Microbial Isolate Among Women with Premature Rupture of Foetal Membranes and Pregnancy

Outcome in National Hospital Abuja.

Munirah Almustapha1, Shuaibu M Rais Ibraheem2, Korede Durojaiye2, Yakubu Samuel3.

1Department of Obstetrics and Gynaecology, Federal Medical Centre Abuja. 2. Department of Obstetrics and

Gynaecology, National Hospital Abuja. 3. IVF Unit, National Hospital Abuja

ABSTRACT

Correspondence

Munirah Almustapha,

Department of Obstetrics and

Gynaecology,

Federal Medical Centre Abuja

munirah.almustapha@yahoo.com

Background: Premature rupture of foetal membranes is a significant contributor

to perinatal morbidity and mortality, and in the tropics where there is lack of

facilities for neonatal intensive care unit, this poses a significant therapeutic

dilemma in current obstetrics practice. Aim: To determine the profile of

microorganisms, their antimicrobial sensitivity pattern, gestational age at delivery,

mode of delivery, cases of neonatal sepsis and cases of endometritis.

Methodology: A prospective study was conducted among pregnant women

presenting with premature rupture of foetal membranes at National Hospital

Abuja. The Participants were recruited consecutively and a structured interviewer

questionnaire was completed. Endocervical and high vaginal swab were collected

to isolate microorganisms and their sensitivity pattern was investigated, the

subjects were followed up till delivery and outcome of pregnancy was noted.

Results: A total of 101 cases of PROM were analysed, pathogens were isolated in

20.9% of cases. The common organisms isolated are Candida albicans (8.9%),

Staphylococcus aureus (5.0%) and Escherichia coli (3.0%). Most of the organisms

were sensitive to Ceftriaxone, Amoxyclav and Imepemen. Vaginal delivery was

the mode of delivery in 56.4% and 51.5% had preterm delivery. Neonatal sepsis

was seen in 3% of the new born and no cases of maternal endometritis were

recorded. Conclusion: It has been shown from this study that some pathogens are

associated with PROM. The study also found that Ceftriaxone and Imepenem were

the antibiotics with highest sensitivity. Therefore, Prophylactic use of antibiotic

should be based on demonstrated microbial pattern and their sensitivity. Further

research is needed to explore the association between PROM and Candida

albicans as the commonest organism seen.

Keywords: Microbial Isolate, Sensitivity, PROM, Microorganism.

INTRODUCTION

Intact foetal membranes with normal amniotic fluid

volume are necessary for normal foetal growth and

development. The membranes serve as a barrier that

separates the sterile foetal environment from the

bacteria colonised vagina.1 Premature rupture of

membranes (PROM) is defined as rupture of the foetal

membranes prior to onset of labour.1,2 Rupture of

membranes beyond 37th week is Term PROM and

when it occurs before 37 completed weeks is Preterm

PROM (PPROM). Rupture of membrane for more than

24hours before delivery is prolonged rupture of

membrane.2,3

Premature rupture of membranes complicates

10% of pregnancies. [4-6] Preterm PROM affect 2% of

pregnancies and is associated with 30 – 40% of preterm

delivery and is the leading cause of prematurity with its

associated consequences.4,7] It affects 120,000 - 150,000

pregnancies in the United States each year. 6,7 It has a

tremendous socio-economic impact in the society.1

Amustapha et al. Microbial Isolate Among Women with Premature Rupture of Foetal Membranes and Pregnancy Outcome

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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The aetiopathogenesis of PROM is complex and

multifactorial.1 A number of mechanism have been

proposed these include intrinsic membrane weakness,

mechanical stress, and ascending infection which is the

greatest risk factor.1,5,6 There is evidence demonstrating

an association between ascending infection from the

lower genital tract and PROM.8 It has been

demonstrated that bacterial product such as proteases

and phospholipases decrease the strength, elasticity of

the membrane and stimulate the release of

prostaglandins leading to preterm contractions.1,6

Infection also causes host immune response releasing

proinflammatory cytokines and mediators causing

weakening of the membranes by disrupting its

extracellular matrix and releasing metalloproteinase,

hence increasing the risk of PROM.1 Microbial

organism implicated in PROM are polymicrobial and

include Trichomonas vaginalis, Chlamydia

trachomatis, Neisseria gonorrhea, Group B

streptococci and those causing Bacteria vaginosis,

women infected with such organisms have an increased

risk of PPROM.1 Organisms isolated in some studies in

Nigeria include: staphylococcus auresu, Gardnerela

vaginalis, Candida, Strep. Pyogens among others. [5,9]

The diagnosis of PROM is made from patient

history which has a sensitivity of 90%, and is confirmed

by a sterile speculum examination to evaluate for

pooling of liquor in the posterior fornix of the vagina or

trickling of liquor from the cervix, some simple test may

be performed.1,3,6,8 The interval between rupture of

membranes and onset of labour is called latent period of

leaking, which is the key factor for determining

maternal and foetal outcomes.6

PROM is a significant risk factor for both

preterm birth, maternal and early neonatal sepsis.

Studies has shown that prompt laboratory screening for

infection and early institution of broad-spectrum

antibiotic significantly improved neonatal outcome, by

preventing infections, prolonging the latency period and

increasing gestational age at delivery, thereby reducing

the incidence of maternal and neonatal morbidity and

mortality. 6,8,10-12

Although several studies have been conducted

on microbial isolate and sensitivity pattern in women

with PROM in Nigeria where different microbial flora

and their sensitivity pattern were noted, but no study

was found from Nigeria in the course of literature

search, on microbial isolate before and 24 hours after

delivery, their sensitivity pattern and pregnancy

outcome. It is based on this background that this study

was designed to identify microbial isolate before and 24

hours after delivery, their antibiotic sensitivity pattern,

gestational age at delivery, mode of delivery, neonatal

outcome, cases of neonatal sepsis and cases of maternal

endometritis. Findings from this study will help

improve the clinical management of our patient.

The aim of this study was to determine the

profile of microorganisms among women with PROM

between gestational age of 28 weeks to 42 weeks at

National Hospital Abuja.

Objectives

1. To determine the microorganism isolates associated

with PROM and the antimicrobial susceptibility

pattern of microorganism(s) isolated

2. To determine microbiological isolate before and

24hours after delivery

3. To determine the gestational age at delivery, mode

of delivery and neonatal outcome

4. To determine if there are cases of neonatal sepsis

5. To determine if there are cases of endometritis

METHODS

The study was a prospective study conducted from 1st

October 2017 to 31st August 2018, in the Department of

Obstetrics and Gynaecology National Hospital Abuja

among pregnant women with PROM between 28 to 42

weeks of gestation, confirmed by sterile speculum

examination with absence of labour who consented to

participate. Those excluded include PROM on

antibiotic and who had previous digital examination

before presentation.

The minimum sample size was determined by

using the formula 13: n= z2pq/d2

Where:

n = minimum sample size required

z =z – score corresponding to desire confidence level at

95% (z=1.96)

p= estimated proportion of variable of interest in the

population = 6.8% [14] (i e 0.068)

d= tolerable margin of error or precision usually

expressed as a decimal, 0.05 for a 5% margin of error

q = 1 - p (proportion of population without the

characteristic)

For this study,

p= 0.068

d= 0.05

z= 1.96

q=1- 0.068 = 0.932

Sample size n = (1.96)2 x 0.068x 0.932/ 0.0025

n= 97.4 approximately 97 subjects.

Adjustment for expected response rate: to

accommodate for attrition, (with the anticipation of a

90% response rate), attrition rate = 100% - 90% = 10%,

therefore attrition rate is 10%= 0.10

The estimated adjusted sample size, n=n/1 – R=

n/1 – 0.10, Thus ns = 97/0.9=107.8 approximately 108

subjects.

Ethical approval was obtained from the National

Hospital Abuja Health research and ethic committee

with assigned number NHA/EC/007/2017.

Eligible women that presented to the labour ward

or Gynae emergency with PROM between 28 weeks to

42 weeks’ gestation were consecutively recruited into

the study until required sample size was obtained. At

recruitment informed consent was obtained from each

participant. A detailed history was obtained,

participants were physically examined and a sterile

Amustapha et al. Microbial Isolate Among Women with Premature Rupture of Foetal Membranes and Pregnancy Outcome

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

279

speculum examination was conducted to confirm

PROM (evidence by pooling of liquor in the posterior

fornix of the vagina or trickling from the cervical os).

Under aseptic condition a separate sterile swab stick

was used to collect from both the endocervical secretion

and high vagina, each swab was placed in the swab

container which was properly labelled with

identification number for each participant that is similar

with the labelling on data collection form to avoid cross

contamination and was immediately send to the

laboratory for analysis by the laboratory scientist

already pre informed.

A structured interviewer questionnaire was

completed for all the participants to obtain information

on their bio data and other information relevant for the

study. The participants were followed up till delivery.

Mode of delivery (vaginal or caesarean section), the

gestational age at delivery and neonatal outcome were

noted. Twenty-four hours after delivery a repeat

endocervical swab for microbiological study was taken

to determine organism before and after delivery(

participant were already counselled and pre informed at

recruitment), and the participants were assessed for

clinical feature of endometritis by temperature charts

monitoring for fever(T-38 degree Celsius and above),

abdominal examination for uterine tenderness and

abnormal foul-smelling lochia during their hospital

stay, educated before discharge on how to recognize

symptoms at home, and re assessed at the post-natal

clinic ( first visit , at 2 weeks post-partum). Before their

scheduled postpartum visit, the mothers were regularly

contacted via mobile phone by the principal investigator

to hear from them about their state of health. The

neonate after delivery were assessed together with the

neonatologist for features of neonatal sepsis using full

blood count and blood culture.

Specimen Processing

At the laboratory the registered sample were inoculated

on various media which include blood agar,

MacConkey agar, Chocolate agar, and Thayer Martins

media. These were incubated in air at 37oC for 24 – 48

hours. A wet preparation from the specimen was then

made by adding few drops of saline to each swab and

then put on a slide mount under microscope to examine

for the presence of trichomonas vaginalis trophozoites,

motile bacteria, Candida, epithelial cells and pus cells.

After 24-48hrs of inoculation the media plates were

observed for any growth and the morphology of the

bacteria described, a direct gram smear is made after

identifying the morphology and stained using crystal

violate, loguls iodine, acetone and safranin, the slides

are then viewed under microscope to identify the

organisms, these were further subjected to various

biochemical tests in order to identify the specific

bacteria isolated, using standard procedure and

algorithm,

The significant pathogen(s) identified were

further evaluated for antimicrobial susceptibility testing

using the kirby-Bauer method, these were then

interpreted using the interpretation chart and the

organisms were reported sensitive, intermediate and

resistant. The antibiotic used are: Ceftriaxone,

Erythromycin, Amoxiclav, Cotrimoxazole, Imipenem,

Ciprofloxacin, Gentamicin and Ampicillin.

The data obtained was imputed into an SPSS

computer statistical software version 23 and analysed

using same software. Categorical variables were

presented using proportion and percentage.

RESULTS

During the study period from 1st October 2017 to 31st

August 2018, 108 patients with premature rupture of

membranes were recruited. Of the 108, seven patients

were lost to follow-up and hence excluded from the

study. The analysis was based on 101 patients with

PROM.

Table 1. Socio-Demographic Characteristics of the

Study

Characteristics

Frequency

(n=101)

Percentage

(100%)

Age

20 – 24

25 – 29

30 – 34

35 – 39

40 – 44

≥ 45

6.9

28.7

43.6

16.8

3.0

1.0

Occupation

House wife

Student

Civil Servant

Business Woman

56.4

4.0

15.8

23.8

Educational

status

Primary

Secondary

Tertiary

1.0

35.6

63.4

Parity

Primigravida

Para 1

Para 2

Para 3

Para 4

39.6

22.8

27.7

5.9

4.0

Amustapha et al. Microbial Isolate Among Women with Premature Rupture of Foetal Membranes and Pregnancy Outcome

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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Table 1 shows the socio-demographic characteristics of

the study. The age range of the women was 20 to 45

years with mean age of 31.32± 4.77. majority are house

wives with tertiary level of education. Primigravida

account for 39.6%.

A total of 21 organisms were isolated from both

HVS and ECS. Candida albicans was isolated in 9

(8.9%) of cases, Staphylococcus aureus in 5 (5.0%) and

Escherichia coli in 3 (3.0%), Enterococcus spp,

Trichomonas vaginalis, streptococcus viridans and

providentia spp 1(1%) as shown in Table 2.

Eight antibiotics were tested against cultured

organisms. The drugs with highest sensitivity were

Ceftriaxone (81.8%), Imepenem (81.8%) and

Amoxyclav (72.7%). Those with least sensitivity are

Erythromycin (27.3%), Gentamicin (27.3%) and

Ampicillin (9.1%). All organisms are resistant to

Ciprofloxacin and Co-trimoxazole. Staphylococcus

aureus was 100% sensitive to Ceftriaxone and 60% to

Erythromycin, Amoxyclav and Imepenem. Escherichia

coli was 100% sensitive to Amoxyclav, Gentamicin and

Imepenem. While Enterococcus spp, Streptococcus

viridans and Provedentia are 100% sensitive to

Ceftriaxone, Amoxyclav and Imepenem as shown in

Table 3 below.

E. coli (Escherichia coli), Strept spp (Streptococcus

spp), Staph aureus (Staphylococcus aureus)

Majority of the patient had preterm delivery 54(56.4%).

High percentage occurred at estimated Gestational age

of 28-33 weeks. 91.1% of the cases presented with < 12-

hours onset of PROM (Table 4) and majority (55.4%)

had latency period of > 24 hours. Fifty-two of the

patients had spontaneous vaginal delivery accounting

for 51.5%, while 49(48.5%) delivered by caesarean

section.

Of the 101neonate delivered,56.4% were

delivered preterm and 52.5% had low birth weight.

33.6% had first minute Apgar score less than 7 and

51.55 were admitted into NICU and 6 neonatal deaths

Table 2. Microbial Isolate

Micro organism

HVS

N (10)

ECS

Before

Delivery

N (8)

ECS

After

Delivery

N (3)

Candida albicans

Staphylococcus

aureus

Escherichia coli

Enterococcus spp

Trichomonas

Vaginalis

Streptococcus

viridians

Providentia spp

7 (6.9)

2(2.0)

0(0)

1(1.0)

0(0)

1(1.0)

3(3.0)

2(2.0)

1(1.0)

0(0)

1(1.0)

0(0)

1(1.0)

0(0)

1(1.0)

0(0)

Table 3. Microbial Sensitivity Pattern

Drugs

Number Sensitive and Percentage

Staph

aureus

n =5

(%)

E. coli

n =3

(%)

Enterococcus

n = 1 (%)

Strept

spp

n = 1

(%)

Providencia

n = 1 (%)

Total

Number

11(100%)

Ceftriaxone

5(100)

(33.3)

1(100)

9(81.8)

Erythromycin.

3(60)

0(0)

3(27.3)

Amoxyclav

3(60)

3(100)

1(100)

0(0)

8(72.7)

Cotrimaxozole

0(0)

Imepenem

3(60)

3(100)

1(100)

9(81.8)

Ciprofloxacin

0(0)

Gentamicin

0(0)

3(100)

0(0)

3(27.3)

Ampicillin

0(0)

1(100)

0(0)

1(9.1)

Amustapha et al. Microbial Isolate Among Women with Premature Rupture of Foetal Membranes and Pregnancy Outcome

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

281

occurred. Only 3 neonate developed neonatal sepsis

(Table 4).

Table 4. Gestational Age at Delivery / Neonatal

Outcome

Variable

Frequency

Percentage

(%)

Gestational Age

(Weeks)

28 – 33

34 – 36

37 – 42

39.6

16.8

43.6

Duration of

PROM

< 12 hours

>12 hours

91.1

8.9

NEONATAL

OUTCOME

Prematurity

Low birthweight

Apgar score <7 in

1minute

NICU Admission

Death

Neonatal sepsis

56.4

52.5

33.6

51.5

5.9

3.0

DISCUSSION

In this study 21 organisms were isolated from both High

vaginal and Endocervical swab accounting for 20.9%

(9.9% from HVS and 11.0% from ECS) which is lower

compared to findings of 44.4% and 48.3% from

Nigeria,[9] and Togo 14 respectively.

The organisms isolated are Candida albicans

(8.9%), Staphylococcus aureus (5.0%), Escherichia coli

(3%), Trichomonas vaginalis (1%), Enterococcus spp

(1%), Streptococcus viridans (1%) and Providencia spp

(1%) in decreasing order. This study is similar to

findings of Gahwagi et al,16 were Candida albican was

the most frequent organism isolated followed by

Gardnerella vaginalis which was not isolated in this

study.This is comparable to the study findings of Karat

et al,17, Aboyeji et al,9 Gichuhi et al,18 Bharathi et al[19]

and Zeng et al,[20] although Aboyeji et al found

Gardneralla vaginalis as the most common organism

which was not isolated in this study, and Karat et al

found Staph aureus as the commonest organism

followed by E coli and Candida albican. Gichihi et al

found E. Coli as commonest organism also

Enterococcus spp, Trichomonas vaginalis and

Streptococcus viridian were isolated as found in this

study. It is not yet clear whether these organisms

isolated are direct causes of PROM or they are simply

incidental findings, however all the isolated organisms

were earlier documented as possible risk factors. 5,9,21

Candida albicans was the most common

organism isolated in the present study. The association

between the Candidiasis and rupture of membrane is

still unclear, however, there is evidence of release of

inflammation Cytokines during Candida infestation

which may cause membrane rapture.22

Staphylococcus aureus was isolated in this study

as seen in other studies. 5,9,17 Recent evidence implicated

Staph aureus as an emerging cause of chorioamnionitis

and premature rapture of membrane which are

associated with preterm birth and neonatal disease.23

According to the literature Staph aureus induced the

release of pro inflammatory Cytokines which promotes

neutrophils release of MMP that directly degrade

membrane component.23

Escherichia coli was found in 3% of the cases

and has been indicated in previous study to be capable

of penetrating intact foetal membranes causing intra

amniotic infection and subsequently rapture of

membrane.5 Other organisms that are implicated with

PROM such as Bactreriodes spp, Ureaplasma

urealyticum, Chlamydia among orders were not isolated

due to lack of specific culture for them.

Of the 11.0% organisms isolated from

endocervical swab, 8% were from ECS before delivery

(at presentation) and 3% from ECS 24-hours after

delivery as presented in Table 2 above. The 3 organisms

isolated 24 hours after delivery are E coli, Candida

albicans and Streptococcus viridans. Among the three

organisms isolated above, one patient has a positive

culture for E coli which was identical to the one isolated

before delivery in her ECS, this could be due to the

resistance of the organism to the prophylactic

antibiotic(erythromycin) prescribed on before delivery.

Although this assumption cannot be confirmed because

the serotype of the organism was not done. The

remaining two patients had sterile culture in their ECS

before delivery. The presence of these organisms

(Candida albicans and Streptococcus viridans) twenty-

four hours after they delivered in their ECS could be due

to contamination during vaginal birth.

The goal of antibiotic therapy is to reduce the

frequency of maternal and foetal infection and to

prolong the latency period.21 Among the eight

antibacterial agents tested, Ceftriaxone (81.8%) and

Imepenem (81.8%) shows highest sensitivity followed

by Amoxyclav (72.7%). While Erythromycin (27.3%),

Gentamicin (27.3%) and Ampicillin (9.1%) were least

sensitive. All these drugs are safe in pregnancy,

however Amoxyclav has been found to be associated

with Necrotizing enterocollitis so is not recommended

in PROM.11 Ciprofloxacin and Co-trimoxazole shows

100% resistance to the organisms isolated. This finding

is comparable to that of Eleje et al21 which found them

to be effective with Ampicillin-sulbactam as the most

effective among them. However, Ampicillin-sulbactam

was not among the drugs tested in this study. Also,

Adewumi et al24 found ceftriaxone, amoxiclav,

cefuroxime and ciprofloxacin to have highest sensitivity

in their study, but ciprofloxacin was shown in this study

to be resistant to all the organisms isolated and the drug

is not recommended to use in pregnancy.24

Amustapha et al. Microbial Isolate Among Women with Premature Rupture of Foetal Membranes and Pregnancy Outcome

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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All the organisms isolated from this study

shows100% sensitivity to Ceftriaxone except E coli

(33.3%). Also, Erythromycin shows 100% resistance to

all the organisms except Staph aureus that was 60%

sensitive. This is important because Erythromycin and

Ceftriaxone are the common antibiotic used in our

practice.

In the present study 56.4% of the patients

delivered preterm with highest percentage of 39.6%

occurring at gestational age between 28 – 33 weeks, this

is comparable to findings of Isaac et al (30-32 weeks).26

And most of the patients presented < 12-hour onset of

PROM and had latency period of >24-hours.

Spontaneous vaginal delivery was the mode of delivery

in 51.5% of the patients. This was similar to findings

from various studies, 25,26,27 because PROM alone is not

a contraindication to vaginal delivery. Those that had

caesarean section have other added obstetric

indications.

Total of 101 neonates were delivered during the

study period, 51.5% of them were admitted into

neonatal intensive care unit due to various indication

notably prematurity, low birth weight and birth

asphyxia. Only 3%of the neonate developed neonatal

sepsis this is similar to 2.9% finding of Shivaraju et al27

but lower than that of Isaac et al (10%).26 The study also

has no cases of endometritis during the puerperium

which is similar to the findings of Salou et al[14] this

could be due to the prophylactic antibiotic given to the

patients.

CONCLUSSION

Microbial organisms were isolated in 20.9% of the

patients, the common organisms are Candida albicans,

staphylococcus aureus and Escherichia coli.

Ceftriaxone, Imepenem and Amoxyclav are the most

sensitive antibiotics. Therefore, Prophylactic use of

antibiotic should be based on demonstrated microbial

pattern and their sensitivity, also periodic review of

these findings is necessary to look for emergence of

antibiotic resistance and abuse. There is also need to

further explore the association of candida with PROM

as the commonest organism isolated in the study.

Limitations

Some microorganism like Chlamydia tracomatis and

Mycoplasma spp could not be isolated due to lack of

facility for their identification.

Recommendation

In light of the above, the study would recommend the

following;

1. Ceftriaxone is recommended to be used in

combination with Erythromycin as prophylaxis for

PROM.

2. Routine endocervical swab should be taken in

patient with PROM.

3. Further research is needed to explore the association

of candida with PROM and other risk factors.

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Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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QUESTIONNAIRE

MICROBIAL ISOLATE AMONG WOMEN WITH PREMATUER RUPTURE OF FOETAL MEMBRANES

(PROM) AND PREGNANCY OUTCOME.

Dear Respondent,

This questionnaire on the above subject is for academic purpose, and also towards improving the management of

pregnancies. All information obtained will be kept confidential.

A. RESPONDENT’S SOCIO-DEMOGRAPHIC PROFILE

1. Serial No……………………………………..

2. Hospital No…………………………………

3. Age………………………………….

4. Occupation of patient……………………………..

5. Occupation of husband…………………………….

6. Educational Status of patient………………………

7. Educational status of husband…………………….

8. Address…………………………..

9. Tribe……………………………………

10. Religion…………………………………..

11. Gravidity………………………………….

12. Parity…………………………………….

13. LMP……………………………………..

14. EDD……………………………………

B. INDEX PREGNANCY:

15. Gestational Age……………………

16. Duration of rupture of membranes…

17. Any problem associated with the pregnancy e.g. vaginal bleeding, vaginal discharge, fever,

etc………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

…………………………………………

18. Were you given any antibiotic in the last 7 days?

Yes [ ] NO [ ]

C. OUTCOME

19. Gestational age at delivery………

20. Mode of delivery

a. vaginal delivery

b. caesarean section

21. Any symptoms and signs suggestive of clinical infection?

a. Maternal fever (temp. > 38oc) { }

b. Raised maternal pulse (>100bpm) { }

c. Abdominal tenderness { }

d. Foul smelling PV discharge { }

e. None of the above

22. foetal outcome

a. Birth weight…..

b. Apgar score….

c. Neonatal sepsis. Yes { }, No { }

d. Admission into NICU. Yes { }, No { }

23. maternal endometritis after delivery?

24. If yes specify……………….

25. Endocervical swab (before and after delivery) result………………

26. High vaginal swab result……………………

Thank you.