Spontaneous midgestation abortion associated with Bacteroides fragilis: a case report.

Abstract

A 31-year-old primigravida consulted her gynaecologist in the casualty department of a private hospital in Belgium (Imeldaziekenhuis Bonheiden) with intermittent contractions presenting as lower back pain, vague hypogastric cramps and vaginal discharge of blood and mucus. She was 19 weeks and 3 days pregnant according to dates of conception and an ultrasound at 7 weeks. Her medical history was unremarkable. Serology for CMV IgG, Hepatitis A IgG, Hepatitis B surface antigen and Hepatitis C IgG was negative and there was no immunity for Toxoplasmosis. Routine ultrasound at 18 weeks was unremarkable. A few days prior to her admission in the hospital she recalled vague flu-like symptoms and diarrhoea. Before these symptoms started she had eaten cheese, made with non-pasteurised milk. On admission she had no fever, her abdomen and uterus were soft, non-tender and adequately sized for 19 weeks gestation. A sterile speculum examination revealed bulging membranes and a bloody discharge. Fetal membranes were intact. An ultrasound showed an anatomically normal, very active fetus, with biometry compatible with 19 weeks gestation, normal amount of amniotic fluid, and normal placenta. On abdominal ultrasound the cervix appeared to be 3 cm dilated and fully effaced. The C-reactive protein (CRP) was normal (0.92 mg/dl) and the leucocytosis was up to 19300/ mm with 85% neutrofils. Urinary culture was negative. Based on the patient’s history, chorioamnionitis, possibly due to Listeria monocytogenes from the cheese, was assumed. Because of the infectious risk, the decision was made not to administer tocolysis, nor to perform a cervical cerclage. Amoxycillineclavulanic acid was administered IV 1 g every 6 hours. Despite this treatment the patient developed 38.48C fever and uterine contractions within 12 hours. The CRP had risen to 2.78 mg/dl with a leucocytosis of 20500/mm (80% neutrofil count). Vaginal GBS swab cultured on a GBS selective medium was negative and aerobe and anaerobe blood cultures remained negative as well. A male fetus with Apgar 0 was promptly delivered. Anatomopathological examination showed an immature placenta with intervillous microabcesses containing necrotic debris. The membranes showed severe signs of chorioamnionitis. The fetus showed no congenital abnormalities and no signs of pneumonitis. Cultures taken from the placenta and the fetus both showed infection with B. fragilis. The patient recovered quickly and was discharged from the hospital on day 4 on oral antibiotic treatment, without a fever.