Friday 6th August: E coli

Back on June 9th I wrote a post ("Back in the Saddle") about our autopsy results and how I didn't want to talk about them. I am now feeling more comfortable with people knowing about it, but I am probably still not up for lots of questions about it. Here is a summary of the whole sordid affair.

Basically Salome died due to an E Coli infection. To the best of everyone's knowledge, she was doing OK until about 24 hours before the birth. Then an E Coli infection made it into her bloodstream and she started to decline. The neonatologist estimates that the meconium came into the waters in the last 24 hours before birth, after she was already sick. Then she became distressed in the final stages of the labour, and inhaled the meconium. Then the umbilical cord got compressed in the final stages of the labour as well, which lead to more oxygen deprivation. Apart from the meconium and the perinatal asphyxia she was already sick with an infection. They instigated the treatment for meconium aspiration syndrome, but she didn't respond as they thought she should and that was due to the E Coli infection. That is why Salome did better on day 1 than on day 2, when the NICU team had predicted the reverse.

How often does this happen? I have found it hard to get an idea of how often this happens. In reply to my question about this, the neonatologist wrote: "early onset sepsis (that's the medical classification) happens 3-6/ per 1000 live births, with about 33% of them being E Coli. It is almost never related to what you have eaten. I'm sure that's not the cause." (Note that he wasn't saying that 3 to 6 of every 1000 babies die of early onset sepsis, just that that's how often early onset sepsis occurs). My obstetrician, who is very experienced, says Salome was only the second case she had come across in her career.

How did E Coli get to Salome? We will never know. The most common reason given in this situation is that the E Coli infection got into Salome's system via an 'ascending mechanism', which I am told means bacteria making it from the bowel to the vagina and up into the uterus once the cervical plug has started to come away in the last few days of the pregnancy. However, see the publication below that suggests this may not be the case as often as has previously proposed.

Does this mean I have E Coli? I think it means I did have E Coli. I did not have any noticeable stomach upsets in the last week or so before Salome's birth. It would have been hard for me to notice if I was sick with an E Coli infection. Firstly, I had already been nauseous every day for 9 months. Secondly Salome's birth was preceded by 10 days of pre-labour, which meant diarrhea was happening on each of those days. Thirdly, this occurred in the last week of January, so the weather was stinking hot. Would I have noticed if I had had a temperature? But we went to the delivery suite 3 times over those 10 days and they took my temp every time and nothing came up. I don't think I had a bacterial infection in late January, and both neonatologist and obstetrician has stressed to me that I don't need to have been sick at all for me to have passed the virus on to Salome.

Could Salome's death have been avoided? It is impossible to say. There seems to have been little or no indication along the way that anything was amiss. It may be that she had the E Coli in her system for a quite a while. I've been told it was probably in her blood stream for about 24 hours before her birth, but she could have been exposed to the E Coli for a lot longer than that. If we had somehow known she was sick and cesared (sic) on that day, Salome would probably have died anyway due to the E Coli. As soon as Salome's initial bloods came back, they knew there was something else going on with her apart from meconium aspiration syndrome, so the NICU team were already hitting her with every drug under the sun, including antibiotics. I guess the main causal factor is that E Coli. Could I have avoided the E Coli? Why did I have E Coli in my system? It is hard to remember what I ate in that last few weeks of the pregnancy, but I can't remember eating anything that was an obvious E Coli risk like salami, cooked chicken. But saying that I can't be sure.... Maybe I got cocky. Maybe I thought what harm can this food to my big strapping full term baby? I honestly can't remember. Or maybe I don't want to remember because the guilt and shame would be unbearable. If that's the case, lets let sleeping dogs lie. Seems to me E Coli can be passed on by a huge range of foods, and there are a lot of E Coli infections out there. I don't understand and I don't think I want to understand. It's too painful. Here's what else the neonatologist said in response to my question about why I can't just take antibiotics to rid myself of e coli: "...The infection only occurs at the end of the pregnancy (and will result in labour). Over half the mothers who delivered a baby with early onset sepsis did receive antibiotics during labour, even the sort which would kill E Coli. This means antibiotics is not always the answer...."

What does this mean for possible future pregnancies? So it is not possible to flush out E Coli from my system by taking a truck load of mega strength antibiotics. Apparently I now have what is not referred to as a 'colonised uterus'. If we did want to try for another pregnancy, I would first have a vaginal swab and get that analysed. Any current E Coli would be treated with antibiotics before we started trying to get pregnant again. Then I would have regular vaginal swabs through the pregnancy and I would be expecting to take some antibiotics through the pregnancy depending on what showed up on the swabs. I would then expect to have a Cesarean at about 37 weeks, after maybe spending the previous night in hospital on a drip having antibiotics flushed through my system and the baby's system before the baby was born. My obstetrician says that if we follow this plan, the chances of this happening again with another pregnancy are "low to very low". Not entirely comforting, I'm sure you'd agree.

Please find below a publication related to this topic. I am sorry I don't know where it is from but it has some references at the bottom. Whenever I read it my heart breaks for that poor pregnant woman and her annoying gingivitis. Then I think "But that happened to me too. That happened to my daughter and my family and my household." And my heart breaks all over again.

If I was the arty type I would choreograph a dance to communicate what I feel about this. It would include a lot of rolling on the floor, rocking, tearing of clothes, some wailing as well. I would call it '"colonised uterus". Maybe the soundtrack would be something / anything by Anour Brahem. I listened to an Anour Brahem album over and over as I laboured with Salome, and I am trying to claim his beautiful music back from those associations.

http://www.youtube.com/watch?v=ff_qwu57hok&feature=related

SUMMARY

Normal vaginal bacteria in pregnant, healthy women includes Escherichia coli (Hillier et al. 1993, pg. S276, Table 1). The standard way to identify bacteria is by taking a sample and culturing them in the laboratory (Han et al. 2009, pg. 38). But this can only identify less than 1% of bacteria, because most bacteria is not currently cultivatable in standard laboratories using current techniques and protocols (Han et al. 2009, pg. 38). Researchers are starting to use DNA technologies (in particular, identifying the exact sequence of the bacterial gene known as 16S rRNA, using the DNA identification technique known as PCR (Han et al. 2009; Han et al. 2010)) to more accurately identify vaginal bacteria and bacteria causing infections.

Bacterial infection in the uterus has long been known to play a role in spontaneous preterm birth (Han et al. 2009, pg. 38). Where do these bacteria come from and how do they get into the uterus? The current theory that we have for the last 20 years and perhaps longer, is that the bacteria originate in the lower genital tract, and invade the pregnant uterus via an ascending mechanism (Han et al. 2009, pg. 38). Another way that bacteria is thought to reach the uterus is via the blood stream, originating in parts of the body that are not involved with the reproductive system (Han et al. 2009, pg. 38). Han et al. 2010 report a case where a pregnant women’s baby died in utero on the day the baby was born, from a normal bacteria found in her mouth and not found at all in her vagina or rectum. It appears that the annoying pregnancy gingivitis that caused her bleeding gums during her pregnancy, plus a mild cold and temperature in the 3 days before giving birth, conspired to give the gingivitis bacterium a very small window of opportunity to reach the placenta via the blood stream, while the mother’s immune system was busy efficiently clearing the cold infection. Once the infection reached the placenta, there are no defenses against it. The mother’s immune system treats the placenta as a privileged foreign body and does not attack anything there, and so bacteria that infects the placenta then infects the baby.

Researchers are starting to suggest using the new DNA identification techniques to identify bacterial infection, so as to identify when and what specific antibiotics to use in pregnant women (Han et al. 2009, pg. 46). These recommendations will probably be carried out in scientific studies in the next few years, and if the results show that such strategies of bacterial screening and identification reduce the loss of babies in pregnant women that is currently caused by bacterial infection, then such strategies will probably be implemented as standard care for all pregnant women.

REFERENCES
Hillier S, Krohn MA, Rabe LK, Klebanoff SJ, Eschenbach A (1993) The normal vaginal flora, H2O2-producing lactobacilli, and bacterial vaginosis in pregnant women. Clinical Infectious Diseases, 16, S273-S281.

Han YW, Shen T, Chung P, Buhimschi IA, Buhimschi CS (2009) Uncultivated bacteria as etiologic agents of intra-amniotic inflammation leading to preterm birth. Journal of Clinical Microbiology, 47, 38-47.

Han YW, Fardini Y, Chen C, Iacampo KG, Peraino VA, Shamonki JM, Redline RW (2010) Term stillbirth caused by oral fusobacterium nucleatum. Obstetrics and Gynecology, 115, 442-445.