Vol 43 # 2 June 2011 - Kma.org.kw

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Pregnancy-Associated withAVH and AVH: Course and Outcome (Co-infections in Pregnancy)
June 2011
Informed consent was obtained from all women who
participated in the study.
The study was approved by the Local Health
Directorate and Administrative Committee of the
Diyarbakir State Hospital. The study protocol conforms
to the ethical guidelines of the 1975 declaration of
Helsinki.
Patient groups
We reviewed 32 healthy pregnant women (control
group), 32 pregnant women with Brucella (group B)
and 24 pregnant women infected with BCS and AVH
concurrently (group B + AVH). All pregnant women
were between 20 - 40 years of age and had no history of
spontaneous abortion prior to the study period. None
of the women had a history of blood transfusion.
Definitions
The reproductive outcomes of 88 pregnant women
were followed for the period from July 2003 to May
2010. The first trimester of pregnancy was defined as a
gestational age of 12 weeks or less, the second trimester
as 12 to 24 weeks, and the third trimester as more
than 24 weeks. Fetal death that occurred at less than
24 weeks of gestation was considered spontaneous
abortion, while fetal death that occurred after 24 weeks
of gestation was designated ‘intrauterine fetal death’.
Preterm delivery was defined as the birth of a baby
before 37 weeks but after 24 weeks of gestation [9] .
Depending on the history, symptoms, and clinical
presentation time, BCS patients were divided into three
groups: acute (0 - 2 months), sub-acute (2 - 12 months),
and chronic (> 12 months). Those who had been
diagnosed with BCS previously and cured appropriately
but whose clinical and laboratory findings had become
positive again were regarded as having relapse [9] .
Serological testing
The diagnosis of BCS was based on serum standard
tube agglutination test (SAT), Coombs anti-Brucella test
and / or blood culture in the pregnant women whose
clinical findings suggested BCS. SAT is performed
by mixing dilutions of serum from 1 / 20 to 1 / 2560
with brucella antigen in test tubes. A seroconversion
or a four-fold rise in SAT titer or the first serum
obtained had a serum agglutination titer or a Coombs
anti-Brucella test of ≥ 1 / 160 or a positive growth of
Brucella species in culture were accepted as diagnostic
of BCS. All diagnostic blood cultures yielded Brucella
melitensis as the causative agent. Brucella abortion 99S
antigens of Cromatest (Refik Saydam Hifzissihha Ins,
Turkey) were used for SAT. In cultures, Vitek 2 compact
Instrumented Blood Culture System (Biomerieux Inc.,
France) was used.
All patients had a detailed history taken and
underwent a thorough clinical examination. All patients
were also evaluated by abdominal ultrasonography.
The serological markers of Anti-HAV IgM, HBsAg,
hepatitis Be antigen (HBeAg), antibody to HBeAg
(anti-HBe), antibody to hepatitis B core antigen
IgM (anti-HBc-IgM), anti-HBs and antibody to
hepatitis C virus (anti-HCV) were investigated in the
presence of jaundice and abnormal liver biochemical
tests. Commercial kits based on the enzyme-linked
immunosorbent assay (ELISA) (E170, Roche, Germany)
method were used in hepatitis B virus DNA (HBV-DNA)
detection and polymerase chain reaction technique
(PCR) was used in hepatitis C virus RNA (HCV-RNA)
(ABI Prism 7700 Sequence Detection System- real
time PCR, USA) detection at the Hifzissihha National
Public Laboratories and / or Dicle University Medical
Microbiology Laboratories.
Patient treatment and follow up
Pregnant women who had BCS were treated with
one of four antibrucellosis treatment regimens. The
regimens included: TMP-SMX (co-trimoxazole) or
TMP-SMX / rifampicin or cephtriaxone / rifampicin
or only rifampicin in addition to supportive therapy.
The dose of the antibiotic regimens were as follows;
rifampicin (600 mg/day po for 6 wk), intravenous
cephtriaxone 2 g/day, co-trimoxazole (80 mg of TMP
and 400 mg of SMZ every 12 hours). TMP-SMZ was not
given in the 3 rd trimester because of the risk of jaundice
and kernicterus for the newborn. When required, the
duration of therapy was extended and these data were
recorded.
Pregnant women who participated in our study
were followed up during pregnancy, the neonatal
period and at least for six months after completing
therapy. Antepartum antimicrobial treatment was
given to all pregnant women with BCS. Outpatients
were asked for control visits at two weekly intervals.
After treatment, they were seen once a month. All
patients had a detailed obstetric evaluation. During
these control visits, hepatitis markers, SAT, biochemical
tests, complete blood count, C reactive protein (CRP),
urine test and erythrocyte sedimentation rate (ESR)
were performed [3] . These tests were repeated until
full recovery. The cases were presumed cured, if they
remained seronegative on at least three visits during
the follow-up period. In all B + AVH pregnant women
bed rest was offered and when the tested liver enzymes
increased beyond normal values BCS treatment was
stopped and was restarted after normalization.
Statistics
Statistical analysis was carried out using Stat Cal of
Epi INFO 2000 software package (Center for Disease
Control and Prevention, Atlanta, GA, USA) program.
The chi-square test was used in the statistical analyses.
Chi-square test was used to determine the relationship
between categorical variables. A p-value of < 0.05 was
considered statistically significant.