Abortion care

This guideline covers care for women of any age (including girls and young women under 18) who request an abortion. It aims to improve the organisation of services and make them easier for women to access. Detailed recommendations on conducting abortions at different gestational stages are also included, to ensure that women get the safest and most effective care possible.

Partial protection induced by Salmonella based Brucella vaccine candidate in pregnant guinea pigs.

Residual virulence is a major drawback in current Brucella vaccines. Live vaccines induce abortions in pregnant animals. Hence, a novel anti-Brucella vaccine was developed utilizing rough Salmonella delivering four Brucella antigens. Safety implications during pregnancy, humoral immune responses, and protective efficacy against wild type Brucella was investigated in guinea pig model. The vaccine did not induce abortions or severe complications in pregnant guinea pigs when administered 4 × 108 CFU via intraperitoneal route. Systemic IgG determination against antigen components reveals induction of immunity via the Salmonella delivery. Protection efficacy against abortions was 33.3% (2/6) when midterm sow challenged with virulent Brucella 544 strain while none was protected in control group. Lower Brucella recovery in spleen and liver and reduced histopathological burden were also noticed. Although abortion induced by Brucella challenge was not completely prevented, the vaccine candidate may perform better with optimization of vaccination such as inoculation dose optimization.

The protective effect of berberine against lipopolysaccharide-induced abortion by modulation of inflammatory/immune responses.

OBJECTIVE: Berberine is an isoquinoline derivative alkaloid with anti-inflammatory activity. In this study, we investigated the protective effects of berberine in prevention of LPS-induced abortion. MATERIALS AND METHODS: On the gestation day (GD) 9.5, the pregnant mice were injected with low, medium, and high doses of berberine or with PBS. After 4 h, berberine or PBS-pretreated mice were injected with LPS. On GD 11.5, blood samples and uterine tissues were collected from treated mice and percentage of abortion and serum levels of NO, TNF-α, IL-10, and IL12p70 were measured by macroscopic examination and sandwich ELISA, respectively. RESULTS: Our findings show that mice injected with berberine were resistant to LPS-induced abortion. We also found that this treatment prevents the reduction of IL-10 and the enhancement of NO, TNF-α, and IL-12p70 in LPS-treated pregnant mice. CONCLUSIONS: Taken together, our results suggest that berberine as an anti-inflammatory agent has protective effects on LPS-induced abortion by modulation of inflammatory/immune responses.

Pharmacokinetics of chlortetracycline in maternal plasma and in fetal tissues following oral administration to pregnant ewes.

The purpose of this study was to determine if concentrations of chlortetracycline could be detected in fetal plasma or tissues after administering an oral dose of chlortetracycline (CTC; 500 mg/head/day) reported to be effective in controlling Campylobacter spp. abortions. Five pregnant ewes were administered 250 mg/head twice a day (total dose 500 mg/hd/d) for 7 days. On the beginning of day 7, intravenous catheters were surgically implanted or inserted into the fetus and dam. Plasma samples were collected from the ewe and fetus at various time points before and up to 36 hr after the last dose of CTC. All ewes were then sacrificed, and tissues were harvested from the fetus for drug analysis. Concentrations of CTC in maternal plasma were consistent with our previous study and below the minimum inhibitory concentration of Campylobacter abortion isolates. Concentrations of CTC were below the limit of detection in three of five fetal plasma samples and all of the placenta, amniotic fluid, and fetal stomach contents. Low concentrations were detectable in fetal kidney and liver, suggesting that CTC reaches the fetus, although at a variable and low ratio when compared to maternal concentrations.

Induced abortion.

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Pharmacokinetics of oral chlortetracycline in nonpregnant adult ewes.

The objectives of this study were to determine plasma concentrations and pharmacokinetic parameters of feed-grade chlortetracycline (CTC) in sheep after oral administration of 80 or 500 mg/head daily, divided into two equal doses given at 12-h intervals for 8 days. These are the approved, and commonly used but unapproved, feed additive doses, respectively, in the United States for the prevention of ovine infectious abortion. Blood samples were collected just prior to dosing at 0, 12, 24, 72, 96, and 192 h, as well as 4, 8, 12, 24, and 36 h after the last dose, and noncompartmental pharmacokinetic analysis was performed to estimate elimination half-life and area under the plasma concentration-time curve (AUC). Mean observed maximum CTC concentrations (Cmax ) were 20.0 ng/mL (80 mg dose) and 101 ng/mL (500 mg dose). Mean apparent elimination half-life was 18 h (80 mg dose) and 20 h (500 mg dose). Although published data do not exist to estimate plasma CTC concentrations necessary for the prevention of ovine infectious abortion, concentrations reached in our study suggest that either the FDA-approved and FDA-unapproved dosages are not high enough or that the pharmacodynamic parameter relating preventive dose to pathogen minimum inhibitory concentrations is yet to be determined.

Azithromycin prevents pregnancy loss: reducing the level of tumor necrosis factor-alpha and raising the level of interleukin-10 in rats.

The aim of this study was to determine the effect of azithromycin on LPS-induced pregnancy loss. Thirty-six pregnant female Wistar rats were divided into 4 equal groups as follows: control group, where 0.3 mL of normal saline solution was administered intravenously on day 10 of pregnancy; azithromycin group, where azithromycin was administered orally at 350 mg kg(-1) day on days 9, 10, and 11 of pregnancy; lipopolysaccharide group, where LPS was administered intravenously via the tail vein at 160 µg kg(-1) on day 10 of pregnancy; and the azithromycin + LPS group, where azithromycin was administered orally at 350 mg kg(-1) day on days 9, 10, and 11 of pregnancy and LPS was administered intravenously at 160 µg kg(-1) on day 10 of pregnancy. Blood samples were obtained from the tail vein on day 10 of the experiment. Pregnancy rates were determined. Tumor necrosis factor-alpha (TNF- α ) and interleukin (IL-10) levels were measured by ELISA. Azithromycin prevented (P < 0.05) LPS-induced pregnancy loss. Higher TNF- α and IL-10 levels were measured (P < 0.05) in the LPS and azithromycin + LPS groups, respectively. In conclusion, azithromycin may be useful in infection- or endotoxemia-dependent pregnancy loss.

IFN-γ expression in placenta is associated to resistance to Chlamydia abortus after intragastric infection.

Intragastric infection mimics the natural route of infection of Chlamydia abortus (etiological agent of ovine enzootic abortion). In the mouse model, intragastric experimental infection induces very mild signs of infection followed by late term abortions, as it is shown by the natural ovine host. In order to evaluate the immune mechanisms associated to the dissemination of the pathogen from the gastrointestinal tract, we have administered an intragastric dose of C. abortus to pregnant mice. Systemic and local expression of cytokines, tissue colonization and excretion of bacteria after parturition were monitored during pregnancy. Susceptible CBA/J mice showed a higher bacterial colonization of the placenta and excretion of live bacteria after parturition that were related to a higher local IL-10 expression. By contrast, resistant C57BL/6 mouse strain had higher local IFN-γ mRNA expression in the placenta just before parturition and a transient bacterial colonization of the reproductive tract, with no excretion of C. abortus after parturition. In summary, intragastric infection not only mimics the natural route of infection of C. abortus, but can also be useful in order to understand the immunopathogenesis of chlamydial abortion in the mouse.

Immune responses and protection against experimental challenge after vaccination of bison with Brucella abortus strain RB51 or RB51 overexpressing superoxide dismutase and glycosyltransferase genes.

Vaccination is a tool that could be beneficial in managing the high prevalence of brucellosis in free-ranging bison in Yellowstone National Park. In this study, we characterized immunologic responses and protection against experimental challenge after vaccination of bison with Brucella abortus strain RB51 (RB51) or a recombinant RB51 strain overexpressing superoxide dismutase (sodC) and glycosyltransferase (wboA) genes (RB51+sodC,wboA). Bison were vaccinated with saline only or with 4.6 x 10(10) CFU of RB51 or 7.4 x 10(10) CFU of RB51+sodC,wboA (n = eight animals/treatment). Bison vaccinated with RB51 or RB51+sodC,wboA had greater (P < 0.05) antibody responses, proliferative responses, and production of gamma interferon to RB51 after vaccination than did nonvaccinates. However, bison vaccinated with RB51+sodC,wboA cleared the vaccine strain from draining lymph nodes faster than bison vaccinated with the parental RB51 strain. Immunologic responses of bison vaccinated with RB51+sodC,wboA were similar to responses of bison vaccinated with RB51. Pregnant bison were intraconjunctivally challenged in midgestation with 10(7) CFU of B. abortus strain 2308. Bison vaccinated with RB51, but not RB51+sodC,wboA vaccinates, had greater protection from abortion, fetal/uterine, mammary, or maternal infection than nonvaccinates. Our data suggest that the RB51+sodC,wboA strain is less efficacious as a calfhood vaccine for bison than the parental RB51 strain. Our data also suggest that the RB51 vaccine is a currently available management tool that could be utilized to help reduce brucellosis in free-ranging bison.

Heat shock cognate protein 70 contributes to Brucella invasion into trophoblast giant cells that cause infectious abortion.

BACKGROUND: The cell tropism of Brucella abortus, a causative agent of brucellosis and facultative intracellular pathogen, in the placenta is thought to be a key event of infectious abortion, although the molecular mechanism for this is largely unknown. There is a higher degree of bacterial colonization in the placenta than in other organs and many bacteria are detected in trophoblast giant (TG) cells in the placenta. In the present study, we investigated mechanism of B. abortus invasion into TG cells. RESULTS: We observed internalization and intracellular growth of B. abortus in cultured TG cells. A monoclonal antibody that inhibits bacterial internalization was isolated and this reacted with heat shock cognate protein 70 (Hsc70). Depletion and over expression of Hsc70 in TG cells inhibited and promoted bacterial internalization, respectively. IFN-gamma receptor was expressed in TG cells and IFN-gamma treatment enhanced the uptake of bacteria by TG cells. Administering the anti-Hsc70 antibody to pregnant mice served to prevent infectious abortion. CONCLUSION: B. abortus infection of TG cells in placenta is mediated by Hsc70, and that such infection leads to infectious abortion.

Escheriosome-mediated delivery of recombinant ribosomal L7/L12 protein confers protection against murine brucellosis.

Brucellosis is an important zoonotic disease that causes abortion in cattle and undulant fever, arthritis, endocarditis and meningitis in human. In spite of the fact that immunization could be an efficient measure to control brucellosis, not a single ideal vaccine against this important disease has been developed so far. In order to develop an effective vaccine against Brucella abortus (B. abortus), various protective immunodominant gene/protein products of the pathogen have been studied in combination with different adjuvants. For example, recombinant ribosomal protein L7/L12 (rL7/L12) although an interesting T-cell antigen, normally failed to evoke protective immune response when used in free form. In the present study we have demonstrated that Escherischia coli (E. coli) lipid liposome (escheriosome)-mediated cytosolic delivery of recombinant rL7/L12 protein can elicit strong immunological responses in the Balb/c mice. In contrast, egg PC/Chol liposome entrapped rL7/L12, in a manner similar to its free form, was found to impart relatively poor immune response. Furthermore, escheriosome entrapped rL7/L12 protein elicited high IgG2a isotype response suggestive of its relevance in imparting protection against brucellosis in mice. Altogether the present study is a clear indicative of the possible use of escheriosome-based delivery of rL7/L12 protein to induce protective immune responses against experimental murine brucellosis.

Factors influencing post abortion outcomes among high-risk patients in Zimbabwe.

Post abortion complications remain one of the major causes of mortality among women of child bearing age in Zimbabwe. Based on this problem, factors associated with mortalities due to abortion were investigated with the aim of improving post abortion outcomes for Zimbabwe's women, and possibly also for women of other African countries. Cases and controls were selected from 4895 post abortion records to conduct a retrospective case-control study. Significant risk factors identified for reducing mortalities due to post abortion complications included the administration of oxytocic drugs and evacuation of the uterus whilst anaemia and sepsis apparently reduced these women's chances of survival. Women who died (cases) from post abortion complications apparently received better reported quantitative care than controls. Recommendations based on this research report include improved education of health care workers and enhanced in-service training, regular audits of patients' records and changed policies for managing these conditions more effectively in Zimbabwe.

The production of EAE-free lambs from infected dams using multiple ovulation and embryo transfer.

This investigation aimed to ascertain whether embryo transfer was a feasible method of breaking the disease cycle caused by Chlamydia psittaci (ovis). Ten naive ewe lambs were inoculated orally with the T76 and G188 isolates of C. psittaci (ovis) in late pregnancy. Five animals which sero-converted to the complement fixation test (CFT) were used as donors for a multiple ovulation and embryo transfer programme. Three ewes excreted chlamydiae at parturition 1 year after inoculation, with one animal exhibiting a CFT titre indicative of clinical disease. Twelve embryos collected from these three donors and transferred to seven disease-free recipients survived and were not infected, nor were their recipient dams. It therefore appears possible to infect ewe lambs during the final stages of pregnancy with the disease manifesting itself during the following breeding season. Embryos collected from infected animals do not appear to transmit the chlamydia causing enzootic abortion.

Prevention of premature birth by screening and treatment for common genital tract infections: results of a prospective controlled evaluation.

OBJECTIVE: Our purpose was to analyze (1) the effects of prevalent lower reproductive tract infections and (2) the effect of systematic diagnosis and treatment to reduce risks of early pregnancy loss (< 22 weeks), preterm premature rupture of membrances, and overall preterm birth. STUDY DESIGN: A prospective, controlled treatment trial was conducted on 1260 women. During the first 7 months of the program (observation, phase I), women were examined at initiation of prenatal care for a panel of lower genital tract microorganisms and bacterial vaginosis. Women were followed up with reexaminations at 22 to 29 weeks and after 32 weeks' gestation. The recommended treatments of the Centers for Disease Control (i.e., 300 mg of clindamycin orally twice daily for 7 days for bacterial vaginosis) were used for infected women during the second 8 months of the study (treatment, phase II). Data were analyzed according to intent to treat by means of univariate and multivariate methods. RESULTS: Overall, presence of bacterial vaginosis (32.5%) at enrollment was associated with pregnancy loss at < 22 weeks' gestation (relative risk 3.1, 95% confidence interval 1.4 to 6.9). Among women in the observation phase bacterial vaginosis was associated with increased risk of both preterm birth (relative risk 1.9, 95% confidence interval 1.2 to 3.0) and preterm premature rupture of membranes (relative risk 3.5, 95% confidence interval 1.4 to 8.9). Within this population (phase I) 21.9% of preterm birth overall (43.8% premature rupture of membranes) is estimated as attributable to bacterial vaginosis. Among women with bacterial vaginosis phase II (treatment) was associated with reduced preterm birth (relative risk 0.5, 95% confidence interval 0.3 to 0.9); there was a similar reduction for women with preterm premature rupture of membranes (relative risk 0.5, 95% confidence interval 0.2 to 1.4). Women with both bacterial vaginosis and trichomoniasis were at highest risk of preterm birth (28%); treatment of both conditions (phase II) reduced preterm birth (17%) but did not eliminate this risk. Earlier patient enrollment and oral antibiotic treatment were associated with reduced preterm birth. CONCLUSIONS: This prospective, controlled trial confirms that the presence of bacterial vaginosis is associated with increased risks of pregnancy loss at < 22 weeks, preterm premature rupture of membranes, and preterm birth. Orally administered clindamycin treatment is associated with a 50% reduction of bacterial vaginosis-linked preterm birth and preterm premature rupture of membranes. Women at risk for preterm birth or preterm premature rupture of membranes because of bacterial vaginosis or common genital tract infections should be screened, treated, reevaluated for cure, and re-treated if necessary.

Septic abortion.

PIP: Abortion-related deaths, which account for 47% of total maternal mortality in the world, result primarily from sepsis and are widespread in developing countries where abortion is illegal or inaccessible. Septic abortion offers opportunities for prevention on the primary, secondary, and tertiary level of medial care. Primary prevention of septic abortion encompasses the provision of effective contraception, provision of safe and legal abortion in cases of contraceptive failure, and appropriate medical management of abortion. Secondary prevention involves the prompt diagnosis of endometriosis and effective treatment to avert more serious infection. The diagnosis of septic abortion should be considered when women of reproductive age present to health facilities with vaginal bleeding, lower abdominal pain, and fever. Tertiary prevention is aimed at avoiding the serious complications of postabortal infection, including hysterectomy and death. Women with high fever, pelvic peritonitis, and tachycardia should undergo uterine evacuation and parental antibiotic therapy. Supportive care for cardiovascular system and other organs may be essential. The medical technology needed to avert serious complications and deaths from septic abortion is available. Lacking is a political commitment on the part of many governments and health care agencies to address this avoidable contributor to maternal morbidity and mortality.^ieng

Acute renal failure in Addis Abeba, Ethiopia: a prospective study of 136 patients.

The causes and clinical course of 136 cases of acute renal failure (ARF) consecutively treated in the Renal Unit of Tikur Anbessa Hospital, Addis Abeba, Ethiopia, between January 1989 and December 1992 are described. There were 106 women and 30 men with mean age of 26.9 +/- 7.2 and 40.7 +/- 14.9 years respectively. Septic abortion is still the leading cause of ARF (71 patients) followed by falciparum malaria (29 patients) and nephrotoxic agents (12 patients). One-hundred-seventeen patients (86%) required dialysis. The overall case fatality rate was 33.8%, with similar mortality rates in septic abortion (36.6%) and falciparum malaria infection (37.9%), but a much lower rate (16.7%) in acute renal failure secondary to nephrotoxic agents. Septicaemia and pneumonia were leading causes of death. Derangement of liver function was associated with higher mortality rates in patients with septic abortion and malaria, whereas leukocytosis was found to be a poor prognostic finding in the latter. Non-oliguric ARF was seen in 33.8% of cases and was found commonly in patients with malaria (75.9%) or in nephrotoxin-induced ARF (83.8%). Mean duration of oliguria was 18.9 +/- 11 days. Compared to the previous report from the same centre, this larger series identified important clinical settings other than septic abortion which predispose to ARF. As renal function tests are not performed routinely in many Ethiopian hospitals and as many patients have non-oliguric ARF, cases may be being missed. Measures to prevent septic abortion and malaria, and the judicious use of nephrotoxic agents, may decrease the incidence of ARF.

[The immunogenicity of a vaccine against enzootic abortion in sheep]. / Imunogénnost vakcíny proti enzootickému potratu oviec.

Immunogenicity of vaccine against enzootic abortion of ewes (EPO) was evaluated in sheep and laboratory white mice. The vaccine contained purified and formalin-inactivated corpuscules of Chlamydia psittaci. Experiment was performed on ten sheep, Slovak Merino breed, which were negative before vaccination in serological assays and blastic transformation of lymphocytes (BTL) tests. The animals were immunized subcutaneously with 2 ml of vaccine which contained 100 micrograms (sheep No. 1-4) and 20 micrograms (sheep No. 5-8) corpuscules of C. psittaci. Control group (No. 9-10) received the same volume of physiological saline. The second dose of vaccine was given one month after the first dose (No. 1-2--100 micrograms each, and No. 5-6--20 micrograms each). Blood for serological evaluation and BTL test was taken before vaccination and 1, 3, and 6 months after vaccination. The sheep which were given the second dose of vaccine were also evaluated two weeks thereafter. Antibody response in complement fixation reaction (CFR) and enzyme-linked immunosorbent assay (ELISA) was compared with the results of BTL. While the antibody response evaluated by CFR was sporadically positive after administration of the higher dose of vaccine only, in ELISA all sera were positive except one lower dose of vaccine (Tab. I). In all post-vaccination intervals positivity was confirmed by BTL test irrespective of the size and number of vaccine dose (Tab. II). Immunization of mice with one dose (100 micrograms) of vaccine significantly but not completely reduced multiplication of C. psittaci in the lungs of mice (Tab. III).