Pseudomembranous colitis, a complication of erythromycin and preterm prelabour rupture of membranes

Authors

  • V Arora,

    1. Department of Obstetrics and Gynaecology, Mid Cheshire Hospital NHS Trust, Leighton Hospital, Crewe, UK
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  • MJM Luckas

    Corresponding author
    1. Department of Obstetrics and Gynaecology, Mid Cheshire Hospital NHS Trust, Leighton Hospital, Crewe, UK
      Dr MJM Luckas, Department of Obstetrics and Gynaecology, Mid Cheshire Hospital NHS Trust, Leighton Hospital, Crewe, CW1 4QJ, UK. Email mulu1@luckas.plus.com
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Dr MJM Luckas, Department of Obstetrics and Gynaecology, Mid Cheshire Hospital NHS Trust, Leighton Hospital, Crewe, CW1 4QJ, UK. Email mulu1@luckas.plus.com

Case report

A 36-year-old primigravida, booked for low-risk antenatal care, sustained preterm prelabour rupture of membranes (pPROM) at 31 weeks and 5 days of gestation, the diagnosis being confirmed on speculum examination. Prior to this, her pregnancy was uneventful and there was no significant history of note. A full blood count (FBC), serum C reactive protein (CRP) and high vaginal swab were unremarkable. An ultrasound scan confirmed a breech presentation with apparent normal growth and anatomy and marked oligohydramnios.

The woman was commenced on oral erythromycin 250 mg qds and received two doses of betamethasone 12 mg intramuscularly 24 hours apart according to the departmental protocol. In view of the fetal presentation, the woman was admitted for conservative management. After careful counselling, a plan was made for caesarean delivery in the event of labour ensuing.

Three days later, the woman developed cramping abdominal pains, which settled over the course of a few hours. Clinical examination revealed a soft nontender abdomen and uterus. The woman was apyrexial and denied any change in the vaginal fluid loss. FBC and CRP were again normal and a cardiotocogram (CTG) was reassuring and failed to demonstrate any significant uterine activity.

On the following day, the woman complained of flu-like illness with rigors; however, her temperature was normal. Again, she complained of abdominal pain and a CTG showed a reassuring fetal heart rate but regular uterine activity. Accordingly, a sterile speculum was performed, which revealed a prolapsed cord. An emergency caesarean under general anaesthesia was performed prior to which the fetal heart rate remained reassuring. The operation was uneventful and no signs of overt chorioamnionitis was apparent at delivery. The woman received intravenous Augmentin of 1.2 g after clamping the cord. The baby, a boy weighing 1980 g, had Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. The baby was taken to special care unit for observation and started on prophylactic antibiotics because of history of prolonged rupture of membranes. Antibiotics were stopped in 48 hours after the blood cultures from the baby were reported negative for infection and a CRP was also reported as normal. The baby had problems with feeding, which were sorted out by end of first week, and developed physiological jaundice, which did not require any treatment. No ventilator support was required.

The woman's initial recovery was unremarkable and she remained apyrexial. However, after 24 hours, she developed fever, profuse watery diarrhoea and abdominal distension without tenderness. The woman became hypotensive and required aggressive fluid rehydration. Bowel sounds were present and the lochia was normal. A FBC demonstrated a haemoglobin of 10.4 gm% and a raised white cell count. An abdominal X-ray (1Fig. 1) showed multiple loops of bowel, and pelvic ultrasound examination failed to demonstrate any abnormality. A stool sample was sent for culture and virology and, on the advice of a microbiologist, she was commenced on intravenous ciprofloxacin 500 mg twice a day and metronidazole 500 mg three times a day.

Figure 1.

Plain abdominal X-ray showing dilated bowel loops.

At this stage, the woman disclosed that she had been passing green stools for 24 hours prior to delivery. The stool sample was therefore examined for Clostridium difficile toxin and this was reported as positive, and subsequent cultures also grew C. difficile. A diagnosis of pseudomembranous colitis was made and full barrier nursing was instituted. The intravenous antibiotics were stopped, oral metronidazole 400 mg three times a day was commenced and the woman received general supportive treatment in the form of continued intravenous fluids. Subsequently, she made an excellent recovery and was well enough to be discharged home on the ninth postoperative day. The baby well enough to be discharged with the mother and was reported as well on follow up.

Discussion

This case is aimed at raising awareness among obstetricians of the hazards of antibiotic therapy. To the best of our knowledge, this is the first case of pseudomembranous colitis in a pregnant woman following erythromycin use reported in the literature.

In 2001, the ORACLE trial1 demonstrated a significant prolongation of pregnancy, reduction in surfactant requirement and fewer positive blood cultures in neonates following antenatal erythromycin administration, and there was also a nonsignificant decrease in the maternal febrile morbidity and need for postpartum antibiotics. There were no reports of significant maternal adverse effects with the antibiotic therapy reported by ORACLE. Within 6 months of publication of the ORACLE trial, oral erythromycin was incorporated into the routine management of women with pPROM in 46% of 252 maternity units contacted by the investigators of the ORACLE trial.2 Erythromycin, a macrolide antibiotic, is known to be implicated in causing pseudomembranous colitis when prescribed for eradication of Helicobacter pylori.3 There has also been a renewed interest in its potential toxicities including pseudomembranous colitis, which are coming to light with increasing use.4

Pseudomembranous colitis has a mortality of approximately 4% in women requiring medical treatment but approaches 14% in those treated surgically.5 Women with pseudomembranous colitis usually present with profuse watery diarrhoea within 6 weeks of antibiotic therapy. Women may also present with signs and symptoms suggestive of an acute abdomen. They usually have severe abdominal pain, fever, leucocytosis and paralytic ileus. The gold standard for diagnosis of pseudomembranous colitis is the detection of C. difficile toxin in the stools, and commercially available enzyme immunoassay kits for detection of C. difficile toxin A and/or toxin B are available for rapid diagnosis; however, they lack sensitivity. Successful management of these patients therefore must include carrying a high index of suspicion especially because of varied presentations of the condition.3 Both oral metronidazole and vancomycin are effective therapies and any other antibiotics should be discontinued if possible. Attention should be paid to general supportive measure like intravenous hydration and potassium supplementation if complicated by paralytic ileus. Surgical intervention may be indicated for women with gross distension of caecum (>10 cm) for deflation to avert perforation and in patients unresponsive to medical treatment with evidence of systemic toxicity.5

Concerns have been raised by neonatalogists about increased usage of broad-spectrum antibiotics in pregnancy and emergence of erythromycin-resistant strains of Group B streptococcus, because of potential long-term adverse effects.6 It is important for obstetricians to also be aware of potential severe maternal adverse effects consequent to the use of erythromycin in this setting. Further risk benefit analysis is needed to establish which cases of pPROM should receive prophylactic erythromycin.

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