Managing a live advanced abdominal twin pregnancy.

Advanced abdominal pregnancies with live twin fetuses are extremely rare and are misdiagnosed in up to 60% of the cases. Such a case is presented here, highlighting the diagnostic and management challenges encountered. A high index of suspicion in making the diagnosis of this rare variety of ectopic pregnancy, emphasizing adherence to basic imaging principles, and appropriate placental management is very important in reducing the associated morbidity and mortality.

Genito-urinary fistula patients at Bugando Medical Centre.

BACKGROUND: Information was collected on 1500 obstetric fistula patients attending Bugando Medical Centre (BMC) in Mwanza, Tanzania. OBJECTIVES: To identify high risk populations of fistula patients treated from 1998-2006. DESIGN: A prospective description study of 1294 patients treated for urine and faecal incontinence at BMC. SETTING: Obstetrics and Gynaecological ward at Bugando Medical Centre. INTERVENTIONS: A total of 1294 patients underwent surgical treatment of incontinence. MAIN OUTCOME MEASURES: Of the 1294 surgical repairs, 84% of the patients were cured, 12% had stress incontinence and 4% failed. CONCLUSIONS: The study shows that low education and poverty were the key factors in the development of fistula. Most obstetric fistulae can be cured, particularly during the first attempt by those properly trained in the skills. Prevention of genital fistula requires raising the education and social status of women including poverty reduction strategies, improving the quality of antenatal care. Increased access to Caesarean section is also needed for prevention of genitourinary fistulas.

Prevalence of urinary tract infection among pregnant women at Bugando Medical Centre, Mwanza, Tanzania.

Urinary tract infections (UTI) are the most common bacterial infections during pregnancy and these infections. Untreated UTI can be associated with serious obstetric complications. This cross-sectional study was carried out to determine the prevalence of UTI among symptomatic and asymptomatic pregnant women attending Bugando Medical centre (BMC) in Mwanza, Tanzania. A total of 247 pregnant women were enrolled, of these 78 (31.5%) were symptomatic and 169 (68.4%) asymptomatic. UTI was diagnosed using mid stream urine (MSU) culture on standard culture media and urinalysis was done using rapid dip stick. The prevalence of bacteriuria among symptomatic and asymptomatic pregnant women were 17.9% and 13.0% respectively, with no significant difference between the two groups (p = 0.307). Using univariate analysis there was no association of parity (p = 0.825), gestational age (p = 0.173), education (p = 0.615), age (p = 0.211) and marital status (p = 0.949) with bacteriuria. The sensitivity and specificity of urine dipstick was 38.9% and 86.7% respectively. Escherichia coli (47.2%) and Enterococcus spp (22.2%) were the most commonly recovered pathogens. The rate of resistance of Escherichia coli to ampicillin, tetracycline, sulfamethaxazole/trimethoprim, gentamicin, ciprofloxacin, nitrofurantoin, ceftriaxone, and imipenem were 53%, 58.8%, 64.7%, 5.9%, 11.8%, 5.9%, 29.4% and 0%, respectively. In conclusion, asymptomatic bacteriuria among pregnant women is prevalent in our setting and majority of Escherichia coli are resistant to ampicillin, tetracycline, SXT and ceftriaxone. Due to low sensitivity of rapid dip stick, routine urine culture and susceptibility testing is recommended to all pregnant women at booking.

Is antenatal syphilis screening still cost effective in sub-Saharan Africa.

OBJECTIVES: To estimate the cost effectiveness of on-site antenatal syphilis screening and treatment in Mwanza, Tanzania. To compare this intervention with other antenatal and child health interventions, specifically the prevention of mother to child transmission of HIV (PMTCT). METHODS: The economic costs of adding the intervention to routine antenatal care were assessed. Cost effectiveness (CE) ratios of the intervention were obtained for low birth weight (LBW) live births and stillbirths averted and cost per DALY saved. Cost per DALY saved was also estimated for previous CE studies of syphilis screening. The CE of the intervention at different syphilis prevalence rates was modelled. RESULTS: The economic cost of the intervention is $1.44 per woman screened, $20 per woman treated, and $187 per adverse birth outcome averted. The cost per DALY saved is $110 with LBW as the only adverse outcome. When including stillbirth, this estimate improves 10-fold to $10.56 per DALY saved. The cost per DALY saved from all syphilis screening studies ranged from $3.97 to $18.73. CONCLUSIONS: Syphilis screening is shown to be at least as cost effective as PMTCT and more cost effective than many widely implemented interventions. There is urgent need for scaling up syphilis screening and treatment in high prevalence areas. The CE of screening interventions is highly dependent on disease prevalence. In combination, PMTCT and syphilis screening and treatment interventions may achieve economies of scope and thus improved efficiency.

Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania.

OBJECTIVE: To evaluate the effect of introduction of treatment and sterilization guidelines on the number of avoidable injections and on the sterility of needles and syringes. METHODS: In 1991, 66 randomly selected health units in Mwanza Region, Tanzania, were visited and factors were determined that might contribute to HIV transmission by injections. In a workshop with all senior health workers from the region, findings were presented and treatment and sterilization guidelines developed. Thereafter, seminars were held at each health centre of the region. Four months after the intervention, data were collected at the same health facilities in order to assess changes in prescribing practices, sterilization procedures, and sterility of needles and syringes. RESULTS: The knowledge on indications for injections improved markedly for paramedical staff. The proportion of outpatients receiving an injection dropped from 23% to 10% and the proportion of patients receiving an avoidable injection dropped from 16% to 6%. Procedures for sterilization, keeping sterilized equipment, and administration of injections improved. A smaller proportion of sterilized needles and syringes tended to be contaminated in dispensaries, but this reduction from 44% to 22% was not significant. CONCLUSION: Considerable improvement in knowledge, prescription practices and sterility procedures was observed at dispensary level after carrying out a training programme.

HIV infection and sexual behaviour among women with infertility in Tanzania: a hospital-based study.

BACKGROUND: Infertility is common in Africa, but virtually no data exist on HIV prevalence among infertile women. Mainly anthropological studies in Africa have shown that infertile women have higher risks of marital instability and possibly also have more sexual partners than fertile women. METHOD: This study was conducted in a hospital in northwest Tanzania during 1994 and 1995. Women presenting themselves with infertility problems to the outpatient clinic were interviewed, examined and blood was drawn. Women who came to deliver in the hospital, excluding primiparae, were taken as a control group. The analysis was limited to women > or = 24 years. In total 154 infertile and 259 fertile women were included in the study. RESULTS: HIV prevalence was markedly higher among infertile women than among fertile women: 18.2% and 6.6% respectively (adjusted odds ratio [OR] for age, residence and occupation 2.7; 95%-confidence interval [CI]: 1.4-5.3). Data on past sexual behaviour showed that infertile women had more marital breakdowns, more lifetime sexual partners and a higher level of exposure to sexually transmitted diseases (STD). CONCLUSION: Women with fertility problems appear to have higher HIV prevalence, which justifies more attention for such women in the context of AIDS programmes. In addition, caution is needed when using sentinel surveillance data from antenatal clinics to monitor HIV prevalence.

PIP: Infertility is common in Africa. Anthropological studies conducted on the continent have found infertile women to have higher risks of marital instability and possibly more sex partners than fertile women. Findings are reported from a study conducted during 1994 and 1995 in a hospital in northwest Tanzania to determine the prevalence of HIV infection among infertile women. Women presenting with infertility problems to the outpatient clinic were interviewed, examined, and blood was drawn. Women who came to deliver in the hospital, excluding primiparae, comprised the control group. A total of 154 infertile and 259 fertile women were included in the study, all age 24 years and older. 18.2% of infertile women and 6.6% of fertile women were infected with HIV. Data on past sex behavior indicated that infertile women had more marital breakdowns, more lifetime sex partners, and a higher level of exposure to sexually transmitted diseases.

Occupational exposure to the risk of HIV infection among health care workers in Mwanza Region, United Republic of Tanzania.

During 1993, we collected data on knowledge of human immunodeficiency virus (HIV) transmission, availability of equipment, protective practices and the occurrence of prick and splash incidents in nine hospitals in the Mwanza Region in the north-west of the United Republic of Tanzania. Such incidents were common, with the average health worker being pricked five times and being splashed nine times per year. The annual occupational risk of HIV transmission was estimated at 0.27% for health workers. Among surgeons, the risk was 0.7% (i.e. more than twice as high) if no special protective measures were taken. Health workers' knowledge and personal protective practices must therefore be improved and the supply of protective equipment supported. Reduction of occupational risk of HIV infection among health workers should be an integral part of acquired immunodeficiency syndrome (AIDS) control strategies.

PIP: An investigation of occupational exposure to human immunodeficiency virus (HIV) among health workers in hospitals in Tanzania's Mwanza region raised serious concerns about a lack of protective measures against such risk. Data, including questionnaires and direct observation, were collected during May-September 1993 in 9 hospitals in the region. Among the 403 hospital workers who completed an acquired immunodeficiency syndrome (AIDS)-related questionnaire, 71% had adequate knowledge scores. On the other hand, observation of hospital wards revealed insufficient measures to reduce the risk of HIV transmission (e.g., non-functioning water taps, lack of plastic bags for disposal of soiled linen, widespread shortage of gloves). 9.2% of 623 nurses and 1.3% of 118 doctors and medical assistants interviewed had pricked themselves in the preceding week; 22% of nurses working in labor wards and 25% of those working in operating theaters had pricked themselves in the previous month. Among the 50 laboratory technicians interviewed, 25% had been pricked in the previous month. In addition, more than half of nursing and medical personnel has been splashed, largely by blood and amniotic fluid, in the preceding month. Assuming an HIV prevalence of 20% among hospital patients in Mwanza, the estimated annual incidence of HIV infection due to occupational exposure is 0.27%, with percutaneous exposure contributing 93% of this risk. Among surgeons, this risk is even higher: 0.7% per year. Prevention of pricking accidents through use of double gloving, forceps to remove syringes, and appropriate containers for needle disposal should be a priority to reduce the risk of occupational HIV exposure.

Injection practices in Mwanza Region, Tanzania: prescriptions, patient demand and sterility.

This paper describes prescription and sterilization practices in Mwanza Region, Tanzania, before the introduction of interventions aiming at reducing HIV transmission by injections. Sixty-six health facilities from Mwanza Region were included in the study. Data were collected in interviews and questionnaires, through structured observation, bacteriological culture and record analysis. Criteria for avoidable injections were based on recommendations of the Essential Drugs Programme and on a regional consensus workshop. One in 4 out-patients received an injection 70% of which were avoidable. Most were given for acute respiratory infections, skin diseases and urinary tract infections. Forty per cent of cultures taken from sterilized needles and syringes yielded growth of microorganisms. Of 120 patients interviewed most preferred to be treated with injections for almost any complaint. Patient demand for injections was felt to be a problem in 85% of the health facilities and may have contributed to overprescription of injectables. Consensus treatment and sterilization guidelines as well as a health education programme were developed and introduced to all health workers through seminars.

Changes in blood transfusion practices after the introduction of consensus guidelines in Mwanza region, Tanzania.

OBJECTIVE: To assess the effect of introducing consensus guidelines on avoidable blood transfusions in Mwanza region, Tanzania. METHODS: Avoidable blood transfusions were determined among 842 blood transfusion recipients in eight hospitals in 1991. In a workshop with senior health workers from the region, consensus guidelines for the prescription of blood transfusions were developed and introduced in the hospitals and after 7 months intervention data were collected on 1042 blood transfusion recipients. The 1991 and 1992 data were compared to estimate the change in the proportion of avoidable blood transfusions. RESULTS: In blood transfusion recipients aged < 5 years there was a significant reduction in the proportion of avoidable blood transfusions from 257 (52%) out of 498 to 197 (33%) out of 595 (P < 0.001), especially at the peripheral hospitals. For children the proportion decreased from 25 to 17% (P < 0.05) and for operated patients the percentage remained at 24%. In pregnant women there was a significant increase in the proportion of avoidable blood transfusions from 10 to 27% and in adults from 37 (25%) out of 146 to 121 (50%) out of 242. The improvement in peripheral hospitals was offset by a similar deterioration in the referral hospital, thus no overall reduction was achieved in the proportion of avoidable blood transfusions. CONCLUSION: The development and introduction of consensus guidelines was not sufficient to change prescribing practice. The proportion of avoidable blood transfusions decreased only in hospitals where compliance was maintained through regular clinic meetings and strict supervision by senior medical staff.

PIP: In 1991, senior health staff in the Mwanza region of Tanzania achieved consensus guidelines for the prescription of blood transfusions and introduced these guidelines through training workshops to staff of all hospitals providing blood transfusions. Seven months after the workshops, researchers collected data on 1042 blood transfusion recipients to evaluate the effect of the introduction of the consensus guidelines on avoidable blood transfusions. A significant reduction in the proportion of avoidable blood transfusions occurred among the 595 5-year-old children (52% vs. 33%; p .001). The reduction was even greater in the peripheral hospitals (59% vs. 32%; p .001). The proportion of avoidable blood transfusions fell considerably among 5-14 year old children (25% vs. 17%; p .05). Avoidable blood transfusions did not decline among operated patients (24%). They increased significantly among adults (25% vs. 50%) and among pregnant women (10% vs. 27%). The referral hospitals had more avoidable blood transfusions at evaluation than at baseline (45% vs. 26%; p .001), while the peripheral hospitals performed significantly better in 1992 than in 1991 (28% vs. 46%). Most of the improvement in peripheral hospitals was limited to 1 hospital (61% vs. 23%; p .001). Among the remaining peripheral hospitals, the improvement was slight (35% vs. 30%; p .05). Hospitals with regular clinic meetings to discuss the consensus guidelines and senior medical staff who strictly supervised and provided feedback to interns either improved significantly or maintained their already good blood transfusion practices. The hospital that maintained an already low proportion of avoidable blood transfusions required physicians to include the indication for blood transfusion in patient records. These findings show that there was no overall reduction in avoidable blood transfusions, and that the development and introduction of consensus guidelines alone did not change prescribing practices.

Blood transfusion practices in Mwanza Region, Tanzania. Bugando Medical Centre.

OBJECTIVE: To determine what proportion of blood transfusions given in Mwanza Region, Tanzania could be avoided. METHODS: A total of 1029 patients who received a blood transfusion in one of eight hospitals were analysed. Two sets of criteria for avoidable blood transfusions were determined, on the basis of a literature review. RESULTS: The following percentages of blood transfusions in five groups of patients were found to be avoidable: operated patients, 8-24%; pregnant women, 8-10%; children aged under 5 years, 31-52%; children aged 5-14 years, 23-25%; and adults, 16-25%. Overall, 23-39% of blood transfusions were avoidable. At least 75% of all avoidable blood transfusions were to children aged under 5 years. CONCLUSIONS: The largest reduction of blood transfusions can be achieved in children aged under 5 years, especially in infants aged less than 1 year. Following this study, blood transfusion prescribers drew up provisional guidelines on blood transfusions, which have been introduced in all hospitals in Mwanza Region. An evaluation study has been carried out and is being analysed.

Are some blood transfusions avoidable? A hospital record analysis in Mwanza Region, Tanzania.

Records of 497 patients who received a blood transfusion in Mwanza Region, Tanzania, were analyzed in order to estimate the proportion of avoidable blood transfusions. This was part of a more comprehensive study which aims at the reduction of transfusion-associated HIV transmission. Blood transfusion recipients were divided into the following groups: operated patients (12%), pregnant women (8%), under-fives (62%), children aged 5-14 years (5%) and adults (13%). Two sets of criteria were applied to estimate the number of avoidable blood transfusions. The total proportion of avoidable blood transfusions using these criteria were 32 and 56%, respectively. If the strictest criteria were applied the proportion of avoidable blood transfusions in operated patients was 44%, in pregnant women with chronic anaemia 18%, in under-fives 62%, in children 31% and in adults 51%. It was concluded that a major reduction in the number of blood transfusions could be achieved, in particular in under-fives.

PIP: In the Mwanza Region, Tanzania, an analysis of evaluable, available records from 370 patients from the peripheral hospital and 127 patients from the referral hospital who received a blood transfusion during January-June 1990 was conducted to identify unnecessary blood transfusions. Guidelines the researchers used to determine whether or not a blood transfusion was avoidable were based on the hemoglobin (Hb) level (e.g. children under 5 years old = or Hb 4 g/dl for criteria A and 5 g/dl for criteria B). The blood transfusion could have been avoided in 44% of operated patients based on both sets of criteria. Two of the 11 blood transfusions given to pregnant women with chronic anemia were avoidable. Among the under 5 years olds, 62% of blood transfusions were avoidable based on criteria A and 35% were avoidable based on criteria B. 31% and 15% of blood transfusions among 5-14 year olds were avoidable based on criteria A and B, respectively. As for adults, 63% of blood transfusions were avoidable based on criteria A and 27% were avoidable based on criteria B. Overall, 32% of blood transfusions were avoidable based on criteria B and 56% based on criteria A. Since limitations undoubtedly existed for this retrospective study, the researchers have begun a prospective study. They will use the research findings to develop and implement blood transfusion guidelines in the region to reduce unnecessary blood transfusions in order to reduce transfer-associated HIV transmission.