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Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 540542

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Transactions of the Royal Society of


Tropical Medicine and Hygiene
journal homepage: http://www.elsevier.com/locate/trstmh

Short Communication

Outcomes of 19 pregnant women with brucellosis in Babol,


northern Iran
Mohammad Reza Hasanjani Roushan a, , Masomeh Baiani a , Nesa Asna b , Fiyyaz Saedi a
a
b

Infectious Diseases Research Center, Babol Medical University, Babol, 4717641367 Iran
Department of Gynecology, Rohani Teaching Hospital, Babol Medical University, Babol, Iran

a r t i c l e

i n f o

Article history:
Received 20 August 2010
Received in revised form 2 June 2011
Accepted 10 June 2011
Available online 13 July 2011
Keywords:
Brucellosis
Pregnancy
Abortion
Recurrent abortion
Treatment

a b s t r a c t
From April 2000 to March 2010, 19 pregnant women with brucellosis were evaluated,
treated and followed up. Ten (53%) pregnant women had spontaneous abortions. Six of
eleven (55%) women infected in the rst trimester had a spontaneous abortion. After
treatment, all subsequently became pregnant and gave birth to normal babies. Among 13
patients who received cotrimoxazole plus rifampin, only four (31%) aborted and nine mothers had normal term deliveries. Two patients with recurrent abortions had brucellosis and
became pregnant and gave birth after treatment. The brucellosis screening program for
pregnant women and those with spontaneous abortion is necessary in brucellosis endemic
regions.
2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd.
All rights reserved.

1. Introduction

2. Patient characteristics and methods

Brucellosis is an important health problem worldwide,


especially in Mediterranean and other developing countries. Transmission of brucellae from infected animals to
humans occurs either by occupational contact or consumption of contaminated dairy products.1 In females, abortion
has been reported mostly in the rst trimester.2,3 Brucella
infection during pregnancy may cause abortion, premature delivery, miscarriage and intrauterine infection and
intrauterine fetal death (IUFD) more frequently than other
bacterial infections.2,46 Incidence of brucellosis in pregnant women was reported to be between 1.3 and 12.2% in
endemic regions.5,7,8 Since limited papers with few cases of
brucellosis in pregnancy were reported in the medical literature, this study was conducted to evaluate the outcomes of
pregnant women with brucellosis in Babol, northern Iran.

From April 2000 to March 2010, we diagnosed 1245


patients with brucellosis of whom 19 were pregnant
women. The diagnoses were made using standard tube
agglutination (STA) titer 1/160 and 2-Mercaptoethanol
(2ME) titer 1/ 80 with compatible clinical ndings. Three
blood samples were obtained from each patient for culture. Patients clinical symptoms and signs were recorded.
After diagnosis, 13 patients were treated with cotrimoxazole plus rifampin for two months. Of six patients with
brucellosis after spontaneous abortion four received gentamicin for seven days and doxycycline for 45 days, one
received doxycycline plus rifampin for 45 days and one
received cotrimoxazole plus doxycycline for two months.
Dosage of cotrimoxazole was 8 mg/kg/day by component
of trimethoprim in three divided daily doses and dosage
of rifampin was 15 mg/kg/day once a day in the morning
before breakfast. Dosage of gentamicin was 5 mg/kg/day
and doxycycline was 100 mg twice a day.
All 19 patients were followed up every three months
for two years. Clinical signs and symptoms as well as
STA and 2ME tests and blood cultures were done to nd

Corresponding author. Tel.: +98 111 3234387; fax: +98 1112227667.


E-mail address: hagar2q@yahoo.ca (M.R.H. Roushan).

0035-9203/$ see front matter 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.trstmh.2011.06.003

M.R.H. Roushan et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 540542

541

Table 1
Clinical manifestations, STA or 2ME tests and outcome of pregnancy in 19 pregnant women with brucellosis
Case no.

Age

Weeks of
pregnancy

STA

2ME

Clinical signs and


symptoms

Treatment
regimen

Outcome of pregnancy

1
2
3
4
5
6
7
8

30
28
20
22
27
23
26
20

3
4
21
4
6
20
28
21

1/160
1/320
1/1280
1/320
1/320
1/640
1/320
1/640

1/80
1/160
1/640
1/160
1/80
1/160
1/80
1/160

Cotri/Rif
Cotri/Rif
Cotri/Rif
Doxy/Rif
Cotri/Doxy
Gen/Doxy
Cotr/Rif
Gen/Doxy

Term delivery
Term delivery
Term delivery
Spontaneous abortion
Spontaneous abortion
Spontaneous abortion
Term delivery
Spontaneous abortion

9
10

26
21

4
16

1/640
1/320

1/160
1/160

Gen/Doxy
Cotr/Rif

Spontaneous abortion
Term delivery

11
12
13

25
36
18

12
26
8

1/1280
1/1280
1/320

1/640
1/160
1/160

Cotr/Rif
Cotr/Rif
Cotr/Rif

Term delivery
Spontaneous abortion
Spontaneous abortion

14
15
16
17
18
19

30
21
23
21
30
28

12
25
7
8
12
20

1/2560
1/320
1/320
1/320
1/640
1/320

1/640
1/160
1/80
1/160
1/160
1/80

Back pain, sweating


Artheralgia, sweating
Sacralgia, artheralgia,
Fever, myalgia, sweating
weakness, sweating
Fever, back pain, rash
Sacralgia, sweating
Fever, back pain,
sweating
Fever, Artheralgia
Myalgia, back pain,
sweating
Arthralgia, sacralgia
Fever, sweating
Back pain, fever,
sweating
Fever, sweating
Fever, sweating
Right knee arthritis
Generalized pain
Myalgia, sweating
Generalized pain

Cotr/Rif
Gen/Doxy
Cotr/Rif
Cotr/Rif
Cotr/Rif
Cotr/Rif

Spontaneous abortion
Spontaneous abortion
Term delivery
Spontaneous abortion
Term delivery
Term delivery

STA: standard tube agglutination titer; 2ME: 2-Mercaptoethanol titer; Cotr: cotrimoxazole; Rif: rifampin; Doxy: doxycycline; Gen: gentamicin.

relapse cases. Data were collected and analyzed. Fishers


exact test was used to compare the rates of abortion
for patients with STA titers <1/640 and those with titers
1/640.

abortions. There was no signicant difference in abortion


rates seen in patients with STA <1/640 (45.5%) and those
with STA 1/640 (62.5%) (P = 0.46). Aborted materials were
not studied.

3. Results

4. Discussion

The mean age of these patients was 25 4.62 years. Brucellosis occurred in two (11%) patients during spring, seven
(37%) in summer, nine (47%) in autumn and one (5%) in
winter. Consumption of fresh cheese (12 cases) and animal husbandry (three cases) were the main risk factors for
brucellosis.
Brucella melitensis was isolated in blood cultures of four
patients (patients no. 6, 12, 15, 19). Repeated spontaneous abortions had been noted in two patients: patient
no. 2 had aborted twice and patient no. 5 four times;
in both patients subsequent pregnancies occurred 57
months after abortion. After successful treatment one
of them aborted again and the other had a normal
delivery. One year after treatment the patient who had
aborted became pregnant and subsequently had a normal
birth. Only ve patients were hospitalized due to vaginal bleeding and fever with brucellosis being diagnosed
as the cause; all spontaneously aborted (patients no. 4,
6, 8, 9 and 15). Active toxoplasmosis, cytomegalovirus
and listeria monocytogen infections were not detected
in patients who had spontaneously aborted; six to nine
months after successful treatment all became pregnant
again.
During treatment with cotrimoxazole plus rifampin in
13 cases, four (31%) spontaneously aborted and nine (69%)
mothers had term deliveries (Table 1). In total, ten (53%)
patients had spontaneous abortions and six (55%) of 11
patients infected in the rst trimester also had spontaneous

In this study 10 (53%) pregnant women with brucellosis had spontaneous abortions. The rate of abortion was
higher than that reported by Lulu et al.9 (31% of 35 patients)
and Khan et al.5 (46% of 92 patients) and was much higher
than that reported by Sharif et al.7 (18% of 30 patients) and
Elshamy and Ahmed (27% of 55 patients).8
Brucellosis causes fewer spontaneous abortions in
humans than in animals because of the absence of erythritol in the human placenta.4 In human maternal bactremia,
toxemia, acute febrile reaction, disseminated intravascular coagulation (DIC) and placentitis may be the cause
of spontaneous abortion and IUFD. In this study, 55% of
patients infected in the rst trimester had spontaneous
abortions and half aborted before treatment. Of the 13
patients who received cotrimoxazole plus rifampin, only
four (31%) aborted and nine (69%) had full term deliveries
(Table 1). Investigators have shown that prompt treatment
of brucellosis may cure the mother and protect the fetus.5,6
We did not nd any association between incidence of
spontaneous abortion and the magnitude of serum agglutination titer as showed by others.6 The weakness of this
study was the lack of isolation of brucella infection of fetus
and placenta. This issue is an important point and needs to
be investigated.
Interestingly, we observed two patients with recurrent
abortions most probably related to brucellosis; we believe
they had chronic brucellosis. Both became pregnant and
had normal deliveries after treatment. These observations

542

M.R.H. Roushan et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 540542

emphasize the need to perform brucella serologic tests during pregnancy in endemic regions.
In summary, the brucellosis screening program for pregnant women and spontaneous abortion cases is necessary
in endemic regions.
Authors contributions: MRHR conceived and designed
the study; MRHR and MB treated and followed up all the
patients; MRHR, MB and FS collected, analysed and interpreted the data; NA was the gynecologic consultant and
participated in the interpretation of the data; MRHR wrote
the draft of the paper which was revised by all authors;
MRHR wrote the nal version of the manuscript which was
read and approved by all authors. MRHR is guarantor of the
paper.
Funding: This work was supported by Infectious Diseases
Research Center of Babol Medical University, Babol, Iran
(GR015-1389).
Conicts of interest: None declared.

Ethical approval: Not required.


References
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1998;18:1969.
3. Seoud M, Saad G, Awar G, Uwaydah M. Brucellosis in pregnancy.
J Reprod Med 1991;36:4415.
4. Hackmon R, Bar-David J, Bashiri A, Mazor M. Brucellosis in pregnancy.
Harefuah 1998;135:37.
5. Khan MY, Mah MW, Memish ZA. Brucellosis in pregnant women. Clin
Infect Dis 2001;32:11727.
6. Kurdoglu M, Adali E, Kurdoglu Z, Karahocagil MK, Kolusari A,
Yildizhan R, et al. Brucellosis in pregnancy: a 6-year clinical analysis.
Arch Gynecol Obstet 2010;281:2016.
7. Sharif A, Reyes Z, Thomassen P. Screening for brucellosis in pregnant
women. J Trop Med Hyg 1990;93:423.
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outcome. J Infect Dev Ctries 2008;2:2304.
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Human brucellosis in Kuwait: a prospective study of 400 cases. Q J
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