International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Yarlagadda S et al. Int J Reprod Contracept Obstet Gynecol. 2018 Jun;7(6):2174-2179

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20182030
Original Research Article

Association of vaginal infections in Preterm labour

Srilakshmi Yarlagadda*, Sajana G., Prasuna J. L. Narra

Department of Obstetrics and Gynecology, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research
Foundation, Chinoutapally, Krishna, Andhra Pradesh, India

Received: 01 May 2018

Accepted: 05 May 2018

*Correspondence:
Dr. Srilakshmi Yarlagadda,
E-mail: ysiri531@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Preterm labour is defined as onset of regular uterine contractions associated with cervical changes
between 28-37 completed weeks of gestation. Prematurity is the cause of 85% neonatal morbidity and mortality.
Preterm labour has multiple etiologies. Vaginal infections have been associated with increased risk for preterm
labour. Screening for genitourinary infections antenatally, especially in high risk cases, prompt recognition and
treatment decrease the incidence of preterm labour.
Methods: Ours was a prospective and retrospective observational study done at Dr. Pinnamaneni Siddhartha Institute
of Medical Sciences and Research Foundation from April 2016 to February 2018 in the Department of Obstetrics and
Gynaecology. The aim is to study the association of vaginal infections in preterm labour. A total of 116 women in
preterm labor were studied. After clinical examination, CBP, CUE, Ultrasound, urine culture and sensitivity were
done. Vaginal swab was taken from posterior fornix and sent for culture and sensitivity and gram staining .Culture
and sensitivity were done in the Department of Microbiology at our Institute.
Results: Out of 116 women in preterm labour, urinary tract infection was seen in 27.58% women. E. Coli was the
commonest microorganism isolated in urine (15.51%). Vaginal infections were seen in 33.62% women. Candida was
the commonest microorganism isolated in HVS cultures.
Conclusions: Screening for genitourinary infections in pregnancy is necessary, especially in high risk cases. Early
detection and prompt treatment of genitourinary infections decrease the incidence of preterm labor, thereby
decreasing the neonatal morbidity and mortality associated with prematurity.

Keywords: Preterm labour, Urinary tract infection, Vaginal infections

INTRODUCTION • Uterine contractions of 4 in 20 minutes or 8 in

60minutes plus progressive cervical changes.
Preterm labour is defined as onset of regular uterine • Cervical dilatation of >1cm.
contractions associated with cervical changes between 28 • Cervical effacement of >80%.
to 37 completed weeks of gestation.
In the developed countries, the incidence of preterm birth
Preterm birth is the leading cause of neonatal morbidity is 5-10%, whereas it is around 25% in developing
and mortality. 85% of neonatal morbidity and mortality is countries.1 Worldwide incidence of premature birth
due to premature birth. The American Association of ranges between 6-11%.2
Paediatrics and ACOG 1997 proposed the following
criteria to diagnose preterm labour. Most of the times, the cause of preterm labour is
unknown, but many conditions have been associated with

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an increased risk of preterm delivery. 30-40% of all cases factors in index pregnancy including genitourinary and
of preterm birth are induced because of maternal or fetal respiratory infections, GDM, anaemia, hypertensive
complications. The remaining 60-70% are likely due to disorders, heart disease or any other medical disease,
subclinical infective or inflammatory causes, especially obstetric risks like hydramnios, multifetal gestation,
genitourinary tract, cervical dysfunction, multiple malpresentation and uterine anomalies.
gestations, idiopathic and possible social, environmental
and nutritional interactions.3 A thorough systemic and obstetric examination was done.
Speculum examination was done to visualise cervix and
The most serious outcome of preterm labour is often vagina and to rule out cervical and vaginal infections.
associated with adverse maternal and neonatal outcomes
related to infection.4 Prostaglandins which are released Per vaginal examination was done to note cervical length
because of infection stimulate uterine contractions and dilatation. CBP, CUE, Obstetric Ultrasound for
leading to preterm labour. Preventive measures can cervical length, AFI, EFW, placental localisation and
prevent preterm labour and adverse neonatal outcome. separation were done.

So, the present study was undertaken to study the role of Swab from the posterior fornix of vagina was taken and
vaginal infections in preterm labour. The main objective sent for gram staining and culture sensitivity. Midstream
is to study the association of vaginal infections in preterm urine sample was sent for culture and sensitivity.
labour.
Microbiological analysis and antimicrobial sensitivity
METHODS testing of urine and high vaginal swab were done in the
Department of Microbiology at our institute. All patients
This was a prospective and retrospective observational were monitored for features of sepsis like fever, maternal
study done at Dr. Pinnamaneni Siddhartha Institute of tachycardia, uterine tenderness and foul smelling vaginal
Medical Sciences and Research Foundation from April discharge.
2016 to Feb 2018 in the Department of Obstetrics and
Gynecology. The NICU at our hospital is well equipped Since this study comes under descriptive statistics, results
and considering the facilities available in it, 28 weeks were analysed by calculating percentages.
was taken as the lower limit for the period of viability in
the present study. RESULTS

Pregnant women between 28-37 weeks of gestation who In the present study, out of 2040 pts who delivered
set into spontaneous preterm labour only were included in beyond 28 weeks between April 2016-Feb 2018, 116
the present study. Gestational age was assessed basing on women presented in preterm labour. The incidence of
the last menstrual period and dating scan. preterm labour at our institute was 5.68 %.

Women who had uterine contractions of 4 in 20min or 8 Table 1: Age.

in 60 min associated with cervical dilatation of ≥1cm and
effacement of >80% between 28-37 completed weeks of Age (N=116) No %
gestation were included in the study. < 20 years 38 32.75
20-25 years 26 22.41
Inclusion criteria 25-30 years 22 18.96
30-35 years 20 17.24
• Pregnant women between 28-37 completed weeks of 35 years 10 8.62
gestation who set into spontaneous preterm labour.
In the present study, majority of women who delivered
Exclusion criteria preterm were in teenage (32.75%).
• Pregnant women with <28 weeks and >37weeks of Table 2: Gravida.
gestation.
• Pregnant women with APH Gravida (N=116) No %
• Pregnant women with PROM Primigravidas 25 21.55
• Pregnant women with IUD G2 27 23.27
• Any pregnant woman whose pregnancy was G3 46 39.65
terminated preterm for any maternal or fetal cause. G4 18 15.51

Written informed consent was obtained from enrolled In the present study, 21.55% were primigravidas, 23.27%
women. Detailed history was taken with respect to age, were second gravidas, 39.65% were third gravidas and
parity, socioeconomic status, residence, previous 15.51% were fourth gravidas.
pregnancy outcomes and for the presence of any risk

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Table 3: Booked/unbooked. significant association with preterm labour in index

pregnancy. 13.79% had previous one abortion, 17.24%
Booked cases 66 56.89 had previous 2 abortions and 7.75% had previous 3
Unbooked cases 50 43.10 abortions.

56.89% were booked cases at our institute, but they had 32.75% in the present study had previous history of one
irregular antenatal checkups. 43.10% were unbooked (or) more preterm deliveries. 10.34% had previous one
cases. preterm delivery, 14.65% had previous 2 preterm
deliveries and 7.75% had previous 3 preterm deliveries. It
Table 4: Socioeconomic status (SES). has significant association with PTL in index pregnancy.

SES (N = 116) No % Table 9: Risk factors for preterm in index pregnancy.

Lower 47 40.51
Lower middle 43 37.06 Risk factor No of cases %
Upper middle 16 13.79 UTI 32 27.58
Upper 10 8.62 Vaginal infections 39 33.62
GDM 8 6.89
It was evaluated according to Kuppuswamy Anaemia 24 20.69
classification. 40.51% belonged to lower SES, 37.06% to Hypertensive disorders 26 22.41
lower middle, 13.79% to upper middle and 8.62% to URTI 18 15.51
upper class. Bronchial asthma 5 4.31
Heart disease 3 2.58
Table 5: Body Mass Index (BMI). Pyrexia 16 13.79
Multifetal gestation 5 4.31
BMI No of cases % Hydramnios 12 10.34
Underweight 52 44.82 Uterine anomalies 3 2.58
Ideal 36 31.03 Malpresentations 10 8.62
Overweight 16 13.79
Obese 12 10.34 It was observed that 74.13% (86/116) patients had one
(or) multiple risk factors for preterm in index pregnancy.
Majority (44.82%) had underweight in the present study. In the present study, 27.58% had UTI and 33.62% had
The weight gain during index pregnancy is also low. vaginal infections, which was significant. 6.89% had
GDM and 20.69% had anemia.
Table 6: Residence.
Hypertensive disorders were noted in 22.41%. Upper
Residence No of cases % respiratory tract infections were seen in 15.51%. 3
Rural 82 70.69 patients had uterine anomalies, one with bicornuate
Urban 34 29.31 uterus unicollis and 2 patients had septate uterus. 2.58%
had congenital heart diseases and 4.31% had bronchial
70.69% lived in rural areas around the hospital and asthma. 13.79% (16/116) had fever, out of which 6
29.31% lived in urban areas. patients responded to antimalarials. 4.31% had twin
pregnancies and 8.62% had malpresentations, the
Table 7: Previous H/O abortions. commonest being breech presentation. Hydramnios was
seen in 10.34% cases.
No. of abortions No of patients %
One abortion 16 13.79 Table 10: Bacteriological profile in urine sample
Two abortions 20 17.24
Three abortions 9 7.75 Micro organism No of urine samples %
E. coli 18 15.51
Table 8: Previous H/O preterm deliveries. Klebsiella 4 3.44
Candida 3 2.58
No of Acinetobacter 1 0.86
No of prev preterm deliveries %
patients S.aureus 6 5.17
1 PTL 12 10.34 Sterile 68 58.62
2 PTL 17 14.65 Contaminated 12 10.34
3 PTL 9 7.75
UTI was seen in 27.58% cases. E. Coli was the
It was observed in the present study that 38.79% (45/116) commonest microorganism cultured in urine (15.51%).
had previous H/O one or more abortions. It has

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Other microorganisms isolated were Klebsiella, Candida, multigravidas. In the study done by Singh U et al, 47%
Acinetobacter and Staphylococcus aureus. were primigravidas and 53% were multigravidas.7 Also,
in a study conducted by Etuk SJ et al, 41.94% were
Table 11: Bacteriological profile in vaginal samples primigravidas and 58.06% were multigravidas.11 The
increased incidence of preterm labour in multigravidas in
No. of HVS the present study could be because more number of
Microorganism %
samples younger women conceived with low interconception
Candida 36 31.03 interval, malnutrition, anemia and genito-urinary
Staphylococcus infections.
1 0.86
aureus
Mixed microbes 2 1.72 In the present study, 56.89% were booked cases and
Sterile 77 66.37 43.1% were unbooked cases. Though 56.89% were
booked cases at our institution, they didn’t come for
Vaginal infection was seen in 33.62% cases which was regular antenatal checkups and so complications like
significant. Candida was the commonest microorganism anemia, UTI, genital infections, hypertensive disorders
(31.03%) seen in HVS cultures. Other organisms isolated were more in them leading to preterm labour. 40.51%
were Staphylococcus aureus and mixed microbes. belonged to lower socioeconomic status and 37.06% to
lower middle class. Because malnutrition, anemia and
DISCUSSION increased chances of infections were more in these
women, the incidence of preterm labour was also high
In the present study, out of 2040 patients who delivered among them.
beyond 28 weeks between April 2016-Feb 2018, 116
cases presented in preterm labour. The incidence of In the present study, 44.82% had underweight and
preterm labour at our institute was 5.68%. This is in close majority (70.69%) lived in rural areas. The incidence of
agreement to the world-wide incidence of preterm labour. anemia, malnutrition and genitourinary infections was
also high in these women which might have led to
Fernandes F et al reported an incidence of preterm labour preterm labour
at 7.81% in their study.5 Beck S et al reported an
incidence of 6 to 11% and Copper et al reported at 7 to Past obstetric history
11%.2,6 However, Uma S et al in their study reported the
incidence of preterm labour as 22%.7 The varied In the present study, it was observed that 38.79% had
incidence in different studies may be due to differences in previous h/o abortion and 32.75% had previous h/o
socioeconomic status, literacy and awareness of antenatal preterm delivery which were significant.
care among the pregnant women.
In the study by Fernandes F et al 35% had previous h/o
Age abortions and 12.11% had previous h/o preterm births.5 In
a case control study done in Iraq by Samim A et al.8 15%
Majority of women were in teenage in the present study had h/o previous pretermbirths. In the study by Kiran P et
(32.75%). 22.41% were between 22-25years. Extremes of al.12 14.4% had previous h/o preterm births and 14.4%
age group accounted for 41.37% cases. This is in had previous h/o abortions.
comparison with the study done by Samim A et al in Iraq,
2006, who reported that 36.5% of cases of preterm labour Risk factors for preterm in index pregnancy
were in extremes of reproductive age group.8 In the study
by Fernandes F et al.5 15.8% were in extremes of age Out of 116 women who delivered preterm in the present
group and 18.8% were in extreme age group in the study study, it was observed that 86 women (74.13%) had one
done by Renay Weiner et al in Kenya.9 This difference or more risk factors.
could be because more teenage and elder women were
present in the present study. Vaginal infections were noted in 33.62% women in the
present study. The commonest organism isolated in HVS
Gravida cultures was Candida species. The other organisms were
Staphylococcus aureus and mixed microbes.
In the present study, 21.55% were primigravida and
78.44% were multigravidas. In the study done by Pradeep Raju S et al the incidence of
vaginal infections was 58.06% in women with preterm
In a longitudinal case series examining demographic and labour.13 Incidence of vaginal infections was high when
obstetric data of 17493 deliveries conducted in a referral compared to the study conducted by Fernandes F et al
centre in Israel by Shlomo E et al, preterm delivery rate who reported an incidence of 8.29%.5 Samim A et al
was higher in grand multipara (93% among reported an incidence of 7.24% of women with vaginal
grandmultipara).10 In the study by Fernandes F. et al.5 infection in preterm labour.8 UTI was noted in 27.58% of
45.11% were primigravidas and 54.39% were cases. The commonest organism isolated was E. Coli

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(15.51%). The other organisms isolated were Candida, ACKNOWLEDGMENTS

Acinetobacter and S. Aureus.
Authors would like to thank Dr. Vishnuvardhan Rao,
Samim A et al reported 40% incidence of UTI in their Professor and HOD of the Department of Microbiology at
study and Pandey Kiran et al. reported 20.34% incidence our Institute for his support in conducting the study.
of UTI in their study.8,12 Fernandes F et al reported Authors would like to thank Dr. Manogna and Dr.
13.65% incidence of UTI. The difference could be due to Sindhu, Postgraduates in the Department of Obstetrics
the differences in the criteria used to diagnose UTI, and Gynecology at our institute for their help in
whether clinically based (or) by urine culture.5 Anemia conducting the study. Authors would like to thank all the
was seen in 20.69% cases. patients and their attendants for their cooperation and
contribution.
Hypertensive disorders were seen in 22.41% cases. This
is comparable to the studies by Fernandes F et al, who Funding: No funding sources
reported an incidence of 21.07% of hypertensive Conflict of interest: None declared
disorders in preterm labour, Etuk SJ et al at 23.8%. Ethical approval: The study was approved by the
Shreshta S et al reported hypertensive disorders in Institutional Ethics Committee
preterm labour at 13.3 % and Taskeen Rehana et al at
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