Nutrition, genital tract infection, hematologic values, and premature rupture of membranes among African American Women.

Abstract

Using a prospective comparative design, African American gravidae with and without genital tract infection were assessed with respect to dietary intakes, serum nutrient values, hematologic values, and pregnancy outcomes. Intakes of ascorbic acid, vitamin A, protein, and iron were the dietary variables while levels of ascorbic acid, protein, albumin, globulin, and ferritin were the variables measured in serum. The hematologic variables included hemoglobin, hematocrit, and red and white blood cell counts. Pregnancy outcome was defined on the basis of premature rupture of the membranes (PROM), and infant birth weight, birth length, gestational age, and head circumference. The sample consisted of 335 nulliparous women who were between 16-35 years of age, 96 of whom had genital tract infection based on laboratory reports. Findings indicated no significant differences between the mean dietary intakes as well as serum values of the infected and non-infected women, and no difference in the incidence of PROM. However, non-infected women had a better mean hematologic profile than the infected gravidae during pregnancy. Also, for the non-infected group, there were significant relationships between head circumference and protein consumption (P = .015) and serum ferritin (P = .05). For the infected women, the relationship between the hemoglobin and hematocrit measurements obtained at the first prenatal visit and infant birth weight, birth length and head circumference were statistically significant.

Full text

Page 1

African AmericanWomen and Their Pregnancies
Nutrition, Genital Tract Infection, Hématologie Values, and
Premature Rupture of Membranes Among African
American Women1
OÃœIDAE. WESTNEY,2 LENNOX
ENID M. KNIGHT,**
HAZIELLARYEA,*i
HAZEL B. HIZA**
S. WESTNEY,* ALLAN
OYEMADE,
SPURLOCK,*î MALCOLM
SIDNEY JO/YESttt
A. JOHNSON**
COLE, t
MANNING,!*
H. EDWARDS**
URA JEAN
BERNICE
O. JACKSON
AND CECILE
Department
and ^Department
College of Allied Health Sciences;
ColumbiaGeneral Hospital and Howard
of HumanDeuelopment,
of Pharmacology,
School
College of Medicine;
*tNutrition
Uniuersity
of Education;*Department
**Department
of Obstetrics
of Nutritional
Uniuersity;
D.C. 20059
and Gynecology
Sciences,
tttD/sirici Program Project; ^Howard
Hospital,
of
Washington,
ABSTRACT using a prospective comparative design,
African American gravidae with and without genital
tract infection were assessed with respect to dietary
intakes, serum nutrient values, hématologie values, and
pregnancy outcomes. Intakes of ascorbic acid, vitamin
A, protein, and iron were the dietary variables while
levels of ascorbic acid, protein, albumin, globulin, and
ferritin were the variables measured in serum. The hé
matologie variables included hemoglobin, hematocrit,
and red and white bloodcellcounts. Pregnancy outcome
was defined on the basis of premature rupture of the
membranes (PROM), and infant birth weight, birth
length, gestational age, and head circumference. The
sample consisted of 335 nulliparous women who were
between 16-35 years of age, 96 of whom had genital
tract infection based on laboratory reports. Findings in
dicated no significant differences between the mean di
etary intakes as well as serum values of the infected
and non-infected women, and no difference in the inci
dence of PROM. However, non-infected women had a
better mean hématologie profile than the infected grav
idae during pregnancy. Also, forthe non-infected group,
there were significant relationships between head cir
cumference and protein consumption (P = .015) and
serum ferritin (P = .02). For the infected women, the
relationship between the hemoglobin and hematocrit
measurements obtained at the first prenatal visit and
infant birth weight, birth length and head circumference
were statistically significant. J. Nutr. 124:987S-993S,
1994.
INDEXING KEY WORDS:
• genital
• pregnancy
• prematurity
tract infection
• African American
•hématologie ualues
women
Genital
endocervix
During
a variety
or symptomatically
vaginalis,
cans are frequent
nant women. G. vaginalis
culturesof asymptomatic
1990) and almost in all women
initis. T. vaginalis
and 25% of pregnant
et al. 1985).
Organisms
symptomaticinfections
Neisseria gonorrhea, Chlamydia
albicans, Gardnerella
ginalis (Minkoff
is conflictingevidence
infections to premature
the membranes
tract infections
are common
the pregnant
of organisms
of the vagina,
problems
as well as the nonpregnant
may reside asymptomatically
in the genitaltract.
Trichomonasvaginalis,
residentsof the genital tract of preg
is present
women
cervix, and
pregnancy.during
state
Gardnerella
and Candidaalbi-
in 40% of vaginal
(Sweet and Gibbs
with nonspecific
aie present
respectively
vag-
and C. albicans
women,
in 20%
(Pritchard
thatarefrequently
include group B Streptococci,
trachomatis,
vaginalis,and Trichomonas
1983, Sweet and Gibbs 1990). There
regarding the linkage
labor, premature
(PROM), preterm
responsiblefor
Candida
va
of these
rupture
and low
of
delivery
1The investigations
the program
of Pregnancy,"
and Human
a grant in 1985 to the Department
School of Human
this supplement
Edwards, Department
HealthSciences,
Tapes of the data are available at cost by sending a written
to the Guest Editor at the above address. Supported by Grant 3 POI
HD17104-05,ENG, NICHO,NIH.
2Correspondenceshould be addressed to: 13601 Creekside Drive,
Silver Spring, Maryland20904.
reported in this paper were made as part of
project "Nutrition,Other Factors, and the Outcome
supportedby the National Institute
Development,National Institutes
of Human Nutrition
Ecology, HowardUniversity.
volume to The Journal of Nutrition
of Nutritional Sciences, College of Allied
Howard University,
of Child Health
of Health, through
and Food,
Guest Editor for
was Cecile H.
Washington,D.C. 20059.
request
0022-3166/94 $3.00 © 1994 American Institute of Nutrition.
987S
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988S
SUPPLEMENT
birth weight (Romero et al. 1989, Mason and Brown
1980, Skoll et al. 1989, Grave«1984).
When frequent resident organisms are localized in
the vagina and cervix there may be a tendency to view
them as not being significant threats to the outcome
of pregnancy. However, there is the possibility that
the organisms may ascend through the cervix and
weaken the fetal membranes, predisposing them to
premature rupture and leading to the early initiation
of labor (Main and Main 1986), prêteraidelivery, and
low birth weight infants.
In the United States the incidence of infant low
birth weight and infant mortality are comparatively
higher among African American women than among
white women. Also, the incidence of genital infection
in pregnancy is higher in the former group as compared
to the latter (Romero et al. 1988, Skoll et al. 1989).
Hence the problems of low birth weight, infant mor
tality, and infection are of special significance to Af
rican American pregnant women. Since genital infec
tion may be a factor in the premature initiation
labor, it is important that efforts be made to lessen or
attenuate such infections through a variety of modal
ities, including nutrition.
Given that organisms must be present in order to
initiate infection, that nutritional status is related to
the course and outcome of pregnancy (Abrams and
Laros 1986, Brown et al. 1981), and that the blood
reflects the nutritional aswell as the diseased condition
of individuals, some questions which were asked in
this study included: (1) Are there differential nutri
tional and hématologie conditions which accompany
the presence or absence of infection of the lower gen
ital tract during pregnancy? and (2) Are there signifi
cant relationshipsbetween selected nutritional
hématologie variables and pregnancy outcomes among
women with and without infection?
The purpose of this study was to determine whether
nutritional factors, specifically the dietary intakes of
ascorbic acid, vitamin A, iron and protein, and serum
levels of ascorbic acid, protein, albumin, globulin and
ferritin are related to the presence of genital tract in
fection and premature rupture of the membranes in
pregnant women. A concomitant purpose of the study
was to assess comparatively the whole blood levels of
hemoglobin, hematocrit, white and red blood cells, and
pregnancy outcomes among gravidae with and without
genital tract infection.
With respect to the variables in the study, all the
nutritionalindependent variables were selected be
cause they are known to play key roles in the health
of the mucous membranes and the functioning of the
immunesystem. Vitamin
maintenance of mucous membranes and epithelial tis
sues. A deficiency of Vitamin A in the body may result
in a diseased condition of the membranes lining the
genitourinarytract(Briggs and Galloway
Ascorbic acid functions in protecting the body against
of
and
A is essential for the
1979).
infection. Studies using guinea pigs have shown that
animals on limited ascorbic acid intake succumbed to
bacterial inoculations which had little or no effect on
animals that had received liberal amounts of this vi
tamin (Levenson et al. 1962). Iron is a component of
hemoglobin. Also, the body utilizes it in the synthesis
of some enzymes and it is needed for immune func
tions (Wardlaw and Insel 1990). Protein, a component
of each body cell, plays a vital role in the effective
functioning of the immune system (Wardlaw and Insel
1990, Chapel and Haeney 1988). Hématologie vari
ables in this study include red blood cell (RBC) and
white blood cell (WBC)counts, and hemoglobin (HG)
and hematocrit (HCT) levels. The dependent or out
come study variables include infant gestational age,
birth weight, birth length, and head circumference.
For the purpose of this study, premature rupture of
the membranes (PROM) was also considered as an
outcome variable.
It was hypothesizedthat: (1) infected gravidae
would report lower oral nutrient intakes of vitamin
A, ascorbic acid, protein, and iron than non-infected
pregnant women,- (2) the serum levels of infected
gravidae would contain lower levels of vitamin A,
ascorbic acid, protein, albumin, and globulin than non-
infected gravidae; (3) red blood cell counts and he
moglobin and hematocrit levels would be higher for
non-infected than infected gravidae, and white blood
cell counts would be higher for infected than non-in
fected gravidae; (4)the birth weight, birth length, head
circumference, and gestational age at birth of the in
fants of infected gravidae would be comparatively less
than that for the infants of non-infected gravidae, (5)
there would be a greater frequency of PROM among
the infected than the non-infected gravidae, and (6)
there would be significant relationships between the
outcome variables and the nutritional and hématologie
variables.
METHODS AMD MATERIALS
To accomplish the purpose of the study and test the
stated hypotheses a prospective comparative design
was utilized. The study was conducted on pregnant
women who were enrolled in the Nutrition Program
Project, a larger study investigating the influence of
nutritional, medical, and psychosocial factors on the
outcome of pregnancy. The sample used for this sub-
study consisted of 335 nulliparous African American
women between 16-35 years of age. All of the subjects
were screened to exclude patients with sickle cell dis
ease, thalassemia, hemoglobin C, and diabetes. All of
the women received prenatal care in a prenatal clinic
of Howard University Hospital, D. C. General Hos
pital, or the D. C. Department of Human Services.
Ninety-six or 28.7% of the women had genital tract
infections.Genital tract infection was determined
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NUTRITION AND GENITAL TRACT INFECTION
989S
based on the results of cervicovaginal cultures taken
by the obstetrician during the first prenatal visit. The
dietary data were collected via repeated, monthly
quantitative twenty-four hour food recalls. Intakes of
vitamin A, ascorbic acid, protein, and iron were cal
culated by computer using the Nutriplanner 6000 sys
tem (Practorcare Inc., San Diego, California).
Serum ascorbic acid, total protein, albumin, glob
ulin, and ferritin values as well as hemoglobin, he-
matocrit, and red and white blood cell counts were
obtained from blood samples collected during the first,
second, and third trimesters of pregnancy and at de
livery (seethe paper of Knight et al. in this publication
for a description of the procedures utilized). Pregnancy
outcome data on gestational age, birth weight, birth
length, and head circumference were obtained from
the records of the subjects. Data regarding premature
rupture of the membranes were obtained from the en
tries by the obstetricians on the delivery records (PO-
PRAS forms) of the mothers. Because many partici
pants entered into the health care system for maternity
care during the second trimester,
trimester were missing for a large percent of subjects.
Additionally, during the second and third trimesters,
due to missed visits or other conditions, data were not
obtained on some of the variables for a number of the
women. Consequently, this precluded some intended
analyses as well as the utilization of the findings from
analyses of some variables due to small sample sizes.
Student's t tests, chi squares, and Pearson's correla
tions were used to analyze the data. Data on genital
tract infections were coded dichotomously to indicate
whether the patient did or did not have genital tract
infection. Nutrient intake values as well as blood and
serum values were used in continuous form for î
and correlations. Continuous data were dichotomized
according to normal and abnormal values of the vari
ables for application of the chi square technique. Sig
nificance was established at the 0.05 level.
data for the first
tests
RESULTS
Socio-demographicdata
The mean age of both the infected and non-infected
subgroups was 21.3 years of age. Their mean annual
family incomes at $7,500 and $8,000, respectively,
were not significantly different. The modal educational
level for both groups was high school; however, the
non-infected participants were slightly more educated
than the infected. Thirty-three percent and 27.8% of
the infected group and the non-infected
spectively, were employed. (SeeTable 1)
group, re
Genital tract infection
Several organisms were identified in the cervico
vaginal smears of the infected women. Some women
TABLE 1
Sociodemographic characteristics
of African American women with genital infections
of the subset
CharacteristicsAge
(years)Mean
ageAge
rangeEducational
(%)Grammar
schoolSome
schoolHigh
schoolSome
onlyBaccalaureate
aboveHousehold
(%)Below
$5,000$5,000-10,999$11,000-20,999$21,000-30,999$31,000-40,999Employment
attainment
high
college
degree or
income (annual)
status(%)EmployedUnemployedGenital
infection
group121.317-23
years0.025.342.728.04.010.524.533.417.614
years0.527.144.322.23.6
infection
group221.316-35
1n = 96.
1n = 239.
were colonized concurrently with two or three types
of organisms. Organisms that were present and the
frequency of their occurrence were: Gardnerella
ginali«,50.0%; Beta Streptococci B, 43.7%; Candida
Albicans, 37.4%; Trichomonas vaginalis, 13.4%, Es-
cheria Coli, 6.2%. Due to the sample size, the infection
variable was not compartmentalized according to types
of organisms. Instead, the woman was classified as
having a genital tract infection if her cervicovaginal
cultures contained any disease-producing pathogens.
The results presented below show: (1)comparative
findings for the infected and non-infected women with
respect to nutrient intakes; serum levels of nutrients;
blood values relative to hemoglobin, hematocrit, and
red and white blood cells; newborn outcomes; and
premature rupture of the membranes (2)relationships
between the independent and outcome variables.
va
Comparison of nutrient intakes
Regarding nutrient intakes, mean twenty-four hour
food recall data for the period of pregnancy showed
that there were no significant differences
amounts of vitamin A, ascorbic acid, and protein con
sumed by the two groups of women during the course
of their pregnancy (Table 2). Their average intakes
of each of these nutrients represented more than 100
percent of the recommended dietary allowances (RDA)
for protein, ascorbic acid, and vitamin A. However,
the reported mean intake of iron for both groups was
in the
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990S
SUPPLEMENT
TABLE 2
Mean values foi selected daily nutrient intakes oÃ- infected
and non-infected pregnant African American women
Infected gravidae'
Non-infected
gravidae2
NutrientsDaily intake%RDADaily intake%RDA
Ascorbic acidVitamin
AIronProtein'n
= 61.2n=
177.169.8
mg7127
IU15.8
mg100.0
g24317853167155.8mg6449
IU15.4
mg98.2
g22316151164
less than the RDA for that nutrient (53% and 51% for
the infected and non-infected group, respectively).
Comparison of serum levels of nutrients
With respect to serum levels of nutrients, for both
groups of pregnant women, the mean values for ascor
bic acid, ferritin, protein, albumin, and globulin, for
the second and third trimesters of pregnancy, and at
delivery, were comparable (Table 3).
Comparison of hématologievariables
At the time of the admission of the women to the
Prenatal Clinic the mean hemoglobin and hematocrit
values for the non-infected women exceeded those of
the infected, but the difference was significant only
for the HCT (P = 0.04). For the second trimester and
at delivery measurements of hemoglobin, hematocrit,
and red and white blood cells for these two groups of
women showed no significant differences in the mean
values. However, third trimester
these variables indicated that the mean RBC count for
the non-infected group was significantly higher than
that of the infected group (P = .032). (Table 3)
Throughoutpregnancy, the mean white blood cell
counts for the infected women remained higher than
those for the non-infected women, though not at sta
tistically significant levels.
With regard to the occurrence of genital tract in
fection in women with normal versus abnormal hé
matologie values, the results of chi square tests showed
that genital tract infection was significantly associated
with abnormally low levels of RBC (<3.5 X IO6mm3)
during the third trimester of pregnancy and at delivery,
P = .008 and P = 0.018, respectively, and abnormally
high levels of WBC (>9.5 X 106/mm3), P = 0.005 (Ta
ble 4).
measurementsof
Comparison of pregnancy outcome measures
and PROM
The mean birth weight of the infants of the women
without infection was higher than that of the infants
of women with infection, but the difference did not
reach statistical significance (see Table 5). The mean
gestational age, birth length, and head circumference
measurementsof both groups did not differ statisti
cally. Chi square tests revealed no association between
genital tract infection and the occurrence of low birth
weight.
Regarding premature rupture of the membranes, no
significant difference existed in the comparative fre
quency of gravidae in both groups who experienced
PROM.
Relationships
outcome variables
between dietary and infant
We now turn to the analyses of the dietary variables
and the infant outcome variables for these groups of
women. For the infected group, no significant rela
tionships were observed for the mean daily nutrient
values for ascorbic acid, iron, vitamin A, and protein
and the infant outcome variables (gestational age, head
circumference, birth length, and birth weight). How
ever, for the non-infected group there was a significant
positive correlation of the mean protein intake and
head circumference (n = 122, r = 0.22, P = 0.015).
Relationships
outcome variables
among serum nutrients and infant
Regarding relationships
trients and the infant variables, for the infected group,
a significant positive correlation was present between
second trimester serum ascorbic acid and gestational
age, n = 22, r = .42, P = 0.05. For the non-infected
group, there was a significant relationship
serum ferritin levels and head circumference (n = 56,
r = .31, P = .02).
between the serum nu
between
Relationships
variables
among hématologieand infant
The relationships
ables, obtained at the first prenatal visit, and infant
outcome variables, are shown in Table 6. Significant
positive correlations were noted between the hemo
globin of infected gravidae and the infant variables of
birth weight, birth length, and head circumference,
and between maternal hematocrit
length and head circumference. These patterns of sig
nificant correlations were not present for the non-in
fected gravidae.
Forthe infected group there was a significant inverse
relationship between second trimester WBC count and
gestational age at birth (n = 22, r = -0.45, P = 0.04).
between the hématologievari
and infant birth
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NUTRITIONAND GENITAL TRACT INFECTION
ms
DISCUSSION
Causai foe organisms
among these gravidae
of genital tract infection
It is to be noted that the most frequent organisms
that were present in the cervicovaginal smears of these
infected women were Gardnerella vaginalis (50%)and
group BStreptococci (43.7%) rather than Candida al-
bicans and Trichomonas vaginalis. Group B Strepto
cocci have been implicated as causative factors in
PROM (Regan et al. 1981, Matorras et al. 1989) and
preterm delivery (Regan 1981, Gravet 1984). How
ever, in the Matorras and Coworkers study (1989) in
a sample of 1050 pregnant women there was no sig
nificant difference with respect to the presence of
group B Streptococci in the genital tract and the in
cidence of preterm delivery.
Research results regarding relationships
Gardnerella vaginalis colonization of the genital tract
and preterm delivery are duplicitous (Gravett 1984,
Minkoff 1983). However, it has been reported that
leukocytes found in the cervicovaginal exúdatefrom
Gardnerella-colonized pregnant women contain high
levels of phospholipase A2 which can stimulate pre
mature labor (Bejaret al. 1981, Gravett 1984).
between
The findings in our study that there were no sig
nificant differences among the infected and non-in
fected women with regard to PROM, birth weight,
and the gestational age of their infants may have been
due to the effectiveness of specific therapy which was
initiated as soon as the diagnoses of the infectious
agents were made. However, despite the treatment
programs, the mean WBC counts of the infected grav
idae continued to be higher than those of the non-
infected women throughout pregnancy and at delivery.
It may be that infection per se generated immuno-
suppression through this mode.
Dietary values and infant and PROM outcomes
For both groups of the women, the mean twenty-
four hour nutrient values as % RDA for vitamin A,
ascorbic acid and protein were more than 100% of the
RDA for these nutrients during pregnancy. On the
other hand, the mean daily intake of iron was consid
erably less than 100% of the RDA for iron during
pregnancy. No significant differences were observed
in the dietary intake of these nutrients between the
infected and non-infected gravidae during pregnancy.
The demographic data bear this out: similar mean ages,
incomes, and educational attainments.
TABLE 3
Biochemical parameters in serum of infected and non-infected gravidae during the second and
third trimesters of pregnancy and at delivery
Biochemical variableAscorbic
acid (mg/10Q mL}Ferritin
(ng/mL)Serum
Protein{ng/mL}Serum
Albumin(g/ÃŒOO mL}Serum
Globulin(g/100ml]Red
blood cells(lOVmm3)White
blood cells (Iff'/mm3)Hemoglobin
(g/100mL)Hematocrit
(%)Cravidae
statusInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedInfected
Non-InfectedSecond0.92
+ 0.07 (30)
1.07 ±0.06(70)25.07
± 3.70 (40)
¡83)6.95 31.40 ± 3.10
±0.14 (25)
6.97 ±0.13 (59)4.34
±0.12 (23)
4.31 ± 0.08 (60)2.71
±0.17(18)
2.60 ±0.12(45)3.87
+ 0.13(26)
3.79 ± 0.08 (65)5.96
+ 0.39(28)
5.12 + 0.28(64)11.66
+ 0.29(28)
11.64 + 0.13(68)33.65
+ 0.89 (30)
34.8.1 ± 0.46 (66)Trimesters/deliveryThird0.90
+ 0.07 (34)
0.92 +0.04(111)20.42
± 3.40 (34)
(118)7.22.09 ±1.80
16 ±0.25 (15)
6.91 ±0.10(17)4.53
±0.10 (12)
4.44 + 0.06(66)2.34
± 0.30 (9)
2.31 + 0.08(55)3.68
± 0.09' (24)
3.94 ± 0.06(64)5.49
± 0.58 (22)
4.78 +0.26(61)11.35
+ 0.34(24)
11.88 ±0.17(58)33.86
+ 1.05 (23)
36.00 ± 0.56 (60)Delivery0.86
± 0.06 (26)
0.99 + 0.07(65)26.79
± 3.10 (29)
(70)6.26.07 ± 2.40
39 ±0.22 (11)
6.54 ±0.13(33)4.25
±0.13 (16)
4.40 + 0.07(37)2.05
+ 0.15(8)
2.04 +0.15(24)4.02
+ 0.31 (10)
4.16 ±0.31 (19)5.97
+ 0.52(12)
4.89 ± 0.63 (20)11.78
±0.54 (15)
12.31±0.36(19)37.71
±1.64(13)
36.94± 1.54 (17)
All values are means + SEM. Numbers
* Significantly different from Non-infected
in parentheses
(P <.0.05)
representthe number of subjects.
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