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Abstract
Cytokines are produced in all tissues of the body. The placenta and membranes have been shown to secrete a large number of pro- and anti-inflammatory cytokines, in labour TNF- is secreted from macrophages in placental tissue.
TNF- is a non-glycoylated protein of 17 KDa and of length 157 amino acid, which form dimmer, and trimers. TNF- production is stimulated by bacterial lipopolysaccharides and is mainly produced by T. helper cells – monocytes – macrophage and neutrophils.
At term, there is an increased production of TNF-. The amniotic fluid concentration of TNF- are higher in women with PROM in the presence of intra-amniotic infection than those without evidence of infection. TNF- can stimulate production of MMPs, which are intrinsically involved in PPROM.
TNF- stimulate arachidonic acid release, which activates the phospholipids metabolic pathway and increases the production of prostaglandin by the myometrium. Increased TNF- concentration in amniotic fluid suggests an inflammatory process. Women with intra-amniotic infection are more likely to develop PPROM.
-Premature rupture of the membranes is a major dilemma in obstetrics, when the problem arises, a decision must be taken, including hospitalization and the use of antibiotics.
-The aim of this study was to clarify the role of tumour necrosis factor in cases with PROM due to lower genital bacterial colonization.
-It was found that vaginal infection is the most important condition associated with PROM and preterm delivery. The presence cytokines as TNF-α and IL-1B stimulate the production of PE2 and PF2α that initiate labour and also stimulate collagenase and stromelysin which cause weakness of amniotic membrane.
-So, this study was conducted to compare the level of TNF-α in the amniotic fluid in cases of PROM whether term (38-42 ws) or preterm (20-37 ws), candidates of the study were 60 patients with premature rupture of the membranes 30 of which were preterm versus 60 normal pregnant females with their membranes intact as a control for comparison, who were attending delivery ward in Suez Canal University Hospital.
-All candidates of the study were subjected to full history taking and complete examination, routine laboratory tests of pregnancy, ultrasonography for gestational age and collection of liquor
(amniotic fluid ) by sterile syringe directly through the external os.
The following special investigations were done ;
1-High vaginal bacterial culture and identification systemically.
2-Assessment of TNF-α by ELISA test.
-Statistical analysis of the results revealed that:
* Among preterm group with PROM ;73% were vaginal swab bacterial culture positive, while 27% were negative.
*Among full term group with PROM ;78% were vaginal swab bacterial culture positive ,while 22% were negative.
*Among the control group,80% were vaginal swab bacterial culture negative.
*Gardnerella Vaginalis was the commonest bacteria encountered in our study (forming 40% of positive vaginal swab cultures of cases with PROM )
*Staph aureus , coming in second rank after Bacterial vaginosis forming 25% of positive vaginal cultures of cases with PROM.
*Then candida albicans forming about 25%,then E.coli , Klebsiella and enterococci with different proportions, constituting 6% of cases.
*Group B streptococci (GBS) forming about 4 % of culture positive PROM cases.
*TNF-α values were significantly high with bacteria positive preterm PROM cases ,also was significantly high among bacteria positive full term PROM cases, whereas among the control group TNF-α values were insignificant ,all were below 1 ng /ml which is considered within the normal range for female under stress of labour.
We may conclude that microbiologic screening in early pregnancy may aid in the assessment of patient risk for PROM ,and substantial potential benefit may be obtained from the control of certain vaginal organisms associated with the morbid events. The high prevalence of bacterial vaginosis and concomitant lower genital tract infections among asymptomatic pregnant women and the resultant adverse pregnancy outcome associated with bacterial vaginosis , confirms reports from developed countries of the need for screening for bacterial vaginosis at the initial antenatal clinic visit. Whether pregnancy outcome was worse in the presence of bacterial vaginosis and other infections than bacterial vaginosis alone could not be determined.
-So ,there was significant relation between TNF-α and presence of vaginal bacterial colonization which points to the role of TNF-α in the process of PROM associated with lower genital colonization.
-TNF-α could be a potential predictor of future rupture of the foetal membranes.