and bacterial vaginosis in a general obstetric population reduces the occurrence of When comparing genital tract cytokine late miscarriage and spontaneous preterm levels of IL-6 and IL-8 between patients and delivery. Early introduction of antibiotic control, P-value was highly significant (P< treatment also allowed study the effect of 0.0001). On the other hand the level of IL-6 and treatment on the frequency of late pregnancy IL-8 in patients group associated with BV with loss.(7) those negative for BV, P-value was insignificant for IL-6 (P= 0.069) while significant for IL-8 Bacterial vaginosis is associated with (P= 0.004). Meanwhile patients positive for BV endometritis. It is likely that it is the versus control group BV negative cases P-value endometritis which leads to problems in were highly significant for IL-6 (P= 0.004) and pregnancy, particularly early complications significant for IL-8 (P=0.037).The odds ratio

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(OR) was 5.19 and 95%confidence interval (CI) All bacteria produce proteins with an amino- ranged from 2.45-10.99 for IL-6 while OR was terminal N-formylated methionine, and the f- 3.08 and 95% CI ranged from 1.74-5.30 for IL- Met-Leu Phe (fMLP) peptide is a potent 8. The risk estimates of IL-6 for further chemotactic factor for inflammatory cells, miscarriage is 5 times and that of IL-8 is 3 times. especially neutrophils. The fMLP receptors for chemokines and for the complement fragments Similarly, Jun et al., (26) found that pre-term C5a, C3a, and C4a. Thus, there is a common labor may be due to intrauterine infection and mechanism for attracting neutrophils, whether by IL-6 in cervical fluid was earlier found to have complement, chemokines, or bacterial diagnostic and prognostic value for both pre- products.(30) term rupture of membranes and preterm delivery. Furthermore, bacterial vaginosis is Hattori et al.,(34) found that endometrial reported to cause late miscarriage through expression of Il-6 and IL-1α are reduced in a inflammation and production of IL-1α group of women experiencing unexplained prostaglandin.(27) Complement 3 and 4, which are recurrent miscarriage (RM). On the other hand, elevated with non-specific inflammatory the finding of reduced IL-6 synthesis in phase.(28) endometrial tissue from women experiencing RM is consistent with previous reports. (35, 36) It is possible that any inflammation might be Endometrial IL-6 produced by APCs is localized to the uterus and not reflected by blood implicated as a key immune-deviating cytokine, parameters.(29) Cervical inflammatory cytokines acting to promote Th2 differentiation through may thus be needed to be assessed and we induction of IL-4 synthesis to selectively therefore paid attention to IL-6 and IL-8 polarize Th2 cells, and concurrently inhibits Th1 concentrations cervical secretion as possible development through upregulating suppressor of predictors of further miscarriage in recurrent cytokine signaling (SOCS)-1.(37) During the cases. process of embryo implantation, IL-6 facilitates Cytokines which are secreted in response to tissue remodeling to allow trophoplast invasion pathogens mainly by macrophages, are a by induction of decidual cell metalloproteinases structurally diverse group of molecules and (MMP)-14 and MMP-11(38) and potentially by include IL-1, IL-6 and TNF-α, and IL-8 are regulating decidual angiogenesis.(39) Importantly, involved in local inflammatory responses, Il-6 a key regulator of early placental helping to attract neutrophiles to sites of development acting to regulate trophoblast cell infection. Thus, chemokines direct the migration proliferation , differentiation and synthesis of of the leukocytes along a gradient that increases hCG, IL-1 and Il-6, and expression of integrins in concentration toward site of infection. (30) and other markers of trophoblast invasion.(40 ) It was shown that production of Th2 BV diagnosed in early pregnancy is cytokines including IL-6 by peripheral blood undoubtedly associated with preterm labor or mononuclear (PBMCs) are significantly elevated late miscarriage (41, 42) and with delivery of low with miscarriage. (31) However, it has also been birth – weight infants. (43) There are several reported that Th1 cytokines might not be theories to explain this relationship. The first predominant in recurrent miscarriage patients (32) maintains that protease produced by various and it should be borne in mind that cytokines bacteria found in bacterial vaginosis weaken and also act locally, with T helper cells constituting destroy the connective tissue framework of the only a minor population within the secretory fetal membranes and thus lead to their rupture. endometrium and first trimester-decidua tissue. (44) It has also been suggested that mucinases and It is known that cytokines can be produced by sialidases produced by the bacteria hydrolyse the the epithelial and stromal cells of the protective cervical mucine so allowing the entry endometrium and decidual and cytotrophoblast of micro-organisms into the uterus where they cells of placenta. Epithelial cells are major cause infection and inflammation.(45) In support source of cytokines in non-pregnant of this theory is frequent histological evidence of endometrium, but after decidualization, there is endometritis in non-pregnant women with BV increased production by various populations of and recovery of bacteria associated with BV stromal cells.(33)The degree of interaction from fetal membranes and amniotic fluid between the two systems is yet to be determined subsequent to premature rupture of membranes and cytokine shift theory is still controversial.(34) and preterm labor.(46) Furthermore,

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prostaglandins as well as endotoxins and 8- Hay, P.E. (1998): Therapy of bacterial vaginosis. J interleukin-1a have been found in high Antimicrob Chemother ;41:6-9. concentrations in the cervical mucous and 9- Rottini, G. D., Forgiarini, O. and Nordon, E. vaginal secretions of pregnant women with BV. (1990): Identification and partial characterization of (27) cytolytic toxin produced by Gardnerella vaginalis. Infect. Immunol., 58:3751-3758. Ugwumadu et al.,(24) showed that treatment of asymptomatic intermediate abnormal vaginal 10- Wood, J.R., Sweet, R.L. and Catena, A. (1985): flora and bacterial vaginosis in a general In vitro adherence of lactobacillus species to vaginal obstetric population reduces the occurrence of epithelial cells. Am. J. Obstet. Gynecol., 153: 740- late miscarriage and spontaneous preterm 743. delivery. Therefore, initiation of systemic 11- Herz-Picciotto, I. and Samuels, S. J. (1998): antibiotic treatment early might offer the best Incidence of early pregnancy and loss of pregnancy. chance of modifying the risks associated with N. Engl. J. Med.; 319:1483-1484. abnormal vaginal flora bacterial vaginosis. 12- Saito, S., Saaki, Y. and sakai, M., (2005): CD4 Finally, the results obtained in the present (+)CD25 high regulatory T cells in human pregnancy. J. Reprod. Immunol. 65:111-120. work suggest that IL-6 and IL-8 could be considered potentially eligible for use as 13- Laird, S.M., Tuckerman, E.M., Cork, B.A., infection predictive markers in recurrent LRinjawi, S.,Blackmore,A.I. and Li,T.C.(2003): A miscarriages and in evaluation of therapeutic review of immune cells and molecules in women with success in genitourinary infections. Furthermore, recurrent miscarriage. Hum. Reprod. Update. 9:163- 174. the biological material (vaginal swab and cervicovaginal -lavage) used in this work is easy 14- Gravett, M.G., Witkin, S.S., Haloska, G.J., to obtain and non-invasive for the mother or the Edwards, J.L., Cook, M.J., and Novy,M.J. (1994): fetus, which could be an advantage over the use An experimental model for intra-amniotic infection of amniotic fluid. and preterm labor in rhesus monkeys. Am. J. Obstet. Gynecol. 171:1660-1667. REFERENCES: 15- Lockwood, C.J., Ghidini, A. ,Wein, R., 1- Hay,P.E.(2004): Bacterial vaginosis and Lapinski, R., Casal, D. and Berkowitz,R.L.(1994): miscarriage. Curr. Opin. Infect. Dis. ;17:41-44. Increased interleukin-6 concentrations in cervical secretions are associated with preterm 2- Ralph, S.G., Rutherford, A.J. and Wilson delivery.Am.J.Obstet.Gynecol; 171:1097-1102. J.D.(1999): Influence of bacterial vaginosis on conception and miscarriage in the first trimester: 16- Sakai,M.,Sasaki,Y., Yoneda,S., Kasahara,T., cohort study. BMJ ; 319:220-223. Arai,T., Okada,M., Hosokawa,H., Kato,K., Soeda,Y. and Saito,S., (2004): Elevated interleukin- 3- Eschenbach, D.A.,Bekassy, S. and Blackwell, 8 in cervical mucous as an indicator for treatment to A.(1984): The diagnosis of bacterial vaginosis. In prevent premature birth and preterm, pre-labor Mardh,P.A. and Tylor-Robenson, D. (eds), Bacterial rupture of membranes: a prospective study. vaginosis. Almqvist& Wiksell International, Am.J.Reprod.Immunol; 51:220-225. Stockholm, pp.260-261. 17- Jacobsson,B., Mattsby-Baltzer,I. and 4- Blackwell, A.L.Thomas, P.D. Wareham , K. and Hagberg,H. (2005): Interleukin-6 and interleukin-8 Emery, S.J.(1993): Health gains from screening for in cervical and amniotic fluid: relationship to infection of the lower genital tract in women microbial invasion of chorioamniotic membranes. attending for termination of pregnancy. Lancet; BGOG;112:719-724. 342:206-210. 18- Jivraj,S., Anstie,B., Cheong Y.C., Fairlie F.M., 5- Goldenberg,R.L., Hauth, J.C. and Andrews, Laird,S.M. and Li,T.C.(2001): Obstetric and W.W.(2000): Intrauterine infection and preterm neonatal outcome in women with a history of delivery. N. Engl. J. 342:1500-1507. recurrent miscarriage: a cohort study.Hum.Reprod; 6- Everett, C. (1997): Incidence and outcome of 16:102-106. th bleeding before the 20 week of pregnancy: 19- Wennerholm,U.B., Holm,B. and Mattsby- prospective study from general practice. BMJ;315:32- Baltzer,I. (1998): Interleukin-1 alpha, interleukin-6 34. and interleukin-8 in cervical-vaginal secretion for 7- Korn,A.P., Bolan, G. and Padian, N. (1995): screening of preterm birth in twin gestation. Plasma cell endometritis in women with symptomatic Acta.Obstet.Gynecol.Scand; 77:508-514. bacterial vaginosis.Obstet.Gynecol;85:387-390.

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اﻟﻌﻼﻗﺔ ﺑﻴﻦ ﻣﺴﺘﻮﻳﺎت اﻻﻧﺘﺮﻟﻴﻮآﻴﻦ ٦ و٨ ﻓﻰ اﻟﺠﻬﺎز اﻟﺘﻨﺎﺳﻠﻰ ﻟﻠﺴﻴﺪات ﻓﻰ ﺣﺎﻻت اﻻ ﺟﻬﺎض اﻟﻤﺘﻜﺮر اﻟﻤﺼﺎﺣﺐ ﻟﻠﺒﻜﺘﻴﺮﻳﺎ اﻟﻤﻬﺒﻠﻴﺔ

ﺳﺤﺮ ﻃﺎهﺮ١ و ﻣﺤﻤﺪ اﻟﻨﻴﺠﻴﺮى٢

(١) ﻗﺴﻢ اﻟﻤﻴﻜﺮوﺑﻴﻮﻟﻮﺟﻴﺎ واﻟﻤﻨﺎﻋﺔ اﻟﻄﺒﻴﺔ آﻠﻴﺔ اﻟﻄﺐ ﺟﺎﻣﻌﺔ اﻟﻤﻨﺼﻮرة (٢) ﻗﺴﻢ اﻟﻨﺴﺎء و اﻟﺘﻮﻟﻴﺪ آﻠﻴﺔ اﻟﻄﺐ ﺟﺎﻣﻌﺔ اﻟﻤﻨﺼﻮرة

ﺗﻌﺘﺒﺮ اﻟﺒﻜﺘﻴﺮﻳﺎ اﻟﻤﻬﺒﻠﻴﺔ ﻣﻦ أﺷﻬﺮ أﺳﺒﺎب اﻻﻓﺮازات اﻟﻤﻬﺒﻠﻴﺔ ﺧﺎﺻﺔ ﺧﻼل ﻓﺘﺮة اﻟﺨﺼﻮﺑﺔ . وﻳﺤﺪث دﻟﻚ ﻧﺘﻴﺠﺔ ﻧﻤﻮ وﺗﻜﺎﺛﺮ اﻟﺠﺎردﻧﻴﺮﻟﻼ ﻓﺎﺟﻴﻨﺎﻟﻴﺰ ﺑﺪﻻ ﻣﻦ اﻟﺒﻜﺘﻴﺮﻳﺎ اﻟﻤﻬﺒﻠﻴﺔ ﻏﻴﺮ اﻟﻀﺎرة. وﻗﺪ وﺟﺪ أﻧﻪ ﺗﻮﺟﺪ ﻋﻼﻗﺔ ﺑﻴﻦ اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر و ﺗﻠﻚ اﻻﻟﺘﻬﺎﺑﺎت اﻟﺘﻰ ﻏﺎﻟﺒﺎ ﻣﺎ ﺗﻜﻮن ﻣﺼﺎﺣﺒﺔ ﺑﺎ رﺗﻔﺎع ﻓﻰ ﻧﺴﺐ اﻟﺴﻴﺘﻮآﻴﻨﺎت ﻣﺜﻞ اﻻﻧﺘﺮﻟﻴﻮآﻴﻦ ٦و٨ . ﺗﻬﺪف اﻟﺪراﺳﺔ اﻟﺤﺎﻟﻴﺔ اﻟﻰ أهﻤﻴﺔ ﺗﺤﺪﻳﺪ ﻧﺴﺐ اﻻﻧﺘﺮﻟﻴﻮآﻴﻦ ٦و٨ ﻓﻰ ﺣﺎﻻت اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر ﺳﻮاء ﻓﻰ وﺟﻮد اﻟﺘﻬﺎب ﻣﻬﺒﻠﻰ أو ﻋﺪﻣﻪ . و ﺷﻤﻠﺖ اﻟﺪراﺳﺔ ٩٤ ﺳﻴﺪة ﺣﺎﻣﻞ ، ٥٤ ﻣﻨﻬﻢ ﻟﺪﻳﻬﻢ ﺗﺎرﻳﺦ ﻣﺮﺿﻰ ﻟﻼﺟﻬﺎض اﻟﻤﺘﻜﺮر(ﻣﺠﻤﻮﻋﺔ اﻟﻤﺮﺿﻰ) و ٤٠ ﺳﻴﺪة ﻟﺪﻳﻬﻢ ﺣﻤﻞ ﻃﺒﻴﻌﻰ (اﻟﻤﺠﻤﻮﻋﺔ اﻟﻀﺎﺑﻄﺔ) . و ﻗﺪ ﺗﻢ أﺧﺬ اﻟﻌﻴﻨﺎت ﻋﻦ ﻃﺮﻳﻖ ﻣﺴﺤﺎت ﻣﻬﺒﻠﻴﺔ وﻏﺴﻴﻞ ﻣﻬﺒﻠﻰ ﻟﻌﻨﻖ اﻟﺮﺣﻢ . و ﻗﺪ ﺗﻢ ﻓﺤﺼﻬﺎ ﺑﻮاﺳﻄﺔ اﻟﻤﻴﻜﺮوﺳﻜﻮب و ﺻﺒﻐﺔ اﻟﺠﺮام ، وﺗﻘﻴﻴﻢ ﻣﺴﺘﻮﻳﺎت اﻻﻧﺘﺮﻟﻴﻮآﻴﻦ ٦و٨ ﺑﻮاﺳﻄﺔ اﻻﻟﻴﺰا . وﻗﺪ وﺟﺪ أن هﻨﺎك ارﺗﺒﺎط ﺑﻴﻦ اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر و ﺗﻘﺪم ﺳﻦ اﻟﺴﻴﺪة . آﻤﺎ ﻟﻮﺣﻆ زﻳﺎدة ﻓﺮص ﺣﺪوث اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر ﻓﻲ اﻟﺴﻴﺪات اﻟﺘﻰ ﺗﻌﺎﻧﻰ ﻣﻦ اﻻﻟﺘﻬﺎﺑﺎت اﻟﻤﻬﺒﻠﻴﺔ ﺑﻨﺴﺒﺔ ٣٧% ﻓﻰ ﻣﺠﻤﻮﻋﺔ اﻟﻤﺮﺿﻰ و ٢٠% ﻓﻰ اﻟﻤﺠﻤﻮﻋﺔ اﻟﻀﺎﺑﻄﺔ و أن ﻣﻴﻜﺮوب اﻟﺠﺎردرﻳﻨﻴﻠﻼ وﺟﺪ ﻓﻰ ﻧﺴﺒﺔ ٣٣% و ١٥% ﻓﻰ ﻣﺠﻤﻮﻋﺔ اﻟﻤﺮﺿﻰ و اﻟﻤﺠﻤﻮﻋﺔ اﻟﻀﺎﺑﻄﺔ ﻋﻠﻰ اﻟﺘﻮاﻟﻰ . ووﺟﺪ أن ﻣﺴﺘﻮﻳﺎت اﻻﻧﺘﺮﻟﻴﻮآﻴﻦ ٦ و٨ ذات دﻻﻟﺔ أﺣﺼﺎﺋﻴﺔ ﻋﺎﻟﻴﺔ أﻗﻞ ﻣﻦ ٠٫٠٠٠١ ﺑﻴﻦ ﻣﺠﻤﻮﻋﺔ اﻟﻤﺮﺿﻰ و اﻟﻤﺠﻤﻮﻋﺔ اﻟﻀﺎﺑﻄﺔ . وأﻧﻪ ﺑﺎﺳﺘﺨﺪام اﻧﺘﺮﻟﻴﻮآﻴﻦ ٦ اﻟﺘﻮﻗﻊ ﺑﺤﺪوث اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر آﺎن ٥ ﻣﺮات و ﻓﻰ ﺣﺎﻟﺔ اﻻﻧﺘﺮﻟﻴﻮآﻴﻦ ٨ آﺎن ٣ ﻣﺮات . وﻧﺴﺘﺨﻠﺺ ﻣﻦ هﺪﻩ اﻟﺪراﺳﺔ أن اﻻﻟﺘﻬﺎﺑﺎت اﻟﻤﻬﺒﻠﻴﺔ ﺗﺸﻜﻞ ﻋﺎﻣﻼ ﻣﻦ أﺳﺒﺎب اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر و ﺧﺎﺻﺔ ﻓﻰ اﻟﺤﺎﻻت اﻟﻐﻴﺮ ﻣﻌﺮوف أﺳﺒﺎﺑﻬﺎ وأن هﺪﻩ اﻻﻟﺘﻬﺎﺑﺎت ﺗﻜﻮن ﻣﺼﺎﺣﺒﺔ ﺑﺎرﺗﻔﺎع ﻣﺴﺘﻮﻳﺎت اﻟﺴﻴﺘﻮآﻴﻨﺎت ﻓﻰ اﻟﺠﻬﺎز اﻟﺘﻨﺎﺳﻠﻰ وﻟﺬﻟﻚ ﻧﻨﺼﺢ ﺑﺒﺪء ﻋﻼج هﺪﻩ اﻻﻟﺘﻬﺎﺑﺎت ﺑﻮاﺳﻄﺔ اﻟﻤﻀﺎدات اﻟﺤﻴﻮﻳﺔ اﻟﻤﻨﺎﺳﺒﺔ أﻣﻼ ﻓﻰ اﻧﺨﻔﺎض ﻓﺮص ﺣﺪوث اﻻﺟﻬﺎض اﻟﻤﺘﻜﺮر

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