O R I G I N A L A RTICL E ASIAN JOURNAL OF MEDICAL SCIENCES

Vaginal flora in preterm premature rupture of membranes

and their sensitivity to commonly used antibiotics
Shikha Rani1, Reeti Mehra1, Varsha Gupta2, Anju Huria1, Jagdish Chander2
1
Department of Obstetrics & Gynecology, 2Department of Microbiology, Government Medical College & Hospital, Chandigarh, India

Submitted: 21‑02‑2014 Revised: 13‑03‑2014 Published: 30‑05‑2014

ABSTRACT
Background: Ascending infection is one of the most common etiologies in preterm premature Access this article online
rupture of membranes (PPROM). Antibiotics are used in PPROM to prolong the pregnancy
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and to prevent infection. But to prevent drug overuse and resistance, microorganism directed
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antibiotics should be used. So, this study was planned to evaluate vaginal flora in pregnant
women with PPROM and their sensitivity to commonly used antibiotics. Methods: In this
prospective cross‑sectional study, 50 pregnant women (cases) preterm premature rupture of
membranes and 28 pregnant women (controls) without complication were assessed for the
type of vaginal flora and its sensitivity to commonly used antibiotics. Results: Among cases
18 (36%) women showed bacteria on Gram’s staining of vaginal swabs with Gram‑negative
bacteria (10/18) being the most common. Among controls, 16 (57%) women showed
bacteria on Gram’s staining with Gram‑positive bacteria being most common. Among cases
Escherichia coli and Staphylococcus aureus were the commonest isolates. Of 8 (16%) positive
bacterial cultures in cases, 6 (10%) were sensitive to Gentamicin and 2 (4%) to Ampicillin.
Conclusion: Lower genital tract flora of pregnant women with PPROM predominantly consists
of Gram‑negative bacteria, which are sensitive to Gentamicin.
Key words: Vaginal flora, Preterm premature rupture of membranes, Antibiotics

INTRODUCTION is used. However, major pathogens of neonatal infections

are mostly Gram negative bacteria like Klebsiella pneumoniae,
Preterm premature rupture of membranes (PPROM) Escherichia coli, Pseudomonas sp, and Acinetobacter sp.6‑8 Thus,
complicates about 3% of pregnancies and accounts for injudicious use of broad‑spectrum antibiotics can lead to
30‑40% of preterm deliveries.1 Ascending choriodecidual emergence of antibiotic‑resistant organisms.9
infection appears to play an important role in etiology of
PPROM.2 Choriodecidual infection can be diagnosed by This study was planned to evaluate profile of genital
processing of amniotic fluid. However, because of invasive tract organisms in Indian women with PPROM and
nature of procedure, need of expertise and difficulty in their sensitivity to commonly used antibiotics (ampicillin,
cultivating specific organisms, amniocentesis is not routinely cefazolin and gentamicin).
done in low‑resource settings.3,4 Antibiotic therapy has been
observed to prolong pregnancy and reduce maternal and MATERIALS AND METHODS
neonatal morbidity and mortality. CDC also recommends
Group B Streptococcus prophylaxis in all PPROM.5 This cross‑sectional study was conducted from April
2009 to August 2010 in Government Medical College &
Limited data is available from India about type of Hospital, Chandigarh. Study protocol was approved by
vaginal microflora in PPROM. To circumvent which, Ethics Committee of the hospital and abiding to Helsinki’s
broad‑spectrum antimicrobial therapy covering Gram declaration. Written informed consent was obtained from
positive and Gram‑negative aerobic and anaerobic bacteria enrolled women.

Address for Correspondence:

Shikha Rani, Senior Research Associate, Departments of Obstetrics & Gynecology, Government Medical College & Hospital Chandigarh,
India.
E‑mail: [email protected]; Phone: +919646040559.  © Copyright AJMS

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 Rani, et al.: Vaginal flora in PPROM

Patients with live fetus and period of gestation less than occurred after a median duration of 24 h (IQR: 16.5‑55.5)
37 weeks were included in the study. Women who presented of PPROM. Thirty eight (76%) cases delivered vaginally
to the labor and delivery unit with complaints suggesting and 12 (24%) delivered through cesarean section.
rupture of chorioamniotic membranes were enrolled as
cases. Women who presented to outpatient department Bacteria were seen on Gram’s staining of high vaginal swab
at 30‑36  weeks of gestation without active labor were in 18 (36%) cases and 16 (57%) controls. Gram‑negative
enrolled as controls. Patients with maternal complications bacteria were most common among cases (10/18), while
like multiple pregnancies, antepartum hemorrhage, Gram‑positive bacteria were most common among controls
polyhydramnios, preeclampsia, eclampsia, diabetes mellitus, (15/16). Culture of high vaginal swab grew normal flora in
vaginitis and congenital malformed fetus, already received 11 (22%) cases and 11 (39.3%) control subjects. Pathogenic
antibiotics for PPROM were excluded from study. History, organism grew in 9 (18%) of cases in which E. coli was most
general physical and obstetrical examinations were done. common followed by Staphylococcus aureus and 1 (2%) grew
Enrolled women were evaluated using a sterile speculum Candida species. In control group 4 (14.2%) of culture grew
examination. Verification of PPROM was based on pooling pathogenic organism in which 2 (7.1%) were S. aureus and
of amniotic fluid and alkaline pH with nitrazine test. Swab 2 (7.1%) Candida species (Table 2).
from the posterior fornix of the vagina was taken and sent
for Gram’s staining and culture sensitivity. Of 8  (16%) positive bacterial culture in cases, 6  (10%)
were sensitive to Gentamicin and 2  (4%) to Ampicillin.
Microbiological analysis Out of 4 (14.3%) culture, which had grown organism in
Vaginal swabs were obtained from cases and controls and control group, 1 (3.5%) each was sensitive to Ampicillin
sent to the Department of Microbiology. The Gram’s and Gentamicin, 1 (3.5%) to Cefazolin.
staining was done followed by inoculation on Blood and
MacConkey agar as per standard protocols. After overnight None of preterm neonates developed early onset sepsis.
incubation, plates were checked for growth. Identification
of pathogen was done and the significant pathogen was Table 1: Demographic characteristics and
then evaluated for antimicrobial susceptibility testing reproductive history in cases and control groups
using commonly used antibiotics for aerobic (Ampicillin,
Variable Cases Controls
Cefazolin and Gentamicin). Cultures for anaerobic bacteria (n=50) (n=28)
were not used as growing anaerobes is not cost effective as Age, yra 25.0±3.1 24.7±3.9
proven in previous studies and metronidazole is an effective Booked in antenatal clinic of hospitalb 11 (22) 28 (100)
drug for all type of anaerobes. Urban residenceb 28 (56) 21 (75)
Educationb
Nil 2 (4) 0
Statistical analysis
Less than Class 6 5 (10) 6 (21.4)
Data was entered in Microsoft Access  (Microsoft Matric 20 (40) 3 (10.7)
Corporation, Redmond, WA, USA) and analyzed using Secondary 13 (26) 8 (28.5)
Epi‑Info (Center for Disease Control, Atlanta, US). Graduate 4 (08) 4 (14.2)
Postgraduate 6 (12) 7 (25)
Continuous data with normal distribution is represented Gravidac 2 (1‑3) 2 (1‑3)
as mean (standard deviation) and analyzed by student Parityc 1 (0‑1) 1 (0‑1)
t‑test. Continuous data with non‑normal distribution is Previous live birthc 0 (0‑1) 0 (0‑1)
represented as median (interquartile range) and analyzed Mean gestational age (wk)a 34.2±1.6 33.1±1.6
by Mann‑Whitney U test. Categorical data is presented as Values are given as mean±SD, b number (percentage) or c median (interquartile range)
a

proportion and analyzed by Chi‑square or Fischer exact test.

Table 2: Culture of high vaginal swab in cases
RESULTS and control groupa
Type of microorganism Cases n=(50) Controls (n=28)
During the period of study, a total of 50  cases and 28 Escherichia coli 3 (6) 0
controls were enrolled. Demographic characteristics and Staphylococcus aureus 2 (4) 2 (7.1)
reproductive history of enrolled subjects are summarized Pseudomonas aeruginosa 1 (2) 0
Acinetobacter species 1 (2) 0
in Table 1. Mean age, parity status and gestational age at
Klebsiella oxytoca 1 (2) 0
enrolment were similar among cases and controls. Candida species 1 (2) 2 (7.1)
Contaminants 3 (6) 0
Cases presented to hospital with median duration of Normal flora 11 (22) 11 (39.3)
PPROM of 11 h (interquartile range: 8‑24). Amniotic Sterile 27 (54) 13 (46.3)
fluid index at presentation was 4.3  ±  1.5 cms. Delivery Values are given as number (percentage)
a

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 Rani, et al.: Vaginal flora in PPROM

DISCUSSION analyze association between microbiological profile and

gestation at presentation or length of pregnancy. A large
In this cross‑sectional study, we performed lower genital proportion of mothers did not grow any organism in their
tract culture in pregnant women with PPROM. Most vaginal swabs and lack of use of special culture media for
common isolated bacteria were E. coli followed by S. aureus. Mycoplasma may account for decreased rate of isolation.
In resource‑limited settings where microbiological evaluation
of amniotic fluid is not feasible, identification of bacteria To summarize, our study provides important data about
in high vaginal swab can guide antibiotic therapy in women microbiological correlate of PPROM in Indian pregnant
with PPROM. Previous studies have shown good correlation women and most of pathological isolates were sensitive
between genital tract flora and organism grown in amniotic to Gentamicin. Larger studies are needed to formulate
fluid or blood of neonates with early onset sepsis. Karat antibiotic policy for management of women with PPROM
et al. reported S aureus (28%) and E coli (20%) as significant in resource‑limited settings.
vaginal isolates in‑patient with PPROM.7 Carroll et al.
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Authors Contribution:
SR – designed the study, data collection, analysis and written the manuscript; RM & AH – data analysis and revising the manuscript; VG &
JC – microbiological inputs and revision of manuscript.

Source of Support: Nil, Conflict of Interest: None declared.

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