Prenatal detection and management challenges of a huge cystic hygroma of the neck in a resource-constraint setting: A case report.

INTRODUCTION AND IMPORTANCE: Cystic hygroma is a benign congenital malformation of lymphatic and blood vessels, with an incidence of 1 in 6000 live births. Most cases are associated with genetic syndromes and can compromise fetal viability. Due to its rarity, comprehensive data is limited, mainly relying on case reports. CASE PRESENTATION: A 21-year-old pregnant woman at 27 weeks' gestation presented to triage with abdominal pain. Abdominal ultrasound revealed a single living female fetus with an estimated fetal weight of 734 g and a complex cystic mass causing hyper-extension of the neck. The pregnancy was terminated given the poor prognosis. Histopathology of the mass confirmed it to be a cystic hygroma. CLINICAL DISCUSSION: In limited-resource settings, management of huge cystic hygromas often necessitates termination of pregnancy due to a lack of sufficient resources for complex interdisciplinary interventions for the mother and infant after birth. In such cases, focus should be shifted toward promoting shared decision-making and sensitive patient counseling. CONCLUSION: Cystic hygromas that are diagnosed prenatally generally have a poorer prognosis than those diagnosed after birth. The management of cystic hygramas, particularly those diagnosed prenatally, represents a persistent challenge in low-resourced settings. Counseling and treatment recommendations must be tailored based on tumor characteristics, the expected prognosis, and the feasibility of medical or surgical intervention in a given clinical environment.

A multidisciplinary approach to management of a non-traumatic subdural hematoma in the third trimester of pregnancy: A case report and review of literature.

Key Message: Although non-traumatic SDHs are uncommon during and immediately following pregnancy, management of these cases should be carried out by a multidisciplinary team, including obstetricians, pediatricians, neurosurgeons, and anesthesiologists. Abstract: Intracranial hemorrhage represents an uncommon but serious complication of pregnancy. Non-traumatic subdural hematomas (SDH) are uncommon during the prenatal period with limited literature about etiology and management. In this case report, the authors report on a patient with non-traumatic SDH in the third trimester of pregnancy. The patient is a 40-year-old G6P5L5 female at gestational age of 34 weeks and 5 days presenting with frontal headache, nausea, vomiting, and blurry vision. CT scan revealed an acute on chronic right subdural hematoma with midline shift and multiple herniations. An emergency cesarean section and right burr hole SDH evacuation were performed. Etiology of the SDH remains unknown. Although non-traumatic SDHs are uncommon during and immediately following pregnancy, health care providers should always consider this possibility if a patient presents with typical symptoms and signs. Management of these cases should be carried out by a multidisciplinary team, including obstetricians, pediatricians, neurosurgeons, and anesthesiologists to optimize maternal and fetal outcomes.

Knowledge on human papilloma virus and experience of getting positive results: a qualitative study among women in Kilimanjaro, Tanzania.

BACKGROUND: Human papilloma virus (HPV) is a sexually transmitted infection causing more than 80% of cervical cancers. WHO recommends using of sensitive screening methods like HPV-testing to timely prevent future morbidity and mortality from cervical cancer. Pilot studies have shown that HPV-testing is feasible and can be scaled in developing country like Tanzania. However, there is limited information on women understanding, reactions and psychological challenges following diagnosis of high risk HPV (HR-HPV). This study explored the knowledge of women on HPV and their experience after HPV positive results in Kilimanjaro, Tanzania. METHODS: The study was part of a larger study that assessed incidence and persistence of HR-HPV among women aged 18 years and above in Kilimanjaro. This was a cross sectional study conducted in Moshi municipal council among women who had HR-HPV positive results at enrollment. In-depth interviews were conducted with 13 randomly selected women who were attending for follow-up after enrollment. Interviews were conducted at the health facility and Atlas.ti.8 was used to analyze the data using thematic framework analysis. RESULTS: Women had knowledge on HPV infection but they had different reactions following receiving positive HPV results. Reaction toward the positive HPV results had two extremes; some women had psychological effect (hopeless, death sentence, having cancer, being shocked, failure to disclose and psychosexual effects) while others women explained positive results is good as they are identified earlier, will be followed up and it has made them plan to continue with cervical cancer screening in future. CONCLUSION: Women had knowledge on HPV, but positive results lead to negative and positive experiences by women. Clinicians and programs need to develop interventions and good strategies to minimize the psychological and social burden of testing positive for HPV.

Comparison of human papillomavirus-based cervical cancer screening strategies in Tanzania among women with and without HIV.

Cervical cancer is the most common female cancer in Eastern Africa, and the World Health Organization (WHO) recommends human papillomavirus (HPV)-based screening as a key element to eliminate the disease. In this cross-sectional study from Tanzania, we compared nine HPV-based cervical cancer screening strategies, including HPV testing at standard cut-off; HPV testing at increased viral load cut-offs; HPV testing with partial/extended genotyping, and HPV testing with visual inspection with acetic acid (VIA). We pooled data collected during 2008 to 2009 and 2015 to 2017 from 6851 women aged 25 to 65. Cervical cytology samples were HPV tested with Hybrid Capture 2, and HPV positive samples were genotyped with INNO-LiPA Extra II. Human immunodeficiency virus (HIV) testing and VIA were done according to local standards. We calculated sensitivity, specificity, positive and negative predictive value of screening strategies, with high-grade cytological lesions as reference, separately for women with and without HIV. HPV testing at standard cut-off (1.0 relative light units [RLU]) had highest sensitivity (HIV+: 97.8%; HIV-: 91.5%), but moderate specificity (HIV+: 68.1%; HIV-: 85.7%). Increasing the cut-off for HPV positivity to higher viral loads (5.0/10.0 RLU) increased specificity (HIV+: 74.2%-76.5%; HIV-: 89.5%-91.2%), with modest sensitivity reductions (HIV+: 91.3%-95.7%; HIV-: 83.5%-87.8%). Limiting test positivity to HPV types 16/18/31/33/35/45/52/58 improved specificity while maintaining high sensitivity (HIV+: 90.2%; HIV-: 81.1%). Triage with VIA and/or partial genotyping for HPV16/18 or HPV16/18/45 had low sensitivities (≤65%). In conclusion, HPV testing alone, or HPV testing with extended genotyping or increased viral load cut-offs, may improve cervical cancer screening in Sub-Saharan Africa.

Persistence and risk factors of high-risk human papillomavirus infection among HIV positive and HIV negative tanzanian women: a cohort study.

BACKGROUND: High-risk (HR) human papillomavirus (HPV) persistence is the most important risk factor for cervical cancer. We have assessed the type-specific HR HPV persistence among HIV positive and HIV negative Tanzanian women and factors associated with HR HPV persistence. METHODS: In a cohort study including 4080 Tanzanian women, 3074 attended follow-up examination (up to 32 months after enrollment). Cervical samples were obtained for liquid-based cytology and HPV DNA testing using Hybrid Capture 2 and Inno-Lipa Extra II. Information on lifestyle factors was collected through a personal interview. The probability of HR HPV persistence at a given time point since enrollment was estimated non-parametrically using the EMICM algorithm. RESULTS: Among the 462 women HR HPV positive at enrollment, 158 had at least one identical type detected at follow-up. The probability of persistence at 18 months after enrollment was 34.2 (95% CI 29.0-39.4). Stratifying by HIV status, the persistence probability was 42.9% (95% CI 33.5-51.9) among HIV positive, and 28.0% (95% CI 22.1-34.2) among HIV negative. Overall, HR HPV persistence was most common for HPV58, 35, 16, 31, and 52. Among HIV positive women it was HPV45, and HPV16, followed by HPV58 and HPV18, and among HIV negative women it was HPV31, HPV33 and HPV58. Risk factors associated with persistence of HR HPV were older age, longer interval between enrollment and follow-up, binge drinking, and HIV status. CONCLUSIONS: HR HPV persistence was common in Tanzania, and most common among HIV positive women. Overall, persistence was most frequent for HPV 58, 35, 16, 31 and 52. The nonavalent HPV vaccine should be considered.

The association between human papillomavirus and cervical high-grade cytology among HIV-positive and HIV-negative Tanzanian women: A cross-sectional study.

INTRODUCTION: Human papillomavirus (HPV) is the causative agent of precancerous lesions and cervical cancer, cervical cancer being the leading cause of deaths in Tanzanian women. Early detection and treatment of precancerous lesions are important in the prevention of cervical cancer cases. MATERIAL AND METHODS: We conducted a cross-sectional study among 3390 Tanzanian women aged 25-60 years. Information on lifestyle habits was collected, and women underwent gynecological examination with collection of cervical cells for conventional cytological and HPV testing. Blood samples were tested for HIV. The association between cervical high-grade cytology (HGC) and potential risk factors was examined using multivariable logistic regression adjusting for age and high-risk HPV (HR-HPV). RESULTS: The prevalence of HGC was 3.6% and of low-grade cytology was 8.3%. In women who were both HR-HPV-positive and HIV-positive, the prevalence of HGC was 28.3%. It increased by age and was 47% among women aged 50-60 years. Women, who had their sexual debut at age 9-15 years and 16-18 years, respectively, had 2.5 and 2.4 times increased odds of HGC compared with women whose sexual debut was at age 21 years and older. HIV-positive women had increased odds of HGC in comparison with HIV-negative women after adjustment for age (odds ratio [OR] 2.95, 95% CI 1.92-4.54). HR-HPV-positive women had nearly 100-fold increased odds of HGC compared with HR-HPV-negative women (OR 96.6, 95% CI 48.0-194), and this estimate was higher among HIV-positive women (OR 152.2, 95% CI 36.1-642.0). CONCLUSIONS: Increasing age, early age at first intercourse, HR-HPV, and HIV infections were associated with a substantially increased risk of HGC.

HPV types, cervical high-grade lesions and risk factors for oncogenic human papillomavirus infection among 3416 Tanzanian women.

OBJECTIVE: The objective of the present study was to assess the prevalence and type-specific distribution of cervical high-risk (HR) human papillomavirus (HPV) among women with normal and abnormal cytology, and to describe risk factors for HR HPV among HIV-positive and HIV-negative women in Tanzania. METHODOLOGY: A cross-sectional study was conducted in existing cervical cancer screening clinics in Kilimanjaro and Dar es Salaam. Cervical specimens were obtained from women aged 25-60 years. Samples were shipped to Denmark for cytological examination, and to Germany for HR HPV testing (using Hybrid Capture 2) and genotyping (using LiPaExtra). Risk factors associated with HPV were assessed by multivariable logistic regression analysis. RESULT: Altogether, 4080 women were recruited with 3416 women contributing data for the present paper, including 609 HIV-positive women and 2807 HIV-negative women. The overall HR HPV prevalence was 18.9%, whereas the HR HPV prevalence in women with high-grade squamous intraepithelial lesions (HSILs) was 92.7%. Among HPV-positive women with HSIL, HPV16 (32.5%) and HPV58 (19.3%) were the the most common types followed by HPV18 (16.7%) and HPV52 (16.7%). Factors associated with HR HPV included younger age, increasing number of partners and early age at first intercourse. Similar risk factors were found among HIV-positive and HIV-negative women. In addition, among HIV-positive women, those with CD4 counts <200 cells/mm3 had an increased risk of HR HPV (OR 2.2; 95% CI 1.2 to 4.8) compared with individuals with CD4 count ≥500 cells/mm3. CONCLUSION: Given the HPV distribution among Tanzanian women, the current HPV vaccination in Tanzania using quadrivalent vaccine may be considered replaced by the nonavalent vaccine in the future. In addition, appropriate antiretroviral treatment management including monitoring of viremia may decrease the burden of HR HPV in HIV-positive women.

Comprehensive Cervical Cancer Prevention in Tanzania (CONCEPT) study: Cohort profile.

PURPOSE: Cervical cancer is a major cause of death among women in Eastern Africa, and the distribution of human papillomavirus (HPV) according to HIV status is inadequately characterised in this region. In order to guide future cervical cancer preventive strategies that involve HPV testing, the Comprehensive Cervical Cancer Prevention in Tanzania (CONCEPT) study was established in 2015. The CONCEPT cohort aims to investigate the natural history of HPV and determine acquisition and persistence patterns of high-risk (HR) HPV among HIV-positive and HIV-negative women. Further, the influence of lifestyle and sexual/reproductive factors will be investigated. The main objective of this article is to describe how the CONCEPT cohort was established. PARTICIPANTS: Women aged 25-60 years were enrolled from cervical cancer screening clinics in Dar-es-Salaam and Moshi, Tanzania. Data were collected at baseline, at 14 months (first follow-up) and at 28 months (second follow-up). Biological samples included two cervical swabs for careHPV DNA testing, cytology, Hybrid Capture 2, genotyping and blood samples for HIV. Visual inspection with acetic acid was performed, and sociodemographic, lifestyle and sexual/reproductive characteristics were collected through a standardised questionnaire. FINDINGS TO DATE: 4043 women were included in the cohort from August 2015 to May 2017. At baseline, 696 (17.1%) women were HR HPV positive, and among these, 31.6% were HIV positive; 139 women (3.4%) had high-grade squamous intraepithelial lesions. 3074 women (81%) attended the first follow-up. The majority attended after receiving a phone call reminder (35%) or from home via self-samples (41%). At first follow-up, 438 (14.4%) were HR HPV positive and 30.4% of these were HIV positive. FUTURE PLANS: A second follow-up is underway (17 December 2018-October 2020). We plan to integrate our data with a previous cross-sectional HPV study from Tanzania to increase the power of our findings. Researchers interested in collaborating are welcomed, either by extracting data or jointly requesting further investigation from the cohort.

Gynecological hysterectomy in Northern Tanzania: a cross- sectional study on the outcomes and correlation between clinical and histological diagnoses.

BACKGROUND: Hysterectomy is one of the most common gynaecological procedures performed worldwide. The magnitude of the complications related to hysterectomy and their risk factors are bound to differ based on locations, availability of resources and level of surgical training. Documented complications rates and their correlates are reported from high income countries while data from low- and middle-income countries including Tanzania is scare. METHODS: This was a hospital based cross-sectional study conducted at a tertiary facility in northern Tanzania where 178 women who underwent elective gynecological hysterectomies in the department of obstetrics and gynecology within the study period were enrolled. Logistic regression was performed to determine the association between risk factors and occurrence of surgical complication where p-value of < 0.05 was considered statistically significant. The degree of correlation between pre-operative clinical and histological diagnosis was determined by kappa correlation test. RESULTS: A total of 75 (42%) of women had surgical complications within 10 days of surgery. Blood transfusion and intra-operative bleeding were the most common complications observed in 34 (19.1%) and 17 (9.6%) women respectively. Independent risk factors for complications included obesity (OR 3.9; 95% CI 1.44-10.46), previous abdominal operations (OR 8.44; 95% CI 2.52-28.26) and longer duration of operation (> 2 h) (OR 5.02; 95% CI 2.18-11.5). Both uterine fibroid and adenomyosis had good correlation of clinical and histological diagnosis (p-value < 0.001). CONCLUSION: Bleeding and blood transfusion were the most common complications observed in this study. Obesity, previous abdominal operation and prolonged duration of operation were the most significant risk factors for the complications. Local tailored interventions to reduce surgical complications of hysterectomy are thus pivotal. Clinicians in this locality should have resources at their disposal to enhance definitive diagnosis attainment before surgical interventions.