Bacterial vaginosis in pregnancy

The association between menstrual hygiene, workplace sanitation practices and self-reported urogenital symptoms in a cross-sectional survey of women working in Mukono District, Uganda

BACKGROUND

Women worldwide experience challenges managing their periods. Menstrual and genital hygiene behaviours have been linked to negative health outcomes, including urogenital symptoms and confirmed infections. However, evidence testing this association has been limited and mixed. This study aimed to (1) describe the menstrual care practices and prevalence of self-reported urogenital symptoms among working women in Mukono District, Uganda, and (2) test the associations between menstrual and genital care practices, and urogenital symptoms.

METHODOLOGY

We undertook a cross-sectional survey of women aged 18-45 working in markets, schools, and healthcare facilities in Mukono District, with 499 participants who had menstruated in the past two months included in this analysis. We developed an aggregated measure of menstrual material cleanliness, incorporating material type and laundering practices. Associations with urogenital symptoms were tested using the aggregated material cleanliness measure alongside the frequency of changing materials, handwashing before menstrual tasks, and sanitation practices.

RESULTS

Among our sample, 41% experienced urogenital symptoms in the past month. Compared to women exclusively using disposable pads, using appropriately cleaned or non-reused improvised materials (PR = 1.33, 95%CI 1.04-1.71), or inadequately cleaned materials (improvised or commercially produced reusable pads) (PR = 1.84, 95%CI 1.46-3.42) was associated with an increased prevalence of self-reported urogenital symptoms in the last month. There was no difference between those using disposable pads and those using clean reusable pads (PR = 0.98; 95%CI 0.66-1.57). Infrequent handwashing before changing materials (PR 1.18, 95%CI: 0.96-1.47), and delaying urination at work (PR = 1.37, 95%CI: 1.08-1.73) were associated with an increased prevalence of self-reported symptoms.

CONCLUSION

Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of menstrual material used as well as infrequent handwashing and urinary restriction. There is a need for interventions to enable women to maintain cleanliness of their menstrual materials and meet their menstruation, urination and hand washing needs at home and work.

Sensitive Detection of Thirteen Bacterial Vaginosis-Associated Agents Using Multiplex Polymerase Chain Reaction

Bacterial vaginosis (BV) is characterized by a polymicrobial proliferation of anaerobic bacteria and depletion of lactobacilli, which are components of natural vaginal microbiota. Currently, there are limited conventional methods for BV diagnosis, and these methods are time-consuming, expensive, and rarely allow for the detection of more than one agent simultaneously. Therefore, we conceived and validated a multiplex polymerase chain reaction (M-PCR) assay for the simultaneous screening of thirteen bacterial vaginosis-associated agents (BV-AAs) related to symptomatic BV: Gardnerella vaginalis, Mobiluncus curtisii, Mobiluncus mulieris, Bacteroides fragilis, Mycoplasma hominis, Atopobium vaginae, Ureaplasma urealyticum, Megasphaera type I, Clostridia-like bacteria vaginosis-associated bacteria (BVABs) 1, 2, and 3, Sneathia sanguinegens, and Mycoplasma genitalium. The overall validation parameters of M-PCR compared to single PCR (sPCR) were extremely high, including agreement of 99.1% and sensitivity, specificity, and positive predictive values of 100.0%, negative predictive value of 97.0%, accuracy of 99.3%, and agreement with Nugent results of 100.0%. The prevalence of BV-AAs was very high (72.6%), and simultaneous agents were detected in 53.0%, which demonstrates the effectiveness of the M-PCR assay. Therefore, the M-PCR assay has great potential to impact BV diagnostic methods in vaginal samples and diminish associated complications in the near future.

Development of a microarray-based tool to characterize vaginal bacterial fluctuations and application to a novel antibiotic treatment for bacterial vaginosis

The healthy vaginal microbiota is generally dominated by lactobacilli that confer antimicrobial protection and play a crucial role in health. Bacterial vaginosis (BV) is the most prevalent lower genital tract infection in women in reproductive age and is characterized by a shift in the relative abundances of Lactobacillus spp. to a greater abundance of strictly anaerobic bacteria. In this study, we designed a new phylogenetic microarray-based tool (VaginArray) that includes 17 probe sets specific for the most representative bacterial groups of the human vaginal ecosystem. This tool was implemented using the ligase detection reaction-universal array (LDR-UA) approach. The entire probe set properly recognized the specific targets and showed an overall sensitivity of 6 to 12 ng per probe. The VaginArray was applied to assess the efficacy of rifaximin vaginal tablets for the treatment of BV, analyzing the vaginal bacterial communities of 22 BV-affected women treated with rifaximin vaginal tablets at a dosage of 25 mg/day for 5 days. Our results showed the ability of rifaximin to reduce the growth of various BV-related bacteria (Atopobium vaginae, Prevotella, Megasphaera, Mobiluncus, and Sneathia spp.), with the highest antibiotic susceptibility for A. vaginae and Sneathia spp. Moreover, we observed an increase of Lactobacillus crispatus levels in the subset of women who maintained remission after 1 month of therapy, opening new perspectives for the treatment of BV.

Is there a role for probiotics in the prevention of preterm birth?

Preterm birth (PTB) continues to be a global health challenge. An over-production of inflammatory cytokines and chemokines, as well as an altered maternal vaginal microbiome has been implicated in the pathogenesis of inflammation/infection-associated PTB. Lactobacillus represents the dominant species in the vagina of most healthy pregnant women. The depletion of Lactobacillus in women with bacterial vaginosis (BV) has been associated with an increased risk of PTB. It remains unknown at what point an aberrant vaginal microbiome composition specifically induces the cascade leading to PTB. The ability of oral or vaginal lactobacilli probiotics to reduce BV occurrence and/or dampen inflammation is being considered as a means to prevent PTB. Certain anti-inflammatory properties of lactobacilli suggest potential mechanisms. To date, clinical studies have not been powered with sufficiently high rates of PTB, but overall, there is merit in examining this promising area of clinical science.

The frequent shift to intermediate flora in preterm delivery cases after abnormal vaginal flora screening

The effect of screening and treatment for abnormal vaginal flora on the reduction of preterm deliveries remains controversial. We evaluated whether this screening and treatment reduces the preterm delivery rate for general-population pregnant women. Pregnant women of the Intervention group (n = 574) underwent the screening test and the treatment of vaginal metronidazole during the early second trimester, and those of the Control group (n = 1,161) did not. We compared the preterm delivery rate between these two groups. We also compared the profiles of vaginal flora of the preterm delivery cases with those of the pregnant women with a normal course. There was no significant difference in the preterm delivery rate between these two groups. However, in the preterm delivery cases, a frequent shift to intermediate flora was observed not before but after the screening in the Intervention group. This shift may explain why most of the previous studies failed in regard to the prevention of preterm deliveries.

A systematic review of the health and social effects of menstrual hygiene management

Background

Differing approaches to menstrual hygiene management (MHM) have been associated with a wide range of health and psycho-social outcomes in lower income settings. This paper systematically collates, summarizes and critically appraises the available evidence.

Methods

Following the PRISMA guidelines a structured search strategy was used to identify articles investigating the effects of MHM on health and psycho-social outcomes. The search was conducted in May 2012 and had no date limit. Data was extracted and quality of methodology was independently assessed by two researchers. Where no measure of effect was provided, but sufficient data were available to calculate one, this was undertaken. Meta-analysis was conducted where sufficient data were available.

Results

14 articles were identified which looked at health outcomes, primarily reproductive tract infections (RTI). 11 articles were identified investigating associations between MHM, social restrictions and school attendance. MHM was found to be associated with RTI in 7 papers. Methodologies however varied greatly and overall quality was low. Meta-analysis of a subset of studies found no association between confirmed bacterial vaginosis and MHM (OR: 1.07, 95% CI: 0.52–2.24). No other substantial associations with health outcomes were found. Although there was good evidence that educational interventions can improve MHM practices and reduce social restrictions there was no quantitative evidence that improvements in management methods reduce school absenteeism.

Conclusion

The management of menstruation presents significant challenges for women in lower income settings; the effect of poor MHM however remains unclear. It is plausible that MHM can affect the reproductive tract but the specific infections, the strength of effect, and the route of transmission, remain unclear. There is a gap in the evidence for high quality randomised intervention studies which combine hardware and software interventions, in particular for better understanding the nuanced effect improving MHM may have on girls’ attendance at school.

Efficacy of methods used for the diagnosis of bacterial vaginosis

INTRODUCTION

Bacterial vaginosis (BV) has been associated with pelvic inflammatory disease, adverse pregnancy outcomes, increased susceptibility to sexually transmitted infections and infertility. Diagnosis of BV should be rapid, reliable and safe. This is especially vital in pregnant women where intervention may be necessary for the well-being of both the mother and the foetus.

AREAS COVERED

This paper consulted PUBMED, LISTA and Web of Science for point-of-care and laboratory-based tests commonly used for the diagnosis and management of BV in pregnant women. An overview of strengths and weaknesses of the methods used may partially explain why treatment plans have failed. Differences in sampling and detection methods, time of gestation, inter-examiner variability and interpretation of data, and the use of different reference tests, amongst many other factors, complicated a meta-analysis of the data.

EXPERT OPINION

Inconsistencies found in clinical and laboratory detection methods used for the monitoring of treatment have a direct impact on success rates. With current advances in technology, the diagnosis of BV is taking on a new perspective. New information implicating specific vaginal biofilms in adverse pregnancy outcomes through the application of advanced technology promises to change the way we view the aetiology, diagnosis and management of BV.

[Is the bacterial vaginosis risk factor of prematurity? Study of a cohort of 1336 patients in the hospital of Arras]

BACKGROUND

Among risk factors of prematurity, bacterial vaginosis (BV) could play an important role, but few studies took place in our country.

AIM

In a French population of women booking in a hospital maternity, to search a link between prematurity and BV in the first trimester of pregnancy.

METHODS

A hospital cohort study was carried out between May 2006 and September 1(st), 2009. Pregnant women were screening for BV before 13+6 weeks' gestation. BV was determined by a Gram-Stained Vaginal score greater or equal to 7.

RESULTS

One thousand three hundred and thirty-six patients were included in the study among whom 203 patients had BV and 1133 patients did not have. The presence of BV was significantly associated with preterm delivery (OR: 1.6; 95% IC: 1.1-2.7). But this increase concerned only the spontaneous prematurity (ORa: 1.8, 95% IC: 1.0-3.2) and the statistical association disappeared after taking into account maternal tobacco addiction and socio-economic weak level (ORa: 1.6; 95% IC: 0.9-2.9). At the patient with BV, moreover, the risk of miscarriage before 16SA was significantly augmented at the patient with BV (OR: 3.4; 95% IC: 1.1-10.4), but this risk disappeared after taking into account tobacco addiction and maternal level of studies (ORa: 1.9; 95% IC: 0.5-7.2).

CONCLUSION

The presence of BV in the first trimester of pregnancy seems to be associated with increased risks of preterm delivery and early spontaneous miscarriage. However, this relation seems to be partly linked to a level of weaker study and a more frequent tobacco addiction among the women with BV.

Bacterial vaginosis is associated with uterine cervical human papillomavirus infection: a meta-analysis

Background

Bacterial vaginosis (BV), an alteration of vaginal flora involving a decrease in Lactobacilli and predominance of anaerobic bacteria, is among the most common cause of vaginal complaints for women of childbearing age. It is well known that BV has an influence in acquisition of certain genital infections. However, association between BV and cervical human papillomavirus (HPV) infection has been inconsistent among studies. The objective of this meta-analysis of published studies is to clarify and summarize published literature on the extent to which BV is associated with cervical HPV infection.

Methods

Medline and Web of Science were systematically searched for eligible publications until December 2009. Articles were selected based on inclusion and exclusion criteria. After testing heterogeneity of studies, meta-analysis was performed using random effect model.

Results

Twelve eligible studies were selected to review the association between BV and HPV, including a total of 6,372 women. The pooled prevalence of BV was 32%. The overall estimated odds ratio (OR) showed a positive association between BV and cervical HPV infection (OR, 1.43; 95% confidence interval, 1.11-1.84).

Conclusion

This meta-analysis of available literature resulted in a positive association between BV and uterine cervical HPV infection.

Ecology of danger-dependent cytokine-boosted spontaneous abortion in the CBA x DBA/2 mouse model: II. Fecal LPS levels in colonies with different basal abortion rates

PROBLEM

Previous data have shown that 'danger' signals, such as bacterial lipopolysaccharide (LPS) acting via toll-like receptors (TLR), are conditions antecedent to early pregnancy failure in several murine abortion models. Indeed, the abortion rate increased in the CBA x DBA/2 model after injection of tumor necrosis factor-alpha (TNF-alpha) + interferon (IFN-gamma) on gestation day (GD) 7.5 only if the LPS-TLR signaling pathway was intact. High rates of cytokine-boosted abortion >80% loss can be demonstrable in certain animal colonies that have a high endogenous (spontaneous) rate of resorption (30-50%). A specific role for LPS on GD 0.5 determines the endogenous loss rate and on GD 6.5 the responsiveness to cytokine boosting of losses. Th1 cytokines (or the stress that induces these cytokines) increase intestinal permeability and absorption of luminal contents. It was predicted that intestinal availability of LPS was a major factor in the endogenous and cytokine-boosted resorption rates.

METHOD OF STUDY

A fixed weight of fresh mouse droppings from CBA/J female mice house in a high-abortion-rate (30-40%) colony at Clamart, France was homogenized and filtered. Fresh mouse droppings from a low-abortion-rate (10-15%) colony in Berlin, Germany were similarly processed. LPS was assayed using the Limulus amoebocyte lysate bioassay.

RESULTS

To our surprise, there was no significant difference in LPS content of fecal samples from the two colonies.

CONCLUSION

A high endogenous rate of abortion and cytokine (or stress) boosted abortion in the CBA x DBA/2 model is not explained by the LPS content of feces. Possible explanations include: fecal LPS does not reflect small intestinal LPS, there are additional TLR signals besides LPS that are important and endogenous stress levels may be higher in high-abortion-rate colonies, so permeability of the intestine (and Th1 cytokine levels) may be already higher. These data have implications for studies on the role of flora in human pregnancy problems.

Predictive value for preterm birth of abnormal vaginal flora, bacterial vaginosis and aerobic vaginitis during the first trimester of pregnancy

INTRODUCTION

Abnormal vaginal flora (AVF) before 14 gestational weeks is a risk factor for preterm birth (PTB). The presence of aerobic microorganisms and an inflammatory response in the vagina may also be important risk factors.

AIM

The primary aim of the study was to investigate the differential influences of AVF, full and partial bacterial vaginosis, and aerobic vaginitis in the first trimester on PTB rate. The secondary aim was to elucidate why treatment with metronidazole has not been found to be beneficial in previous studies.

SETTING

Unselected women with low-risk pregnancies attending the prenatal unit of the Heilig Hart General Hospital in Tienen, Belgium, were included in the study.

MATERIALS AND METHODS

At the first prenatal visit, 1026 women were invited to undergo sampling of the vaginal fluid for wet mount microscopy and culture, of whom 759 were fully evaluable. Abnormal vaginal flora (AVF; disappearance of lactobacilli), bacterial vaginosis (BV), aerobic vaginitis (AV), increased inflammation (more than ten leucocytes per epithelial cell) and vaginal colonisation with Candida (CV) were scored according to standardised definitions. Partial BV was defined as patchy streaks of BV flora or sporadic clue cells mixed with other flora, and full BV as a granular anaerobic-type flora or more than 20% clue cells. Vaginal fluid was cultured for aerobic bacteria, Mycoplasma hominis and Ureaplasma urealyticum. Outcome was recorded as miscarriage <or=13 weeks + 6 days [early miscarriage (EM), n = 8 (1.1%)], between 14 + 0 and 24 weeks + 6 days [late miscarriage (LM), n = 7 (0.9%)], delivery or miscarriage <or=34 weeks + 6 days n = 29 (3.8%)], <or=36 weeks + 6 days n = 70 (9.2%)]. PTB between 25 + 0 and 36 weeks + 6 days was further divided in severe PTB (SPTB, 25 + 0 to 34 weeks + 6 days) and mild PTB (MPTB, 35 + 0 to 36 weeks + 6 days).

RESULTS

Women without abnormalities of the vaginal flora in the first trimester had a 75% lower risk of delivery before 35 weeks compared with women with AVF [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.12-0.56]. The absence of lactobacilli (AVF) was associated with increased risks of PTB (OR 2.4; 95% CI 1.2-4.8), EPTB (OR 6.2; 95% CI 2.7-14) and miscarriage (OR 4.9; 95% CI 1.4-17). BV was associated with increased risks of PTB (OR 2.4; 95% CI 1.1-4.7), EPTB (OR 5.3; 95% CI 2.1-12.9) and miscarriage (OR 6.6; 95% CI 2.1-20.9) and coccoid AV was associated with increased risks of EPTB (OR 3.2; 95% CI 1.2-9.1) and miscarriage (OR 5.2; 95% CI 1.5-17). In women with BV, partial BV had a detrimental effect on the risk of PTB for all gestational ages, but full BV did not. Preterm deliveries later than 24 weeks+ 6 days were more frequent when M. hominis was present (EPTB OR 13.3; 95% CI 3.2-55).

DISCUSSION

Bacterial vaginosis, AV and AVF are associated with PTB, especially LM and severe PTB between 25 and 35 weeks. The absence of lactobacilli (AVF), partial BV and M. hominis, but not full BV, were associated with an increased risk of preterm delivery after 24 weeks+ 6 days. As metronidazole effectively treats full BV, but is ineffective against other forms of AVF, the present data may help to explain why its use to prevent PTB has not been successful in most studies.

Patterns of cytokine profiles differ with pregnancy outcome and ethnicity

BACKGROUND

Preterm birth (PTB) is hypothesized to be an inflammatory response disease. However, no single factor alone is likely to explain PTB risk. It is more probable that coordinated networks of cytokines affect risk.

METHODS

Therefore, we examined the relationships between amniotic fluid (AF) cytokines/chemokines and related biomarkers in PTB and normal term deliveries in African Americans and Caucasians. Data were obtained from African American (41 preterm labor and 91 term labor) and Caucasian (105 preterm labor and 100 term labor) pregnant mothers. Pro-inflammatory cytokines and related molecules interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor- (TNF)-alpha, TNF soluble receptors (sTNFR1 and sTNFR2), and anti-inflammatory cytokine IL-10 that were all previously associated with PTB were studied. Correlations between biomarkers were calculated; differences of correlation coefficients between AF from African American and Caucasian samples in preterm labor and term labor were measured.

RESULTS

Multiple differences were observed between African American and Caucasian preterm and term birth groups. In term birth the strongest differences were between pro- and anti-inflammatory correlations, whereas in PTB differences were equally distributed between pro-inflammatory/anti-inflammatory and pro-inflammatory/pro-inflammatory correlations. Three correlation patterns differed significantly between AF from PTB African Americans with and without microbial invasion of the intra-amniotic cavity (MIAC); no differences were observed in Caucasians with MIAC.

CONCLUSION

Correlation analyses of cytokine measurements suggest coordinated interplay during pregnancy; significant differences exist between African Americans and Caucasians. Such analyses can serve as a means of understanding risk factors in these populations.

Pregnancy outcome after early detection of bacterial vaginosis

OBJECTIVE

To assess if detecting bacterial vaginosis either in early pregnancy or at midtrimester may predict adverse pregnancy outcome in women at risk for preterm delivery.

STUDY DESIGN

242 pregnant women with a previous preterm delivery were evaluated for bacterial vaginosis either in the first trimester (prior to 10+0 weeks) or in the second one (24-26 weeks). Adverse outcome was intended as miscarriage (< or =25 weeks), or premature delivery (< or =36+6).

RESULTS

The risk of adverse pregnancy outcome was significantly increased in women diagnosed at first trimester with bacterial vaginosis (OR: 4.56; 95% CI: 2.54-8.93); the same finding at midtrimester did not increase significantly the risk of preterm delivery.

CONCLUSIONS

Early screening for bacterial vaginosis in pregnant women who experienced a preterm delivery may help in predicting the risk of adverse outcome.

Preconceptional antibiotic treatment to prevent preterm birth in women with a previous preterm delivery

This article addresses the question of whether the uterine cavity is normally sterile and reviews the difficulties in conducting microbiologic studies of the endometrium, the limitations of conventional microbiologic techniques (cultivation-dependent), and the potential contribution of molecular microbiology to examine microbial diversity and burden of the endometrium. Issues pertaining to the diagnosis of chronic endometritis and the need for information about the prognostic value of this finding in subsequent pregnancies are discussed. The results of a randomized clinical trial of antibiotic administration versus placebo in women with a previous preterm birth are reviewed and commentary is provided. The emerging picture is that microbial-host interactions in the endometrial cavity are important for reproductive success. This is a US government work. There are no restrictions on its use.

Ecology of Danger-dependent Cytokine-boosted Spontaneous Abortion in the CBA × DBA/2 Mouse Model. I. Synergistic Effect of LPS and (TNF-α + IFN-γ) on Pregnancy Loss

PROBLEM

Previous data have shown "danger" signals, such as bacterial lipopolysaccharide (LPS) acting via toll-like (tlr) receptors are required for early pregnancy failure in several murine abortion models. Indeed, the abortion rate increased in the CBA x DBA/2 model after a gestation day (gd) 7.5 injection of tumour necrosis factor (TNF)-alpha + interferon (IFN)-gamma only if the LPS-tlr signalling pathway was intact. High rates of cytokine-boosted abortion >80% loss can be achieved in certain animal colonies, that have a high endogenous (spontaneous) rate of resorption (30-50%). A specific role for LPS has been postulated to determine both the endogenous and cytokine-boosted losses.

METHODS

To test the role of LPS in spontaneous and cytokine-boosted abortions, recombinant TNF-alpha + IFN-gamma, and LPS were injected in different doses and sequences intraperitoneally (i.p.) into CBA x DBA/2 mated mice in the Toronto General Research Institute animal facility where the endogenous abortion rate is <30%. The effects of poly IC, a tlr3 agonist that induces IFN-gamma that can reverse LPS-induced tolerance, and effects of anti-MD-1 on TNF-alpha induction by LPS, poly IC, CPG, or HSP in vitro were also examined.

RESULTS

A high endogenous rate of loss similar to that seen in Clamart could be achieved by increasing exposure to LPS on the morning after mating (gd 0.5). The magnitude by which the abortion rate could be increased by an i.p. injection of 2000 u TNF-alpha + 1000 u IFN-gamma on gd 7.5 was independent of the endogenous rate of loss, and could not be increased by doubling the dose. One microgram of LPS given on day 7.5 achieved a similar rate of loss, and if given with the cytokines, synergistically boosted the rate of loss to near Clamart rates. LPS given 1 day prior to the cytokines abrogated the cytokine effect, whereas LPS given day 0.5 had no significant effect on the response to day 7.5 cytokine injection. Blocking MD-1 inhibited TNF-alpha stimulation by poly IC, LPS, CPG, or HSP in vitro, and reduced abortion rates. Poly IC did not avert LPS-type tolerance effects in vivo.

CONCLUSIONS

High endogenous rates of abortion in the CBA x DBA/2 model may be explained by exposure to LPS at the time of mating. Increased rates of loss triggered by cytokines later in pregnancy may depend on increased absorption of LPS from intestinal flora.

Can endometrial infection/inflammation explain implantation failure, spontaneous abortion, and preterm birth after in vitro fertilization?

The endometrial cavity is frequently invaded by microorganisms, and subclinical endometrial infection or inflammation may play a role in implantation failure after IVF, spontaneous abortion, and preterm birth. Microbial products and host-inflammatory mediators such as cytokines and chemokines can cause trophoblast apoptosis and the cascade of events leading to expulsion of the embryo or fetus.

Transient parkinsonism: Induced by progesterone or pregnancy?

We report on the development of transient parkinsonism after progesterone injection in a pregnant patient with a risk of abortion. Etiological possibilities are discussed, including pregnancy itself, possible toxic effects of the dead fetus, and progesterone injection. Progesterone-induced parkinsonism seems the most likely diagnosis in this case.

Maternal LPS induces cytokines in the amniotic fluid and corticotropin releasing hormone in the fetal rat brain

Perinatal infections are a risk factor for fetal neurological pathologies, including cerebral palsy and schizophrenia. Cytokines that are produced as part of the inflammatory response are proposed to partially mediate the neurological injury. This study investigated the effects of intraperitoneal injections of lipopolysaccharide (LPS) to pregnant rats on the production of cytokines and stress markers in the fetal environment. Gestation day 18 pregnant rats were treated with LPS (100 μg/kg body wt ip), and maternal serum, amniotic fluid, placenta, chorioamnion, and fetal brain were harvested at 1, 6, 12, and 24 h posttreatment to assay for LPS-induced changes in cytokine protein (ELISA) and mRNA (real-time RT-PCR) levels. We observed induction of proinflammatory cytokines interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) as well as the anti-inflammatory cytokine IL-10 in the maternal serum within 6 h of LPS exposure. Similarly, proinflammatory cytokines were induced in the amniotic fluid in response to LPS; however, no significant induction of IL-10 was observed in the amniotic fluid. LPS-induced mRNA changes included upregulation of the stress-related peptide corticotropin-releasing factor in the fetal whole brain, TNF-α, IL-6, and IL-10 in the chorioamnion, and TNF-α, IL-1β, and IL-6 in the placenta. These findings suggest that maternal infections may lead to an unbalanced inflammatory reaction in the fetal environment that activates the fetal stress axis.

The International Confederation of Midwives' study of essential competencies of midwifery practice

OBJECTIVE

To delineate the knowledge, skills, and behaviours that would characterise the domain of competencies of the midwife who is educated according to the international definition of the profession.

DESIGN

Phase I: a qualitative Delphi study; Phase II: a descriptive survey research process.

PARTICIPANTS

A stratified random sample of member organisations of the International Confederation of Midwives (ICM) and regulatory representatives from these same countries.

FINDINGS

A list of basic (essential) and additional competencies for midwives who have been educated in keeping with the ICM/WHO/FIGO international definition of the midwife was developed through an interative Delphi process, and then affirmed, using a survey research method. The final list includes 214 individual task statements within six domains of midwifery practice.

IMPLICATIONS FOR PRACTICE

This list of competencies can serve as a basis for educational curriculum design, as a guideline for regulatory policy development, as a reference document for individual practitioners in an assessment of their initial and continued competency and by the ICM and its member associations as a resource for advocating for the role of midwifery within health-care systems world-wide.

MD-1 is a critical part of the mechanism causing Th1-cytokine-triggered murine fetal loss syndrome

PROBLEM

Fetal loss syndrome (abortion/resorption) occurring on or after gestation day (gd) 9.5 in CBA/JxDBA/2 matings is dependent upon presence of TNF-alpha + IFN-gamma, which act by increasing expression of fg12 prothrombinase at the feto-maternal interface. The magnitude by which the abortion rate can be boosted by an injection of these cytokines on gd 7.5 depends on endogenous rate of loss, and appears to depend on microbial flora. Is cytokine-triggered abortion dependent upon a third signaling pathway that senses 'danger'?

METHODS

Female CBA/J were mated to DBA/2 males and, C57B1/6 and C57B1/6 TNFalphaR1-/-Mak were mated to C57B1/6 control or TNFalphaR1-/-Mak males. LPS from Escherichia coli and Salmonella enteritidis, or the combination of TNF-alpha + IFN-gamma, was injected to stimulate abortions. The effect of anti-MD-1, which interferes with expression of CD14 and, hence, with signaling by LPS via the CD14-tlr4 complex, on TNF-alpha + IFN-gamma was tested. The presence of MD-1 in the uterus was evaluated by in situ hybridization, and effect of lipopolysaccharide (LPS) on mice lacking TNF-alphaR1 was tested.

RESULTS

Anti-MD-1 completely abrogated TNF-alpha + IFN-gamma-induced abortions. MD-1 was expressed on trophoblast and in deciduas on gd 8.5 but LPS could not abort mice that lacked the type 1 receptor for TNF-alpha. Pregnant CBA/J females had classical resorptions (abortions) countable on gd 13.5-14.5 in response to LPS from E. coli or S. enteritidis, but C57B1/6 strain mice resorbed only in response to the latter, and E. coli LPS appeared to induce 'occult' losses. 'Occult' loss did not require TNF-alphaR1.

CONCLUSIONS

TNF-alpha + IFN-gamma could not induce murine abortions without co-presence of a 'danger' signal such as LPS acting via CD14 on toll receptors, and LPS could not act without co-signaling by TNF-alpha. Classical resorptions/abortions and 'occult' losses have a different mechanism in these models as reflected in type of endotoxin and requirement for TNF-alphaR1 signaling.