Therapeutic apheresis for genital infections in obstetrics

Development of the fetus at risk of intrauterine infection in the presence of a pregnant syndrome hidden urogenital infections – chlamydia, mycoplasma, ureaplasma, toxoplasmosis, gardnerella infection, herpes viruses and cytomegalovirus lesions.

During the life of women before pregnancy, these infections may not cause significant illness and manifested by periodic exacerbations cystitis adneksitis, vaginitis. However, during pregnancy, the main danger is the fetus, causing defects and violations of its development up to the termination of pregnancy in the early stages (ie, in fact infertility), premature birth, and even fetal death. However, the born alive child has signs of intrauterine and postnatal infection (45%), morphological and functional immaturity and intrauterine growth retardation (18%), serious disorders of the brain (23%), liver, kidneys, lungs [3].

V.K.Chayka and T.N.Demina [4] emphasized that almost no patients with miscarriage, which would not have been the persistence of several viruses or combinations thereof, with intracellular infection or protozoa. On the other hand, I.B.Goda et al. [8] revealed inflammatory changes of placentas in 100% of patients and infections in 80% of stillborn fetuses, allowing the infectious factor considered the main cause of spontaneous abortion and stillbirth in terms of 22-27 weeks.

Consequences of these infections are also phenomena placentitis with hyalinosis and focal necrosis, impaired utero-placental circulation and fetal hypoxia. Exacerbation of pyelonephritis causes concomitant development of preeclampsia, which further exacerbates the adverse conditions for the development of the fetus.

The most common intrauterine infection is cytomegalovirus (CMV or herpes virus 5). CMV antibodies can be detected in 45-100% of the population. In this case, after the initial infection obligate formed lifelong persistence of CMV in the body. Immunodeficiency, including physiological immunosuppression during pregnancy, promotes the activation of CMV infection. Moreover, the infection in itself may contribute to immunosuppression. The frequency of intrauterine infection reaches 70%, while the risk of transmission of CMV to the fetus is 40-50%. When infection of the fetus in the early stages of its development it can occur deformities and even death of the fetus or newborn. However, the majority of infants with congenital infection, there are no symptoms, however later they may suffer from multiple complications, including atrophy of the optic nerve and sensorineural deafness and mental retardation, and even cerebral palsy [7].

Almost all women during pregnancy have anemia, and with CMV this disease is more pronounced. At the same time marked increase in the degree of aggregation of erythrocytes, worse gemoglobin-sinthesizing processes, changes in the structure and function of erythrocyte membranes. Accelerated aging of red blood cells and develops of their quality inferiority. [1]

Almost all women observed these or other pregnancy complications. At 48.1% diagnosed with threatened miscarriage, at 7.6% of installed non-developing pregnancy gestation 9 and 12 weeks, 24% of spontaneous abortions occurred in the timing of 14-27 weeks, 70.9% identified pathology of amniotic fluid, in 46.8% identified a syndrome of intrauterine growth retardation. In 44.4% of cases had premature labor and normal delivery occurred in only 5.5% of women with cytomegalovirus infection. Fetal loss occurred in 26.6% of women and 50% of healthy children at birth in the future are identified deafness and impaired mental and physical development. [6]

Also at high risk for micro- or hydrocephalus, cerebral palsy, delayed mental and psychomotor development, chorioretinitis and optic atrophy with vision loss including blindness [18]. In many cases, neurological symptoms seen neonatologists, however on closer examination can detect a decrease in muscle tone with symptoms of hyperkinetic facial muscles with prolonged retention of hyperkinetic syndrome [16].

Another dangerous genital herpes or herpes simplex virus (HSV), which affects up to 30 million adults in the United States, but in Moscow it is the rate of infection of 19.7% [19]. Herpes simplex virus type 2 (HSV-2) is transmitted through sexual contact. For genital herpes detected decrease total CD3+ and CD4+ cells, inhibition of the activity of natural killer cells and the ability of lymphocytes to the synthesis of endogenous interferon, reducing the total number of leukocytes and monocytes [21].

Genital herpes can lead to obstruction of fallopian tubes and infertility. When intrauterine infection of the fetus it is delayed its development with the emergence of micro- and hydrocephalus and intrauterine pneumonia. In the first half of pregnancy, the there are high risk of spontaneous abortion, and then – preterm birth [26]. HSV infection in 30-50% of cases determines the frequency of spontaneous abortion, non-developing ("non-viable") pregnancy, premature birth, perinatal morbidity and mortality [5].

In addition, chronic HSV infection promotes activation of autoimmune processes also, in particular of antiphospholipid syndrome (APS), which occurs in 20-51% of patients. In the mild cases the frequency of APS is up to 10% of cases, and in severe herpes infection it reaches 64.7% [14, 15], which largely determines the frequency and mechanisms of miscarriage.

The reasons for this activation of autoimmune processes are not entirely clear. Maybe they explain the increase in the release of cytokines in the areas of active inflammation caused by HSV infection. In particular proved the role of interleukin 10 (IL-10) in the overstimulation of B-lymphocytes with generation of alloimmune antiphospholipid antibodies. In addition, we can not exclude the phenomenon of molecular mimicry due to the proximity structure of virus and host antigens. In recent years, information on the role of vaccine therapy of herpes infection in the over-stimulation of antibody, the consequence of which is the development of autoimmune processes, such proximity is activated HSV and human antigens [4].

Epstein-Barr virus (EBV) also applies to herpes (herpes virus 4) and is no less dangerous, predisposing to premature termination of pregnancy, fetal malnutrition, while births causes damage to the nervous system (28%), eyes (7%), recurrent chronic sepsis (13%), hepatopathy and respiratory distress syndrome [4]. High probability of intrauterine infection of the fetus, which in later life may be the cause of chronic fatigue syndrome, prolonged subfebrile, lymphadenopathy, enlarged liver and spleen.

Parvovirus B19 is known as a cause of infectious erythema, mainly in children. However, from 30 to 60% of adults are seropositive against IgG to B19 virus, and from infected pregnant women, even in asymptomatic infection, in 16-25% of cases of fetal death occurs ("non-immunological" dropsy) [7].

Mycoplasma (M. hominis, Ureaplasma) – the smallest micro-organisms, which occupy an intermediate position between bacteria and viruses. They are the causes of spontaneous abortion and premature birth. Striking the eye mucosa, the respiratory tract, gastrointestinal tract and genital organs they cause neonatal pneumonia, meningitis, conjunctivitis, subcutaneous abscesses.

Chlamydia (Chl. Trachomatis) – penetrate into the cells, multiply them, and after their destruction infect neighboring cells. Chlamydia affects 5 million women in the United States and 10 million in Western Europe, including the youth contingent. Infection develops slowly and asymptomatic. In pregnant women it causes urethritis and cervicitis. Also it is the cause of polyhydramnios, placental insufficiency with developmental delay and fetal malnutrition, premature detachment of placenta, promotes miscarriages and premature birth, and postpartum in 4 times more likely to cause the development of endometritis [12, 22].

Chlamydia also induces autoimmune processes leading to spontaneous abortion in the early stages of embryo development [2]. Therefore, plasmapheresis is shown both during pregnancy and in pre gestation period. Thus O.I.Nemchenko et al. [22] after the completion of antibiotic therapy were recommended also a course of plasmapheresis in the near  menstrual cycle.

Toxoplasmosis is caused by protozoa and also accompanied by premature termination of pregnancy, and a high level of perinatal morbidity and mortality. This disease is also accompanied by autoimmunity and auto-aggressive syndrome, as well as secondary immunodeficiency. In the territories of Russia infestation of the population is 30-35%, and in St. Petersburg among persons under the age of 40 years infested 31.1%. Exacerbation of toxoplasmosis occurs with immunodeficiency, including also of pregnancy physiological immunosuppression.

When infestation of pregnant in the first trimester of pregnancy in 75% of fetuses it  may develop severe disease with the occurrence of encephalitis and hydrocephalus, followed by seizures and mental retardation. A significant proportion of these children die in the first year of life, and the survivors have severe disabling brain damage [14]. It should be emphasized that 83% of prenatally infected newborns detected implementation infectious-inflammatory process in the early neonatal period [23].

Practically there no any specific treatment of these infections are caused by various pathogens such as protozoa, fungi, bacteria, viruses, especially as they are generally found in association with each other, and often complete combination thereof. Long-term antibiotic treatment of chlamydia (tetracycline, doxycycline, minocycline, erythromycin, ofloxacin, etc) often lead to severe intestinal dysbiosis and revitalization of conditionally pathogenic flora with more intensified production of indole, skatole, hydrogen sulfide, which contributes to an even greater enhancement of endotoxemia [13].

Against the background of pregnancy such therapy is generally unacceptable. It should be borne in mind that any antibiotic represents a potential risk to the fetus, as tests of their embryotoxic or teratogenic effect in pregnant women nobody spent [4].
The main reason for the development and chronicity of these infections, in some way, even opportunistic, consider weakening the body's defenses of women due to past illnesses and various exogenous and endotoxemia social factors.

However, the appointment of immunomodulators and biogenic stimulants such as irrational use cytomedines (thymalin, timogena, Timoptin) poses a threat difficult controlled autoimmune processes due to excessive stimulation of T-lymphocytes, and the use of lipopolysaccharide (pirogenal, prodigiozan) stimulates B-cells with increased production of immunoglobulins and antibodies that can excite autoimmunity [13].

Therefore, the most pathogenetically grounded approach to the treatment of these chronic infections is therapeutic apheresis aimed at removing those pathological products that contributed to the secondary immunosuppression, as well as the quantum techniques immunostimulation (laser irradiation of bloodorhemo-phototherapy). It is necessary to force the body to fight back independently with these pathogens.

Thus, VA Dergunov et al. [11] reported the results of the use of plasmapheresis in the treatment of miscarriage caused by cytomegalovirus and herpes infection in 11 women, each of whom had at least 5 miscarriages. There were performed 3-4 operations plasmapheresis 6-8 weeks before of pregnancy and 1-2 weeks before the "critical period" for each of the women (previous miscarriages), total – up to 7-12 operations. As a result, none of the women had symptoms of preeclampsia and pregnancy all safely resolved in terms of 37-39 weeks of living infants. Positive results of the use of plasmapheresis in combination with laser irradiation of blood in the treatment of genital herpes and cytomegalovirus infection there were reported also by other authors [6, 9, 14, 24, 26, 27, 28].

In particular, O.I.Mihaylova et al. [20] for use in a randomized study of combinations of courses of plasmapheresis with blood ozonation reported a decrease in the rate of complications during the period of gestation by 1.8 times, the severity of infection by 2.5 times, preterm birth is 1.5 times, of severe forms of neonatal infection and  neonatal malnutrition 2.3 times. T.N.Demina et al. [10] recommend the use of plasmapheresis in combination with intravenous immunoglobulin, especially in cases of associated viral and bacterial infections.

When there is an associated vaginitis can be carried colpo-sorption, comprising administering to the vagina of the same enterosorbent polyphepane (lignosorba) as a tampon from a single layer of sterile gauze with 10-20 grams of the drug on the night. Such therapy after 3-4 days weakens vaginal discharges persistently troubled for several months and even years. Such vaginal sanitation creates the best conditions for subsequent childbirth.

More stable results give pair treatment – simultaneous plasmapheresis also for husband. In men, these manifestations of such chronic infections are quite scarce, although they may be accompanied by persistent chronic prostatitis. However, if do not block the source of receipt of pathogens, it is impossible to achieve a lasting effect in women [29].

Such complex therapeutic apheresis and immune stimulatory therapy before gestation provides the best for conceiving, and in some cases easier also conceiving itself  with infertility caused by, for example, chlamydia. During pregnancy, it provides the best conditions for the development of the fetus and prevents intrauterine infection. Just before birth there ensured prevention of infectious and inflammatory complications.

You can leave a message using the form below:
Thank you.

We will contact you soon!
Leave request for training by completing the form below:
Thank you.

We will contact you soon!