Evaluation and optimization of the syndromic management of female genital tract infections in Nairobi, Kenya.

BACKGROUND: Genital tract infections pose a public health concern. In many low-middle-income countries, symptom-based algorithms guide treatment decisions. Advantages notwithstanding, this strategy has important limitations. We aimed to determine the infections causing lower genital tract symptoms in women, evaluated the Kenyan syndromic treatment algorithm for vaginal discharge, and proposed an improved algorithm. METHODS: This cross-sectional study included symptomatic non-pregnant adult women presenting with lower genital tract symptoms at seven outpatient health facilities in Nairobi. Clinical, socio-demographic information and vaginal swabs microbiological tests were obtained. Multivariate logistic regression analyses were performed to find predictive factors for the genital infections and used to develop an alternative vaginal discharge treatment algorithm (using 60% of the dataset). The other 40% of data was used to assess the performance of each algorithm compared to laboratory diagnosis. RESULTS: Of 813 women, 66% had an infection (vulvovaginal candidiasis 40%, bacterial vaginosis 17%, Neisseria gonorrhoea 14%, multiple infections 23%); 56% of women reported ≥ 3 lower genital tract symptoms episodes in the preceding 12 months. Vulvovaginal itch predicted vulvovaginal candidiasis (odds ratio (OR) 2.20, 95% CI 1.40-3.46); foul-smelling vaginal discharge predicted bacterial vaginosis (OR 3.63, 95% CI 2.17-6.07), and sexually transmitted infection (Neisseria gonorrhoea, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) (OR 1.64, 95% CI 1.06-2.55). Additionally, lower abdominal pain (OR 1.73, 95% CI 1.07-2.79) predicted sexually transmitted infection. Inappropriate treatment was 117% and 75% by the current and alternative algorithms respectively. Treatment specificity for bacterial vaginosis/Trichomonas vaginalis was 27% and 82% by the current and alternative algorithms, respectively. Performance by other parameters was poor to moderate and comparable between the two algorithms. CONCLUSION: Single and multiple genital infections are common among women presenting with lower genital tract symptoms at outpatient clinics in Nairobi. The conventional vaginal discharge treatment algorithm performed poorly, while the alternative algorithm achieved only modest improvement. For optimal care of vaginal discharge syndrome, we recommend the inclusion of point-of-care diagnostics in the flowcharts.

Coronavirus disease 2019 and the placenta: A literature review.

Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has been implicated in the clinical pathology of multiple organs and organ systems. Due to the novelty of the disease, there is a need to review emerging literature to understand the profile of SARS-CoV-2 in the placenta. This review sought to evaluate the literature on the mediators, mechanism of entry, pathogenesis, detection, and pathology of SARS-CoV-2 in the placenta. Systematic literature searches found 96 eligible studies. Our review revealed that SARS-CoV-2 canonical mediators, angiotensin-converting enzyme-2 (ACE2), and transmembrane serine protease-2 (TMPRSS2) are variably expressed in various placenta compartments, including the villous cytotrophoblasts, syncytiotrophoblasts (STBs), and extravillous trophoblasts (EVTs) throughout pregnancy. Placental SARS-CoV-2 and coronavirus-associated receptors and factors (SCARFs), including basigin (BSG/CD147), dipeptidyl peptidase-4 (DPP4/CD26), cathepsin B/L (CTL B/L), furin, interferon-induced transmembrane protein (IFITM1-3), and lymphocyte antigen 6E (LY6E) may increase or reduce the permissiveness of the placenta to SARS-CoV-2. EVTs express genes that code for proteins that may drive viral pathogenesis in the placenta. Viral RNA, proteins, and particles were detected primarily in the STBs by in situ hybridization, immunohistochemistry, electron microscopy, and polymerase chain reaction. Placental pathology in SARS-CoV-2-infected placentas included maternal and fetal vascular malperfusion and a generally nonspecific inflammatory-immune response. The localization of SARS-CoV-2 receptors, proteases, and genes involved in coding proteins that drive viral pathogenesis in the placenta predisposes the placenta to SARS-CoV-2 infection variably in all pregnancy trimesters, with antecedent placental pathology. There is a need for further studies to explicate the mechanism of entry and pathogenesis of SARS-CoV-2 in the placenta.

Potential pharmacologic interventions targeting TLR signaling in placental malaria.

Complications from placental malaria cause poor pregnancy outcomes, including low birthweight, preterm delivery, and stillbirths. Many of these complications are driven by maternal innate proinflammatory responses to the sequestration of Plasmodium falciparum in the placenta. However, recent studies show that, in reaction to maternal innate immune responses that are detrimental to the fetus, the fetus mounts innate immune counter-responses that ameliorate pregnancy outcomes. Such fetal-maternal conflict in placental malaria has potential for pharmacologic modulation for better pregnancy outcomes. Here, we discuss placental malaria pathogenesis, its complications, and the role of innate immunity and fetal-maternal innate immune conflict in placental malaria. Finally, we discuss pharmacologic immunomodulatory strategies and agents with the potential to improve placental malaria outcomes.

Association between utilization and quality of antenatal care with stillbirths in four tertiary hospitals in a low-income urban setting.

INTRODUCTION: About 2.6 million stillbirths per year occur globally with 98% occurring in low- and middle-income countries including Kenya, where an estimated 35 000 stillbirths occur annually. Most studies have focused on the direct causes of stillbirth. The aim of this study was to determine the association between antenatal care utilization and quality with stillbirth in a Kenyan set up. This information is key when planning strategies to reduce the stillbirth burden. MATERIAL AND METHODS: This was a case-control study in four urban tertiary hospitals carried out between August 2018 and April 2019. A total of 214 women with stillbirths (cases) and 428 with livebirths (controls) between 28 and 42 weeks were enrolled. Information was obtained through interviews and data abstracted from medical records. Antenatal care utilization was assessed by the proportions of women not attending antenatal care; booking first antenatal care visit in first trimester and not making the requisite four antenatal care visits. Quality of antenatal care was assessed using individual surrogate indicators (antenatal profile testing, weight/blood pressure/urinalysis testing in each antenatal visit, utilization of early obstetric ultrasound, completeness of antenatal records) and a codified indicator made up of seven parameters (attending antenatal care, booking first antenatal care in the first trimester, making four or more antenatal visits, having all antenatal profile tests, having a complete antenatal record, having blood pressure and weight measured at all visits). The association between antenatal care utilization and quality with stillbirth was assessed using univariate and multivariate analysis using logistic regression. Statistical significance was defined as a two-tailed P value ≤ .05. RESULTS: Women with stillbirth were likely to have a parity ≥4 (19.6% vs 12.6%, P = .02), have an obstetric complication (36% vs 8.6%, P = .001) and have a medical disorder (5.6% vs 1.6%, P = .01). The odds of a stillbirth were four times higher among those who did not attend antenatal care ( odds ratio [OR] 4.1, 95% confidence interval [CI] 1.6-10, P < .003). Compared with four antenatal care visits, those who had one or two visits had higher odds of a stillbirth: OR 2.96 (95% CI 1.4-6.1), P = .003, and OR 2.9 (95% CI 1.7-5), P = .003, respectively. As per the individual surrogate indicators, the likelihood of a stillbirth was lower in women who received good quality antenatal care: Hemoglobin testing (OR 0.6, 95% CI 0.4-0.8, P = .03), blood group test (OR 0.4, 95% CI 0.2-0.6, P < .001), HIV test (OR 0.3, 95% CI 0.2-0.5, P = .001), venereal disease research laboratory test (OR 0.2, 95% CI 0.1-0.4, P = .001), weight measurement (OR 0.7, 95% CI 0.5-1.0, P = .047). As per the composite indicator, the quality of antenatal care was poor across the board and there was no association between this surrogate indicator and stillbirth. CONCLUSIONS: Lack of antenatal care, attending fewer than four antenatal visits and poor quality antenatal care as measured by surrogate indicators were significantly associated with stillbirth. In addition, women with low education level, obstetric complications, multiparity and medical complications had a significantly higher likelihood of stillbirth. Improving the utilization of four or more antenatal visits and the quality of antenatal care can reduce the risk of stillbirth.

Association between obstetric and medical risk factors and stillbirths in a low-income urban setting.

OBJECTIVE: To evaluate the association between obstetric and medical risk factors and stillbirths in a Kenyan set-up. METHODS: A case-control study was conducted in four hospitals between August 2018 and April 2019. Two hundred and fourteen women with stillbirths and 428 with live births at more than >28 weeks of gestation were enrolled. Data collection was via interviews and abstraction from medical records. Outcome variables were stillbirth and live birth; exposure variables were sociodemographic characteristics, and medical and obstetric factors. The two-sample t test and χ2 test were used to compare continuous and categorical variables respectively. The association between the exposure and outcome variable was done using logistic regression. A P value less than 0.05 was considered statistically significant. RESULTS: Stillbirth was associated with pre-eclampsia without severe features (odds ratio [OR] 9.1, 95% confidence interval [CI] 2.6-32.5), pre-eclampsia with severe features (OR 7.4, 95% CI 2.4-22.8); eclampsia (OR 9.2, 95% CI 2.6-32.5), placenta previa (OR 8.6 95% CI 2.8-25.9), placental abruption (OR 6.9 95% CI 2.2-21.3), preterm delivery(OR 9.5, 95% CI 5.7-16), and gestational diabetes mellitus, (OR 11.5, 95% CI 2.5-52.6). Stillbirth was not associated with multiparity, anemia, and HIV. CONCLUSION: Proper antepartum care and surveillance to identify and manage medical and obstetric conditions with the potential to cause stillbirth are recommended.

The Relationship Between Counseling and Adherence to Antiretroviral Therapy Among Pregnant and Breastfeeding Women Enrolled in Option B.

The aim of the study was to investigate the relationship between counseling prior to starting antiretroviral treatment (ART) and adherence to treatment among women enrolled in Option B+ in Zambia. Using convenience sampling, 150 HIV+ women enrolled in an Option B+ treatment regimen in rural and urban districts were recruited. Four generalized Poisson regression models were built to assess the association between counseling and adherence to ART. In all, 75% of the participants reported adherence in the past 7 days. In adjusted analyses, there was a significant positive relationship between counseling and adherence in the rural district (prevalence ratio [PR] 2.52, 95% CI [1.19, 5.35], n = 81) but not in the urban district (PR = 0.77, 95% CI [0.15, 3.91], n = 69). Offering counseling prior to initiating antiretroviral treatment to HIV+ women is particularly important for promoting medication adherence in rural settings of low resourced countries.

Valve distribution of the popliteal vein: A structural basis for deep venous thrombosis?

OBJECTIVE: To describe the relationship between number and distribution of valves. METHODS: Sixty-six popliteal vein specimens were used for the study after routine dissection at the Department of Human Anatomy, University of Nairobi. The extents of the popliteal vein were identified at the adductor hiatus and soleal arch, cut at these points and then longitudinally sliced open. The number and distribution of valves were then recorded. Data were presented using photomacrographs and tables. RESULTS: The median number of valves was 1 (mean 0.8; range 0-2), with the lower part of the popliteal vein as the most consistent valve position. Most striking was the valve absence noted in 27 (41%) of the veins. CONCLUSION: These findings suggest that a significant proportion of popliteal veins do not have valves thus providing a credible structural link that may predispose the popliteal vein to deep venous thrombosis in the study population.

Placental Structure in Preterm Birth Among HIV-Positive Versus HIV-Negative Women in Kenya.

BACKGROUND: Preterm birth (PTB) is a major cause of infant morbidity and mortality in developing countries. Recent data suggest that in addition to Human Immunodeficiency Virus (HIV) infection, use of antiretroviral therapy (ART) increases the risk of PTB. As the mechanisms remain unexplored, we conducted this study to determine whether HIV and ART were associated with placental changes that could contribute to PTB. SETTING: We collected and evaluated placentas from 38 HIV-positive women on ART and 43 HIV-negative women who had preterm deliveries in Nairobi, Kenya. METHODS: Anatomical features of the placentas were examined at gross and microscopic levels. Cases were matched for gestational age and compared by the investigators who were blinded to maternal HIV serostatus. RESULTS: Among preterm placentas, HIV infection was significantly associated with thrombosis (P = 0.001), infarction (P = 0.032), anomalies in cord insertion (P = 0.02), gross evidence of membrane infection (P = 0.043), and reduced placental thickness (P = 0.010). Overall, preterm placentas in both groups were associated with immature villi, syncytial knotting, villitis, and deciduitis. Features of HIV-positive versus HIV-negative placentas included significant fibrinoid deposition with villus degeneration, syncytiotrophoblast delamination, red blood cell adhesion, hypervascularity, and reduction in both surface area and perimeter of the terminal villi. CONCLUSIONS: These results imply that HIV infection and/or ART are associated with morphological changes in preterm placentas that contribute to delivery before 37 weeks. Hypervascularity suggests that the observed pathologies may be attributable, in part, to hypoxia. Further research to explore potential mechanisms will help elucidate the pathways that are involved perhaps pointing to interventions for decreasing the risk of prematurity among HIV-positive women.

Breast-feeding and human immunodeficiency virus infection: assessment of knowledge among clinicians in Kenya.

In Kenya, human immunodeficiency virus (HIV) prevalence ranks among the highest in the world. Approximately 60 000 infections yearly are attributed to vertical transmission including the process of labour and breast-feeding. The vast of the population affected is in the developing world. Clinical officers and nurses play an important role in provision of primary health care to antenatal and postnatal mothers. There are a few studies that have explored the clinicians' knowledge on breast-feeding in the face of HIV and in relation to vertical transmission this being a vital component in prevention of maternal-to-child transmission. The aim of this study was to evaluate clinicians' knowledge on HIV in relation to breast-feeding in Kenya. A cross-sectional survey was conducted to assess knowledge of 161 clinical officers and nurses serving in the maternity and children' wards in various hospitals in Kenya. The participants were derived from all district and provincial referral facilities in Kenya. A preformatted questionnaire containing a series of questions on HIV and breast-feeding was administered to clinicians who were then scored and analyzed. All the 161 participants responded. Majority of clinicians (92%) were knowledgeable regarding prevention of mother-to-child transmission. Regarding HIV and breast-feeding, 49.7% thought expressed breast milk from HIV-positive mothers should be heated before being given. Majority (78.3%) thought breast milk should be given regardless of availability of alternatives. According to 74.5% of the participants, exclusive breast-feeding increased chances of HIV transmission. Two-thirds (66.5%) would recommend breast-feeding for mothers who do not know their HIV status (66.5%). This study observes that a majority of the clinicians have inadequate knowledge on breast-feeding in the face of HIV. There is need to promote training programmes on breast-feeding and transmission of HIV from mother to child. This can be done as in-service training, continuous medical education and as part of the formal training within medical institutions.

Comparative regional morphometric changes in human uterine artery before and during pregnancy.

INTRODUCTION: Uterine artery undergoes structural modifications at different physiologic states. It is expected that due to its unique course, hemodynamic stresses in the vessel would vary resulting in differences in arterial dimensions. The objective of this study was to investigate regional morphometric changes in the human uterine artery. METHODS: Twenty four uterine arteries (12 each from non-gravid uteri and gravid uteri) were obtained during autopsy after ethical approval from women aged between 21 to 47 years. Sections from proximal, middle and distal segments of the artery taken within 72 hours were processed for paraffin embedding, sectioned and stained with Mason's Trichrome. Micrographs of the slides were analyzed using Scion Image Multiscan software. Data were entered into and analyzed with Statistical Programme for Social Sciences. RESULTS: The pregnancy related increase in diameter and wall thickness are most pronounced in the proximal segment. In the distal segment, however, wall thickness reduces significantly (p < 0.05). Intimal thickness was lesser in pregnancy compared to non-gravid state in all the segments. CONCLUSION: Regional morphometric changes in the uterine artery during pregnancy may be designed to regulate blood flow to the uterus and placenta during pregnancy.

Pulmonary thromboembolism in an East African tertiary referral hospital.

Pulmonary thromboembolism (PTE) is a frequent cause of mortality in Kenya, but its characteristics are hardly reported in Subsaharan Africa. To describe the pattern of PTE among black Africans, in a Kenyan referral hospital. Retrospective study at Kenyatta National Hospital (KNH), Nairobi, Kenya. Records of patients seen between January 2005 and December 2009 were examined for mode of diagnosis, comorbidities, age, gender, treatment and outcome. Data were analyzed using SPSS version 15.0 and are presented in tables and bar charts. One hundred and twenty-eight (60 male; 68 female) cases were analyzed. Diagnosis was made by clinical evaluation, a Well's score of >4.0, high D-dimer levels and ultrasound demonstration of a proximal deep venous thrombosis (DVT, 35.9%), lung spiral computer tomography (CT, 50%), multidetector CT (7.8%) and angiography (6.3%). Most frequent comorbidities included DVT (36%); hypertension (18.8%); pulmonary tuberculosis (PTB, 12.5%); HIV infection (10.9%), pueperium, diabetes mellitus and cigarette smoking (9.4% each). Mean age was 40.8 years (range 5-86 years) with a peak between 30 and 50 years. Over 46% of patients were aged 40 years and less. Male:female ratio was 1:1.13. All the patients were treated with anticoagulants and thrombolytics with only one having embolectomy. Ninety-two patients (71.9%) recovered, 18.8% of them with cor pulmonale, while 28.1% died. PTE is not uncommon in Kenya. It affects many individuals below 40 years without a gender bias, and carries high morbidity and mortality. Associated comorbidities include venous thrombosis, lifestyle conditions and communicable diseases. Control measures targeting both are recommended.

Branching pattern of middle cerebral artery in an African population.

Branching pattern of middle cerebral artery influences frequency of its aneurysms, and is of potential value in their surgical repair and diagnosis of stroke. This pattern shows inter-population variations but there is paucity of data from Africans. This study aimed at describing branching pattern among black Kenyans. Middle cerebral arteries numbering 288 from 144 formalin fixed brains obtained during dissection and autopsy at Department of Human Anatomy, University of Nairobi, Kenya were studied. Origin of the middle cerebral artery was identified at base of brain and its stem followed by gently separating the fronto-parietal and temporal lobes. Pattern of early cortical, lenticulostriate, and terminal branching was recorded and macrographs taken. Results were analyzed using SPSS version 13.0 for windows and presented using macrographs. All the brains had bilateral middle cerebral arteries which were continuations of the internal carotid artery. Variations of the artery observed included duplication (1.7%), early bifurcation (5.2%), and early cortical branching (47%), predominantly temporal (63.9%). Lenticulostriate arteries arose predominantly from the pre-bifurcation segment as single branches (64.6%), and as common trunks (35.4%). Modes of termination were bifurcation (82.3%), trifurcation (10.8%), primary trunks (6.2%), and quadrifurcation (0.7%). Cortical branching pattern of the middle cerebral artery resembles that of Caucasian and Indian populations suggesting equal vulnerability to aneurysms and stroke. Pattern of origin of lenticulostriate arteries, predominantly from the pre-bifurcation segment and higher percentage of common trunks implies that the population is more prone to ischemia after aneurysm repair. Extra diligence during operation on proximal middle cerebral artery is called for.

Menarcheal age among urban Kenyan primary school girls.

AIM: To determine the mean menarcheal age among urban primary school girls in Kenya. SUBJECTS AND METHODS: A structured questionnaire was administered to 820 primary grade 6-8 girls aged between 12 and 17 years in five public primary schools, Langata division of Nairobi West district, Nairobi Kenya. The girls came from low and middle socioeconomic status residences. Declared menarcheal age by recall to the nearest month was recorded. Data were analysed using SPSS version 15.0 for windows. The results are presented using tables and bar charts. RESULTS: The mean menarcheal age was 12.5 ± 2.8 years with peak at 12-14 years. A substantial number of girls (10.8%) attained menarche before the age of 11 years, with 2% of them attaining it before 10 years. None attained menarche before nine or after 16 years. Of those who attained early menarche, 64.3% were from middle while only 35.7% came from low socioeconomic status residence, respectively. CONCLUSION: Mean menarcheal age of 12.5 years is lower than previously reported with over 10% of the girls attaining menarche by 11 years. Early commencement of reproductive health education and follow-up for complications of early menarche is recommended.

Variant anatomy of the uterine artery in a Kenyan population.

OBJECTIVE: To investigate the uterine artery's origin, branching patterns, and relation to the ureter in a Kenyan population. METHOD: The uterine arteries of the bodies of 53 girls and women were dissected at the University of Nairobi Department of Human Anatomy to study these patterns. Data were analyzed for frequency and the patterns are presented via digital macrographs. RESULTS: The uterine artery consistently originated as a branch of the internal iliac artery. It formed the second or third branch of the anterior trunk in 70.8% of cases; it ascended as a single branch, or from a bifurcation, or from a trifurcation in 76.4%, 17.1%, and 6.7% of cases; and lay posterior to the ureter in 3.8% of cases. In all, 46.2% of the uterine arteries studied varied from the classic description. CONCLUSION: About half of the uterine arteries had a nonclassic origin, branching pattern, or relation to the ureter-as a posterior relation to the ureter had not been previously described. Surgeons operating in the pelvis should be aware of this variant anatomy to avoid injury to the ureter and other organs.

Pattern of limb amputation in a Kenyan rural hospital.

Causes of limb amputations vary between and within countries. In Kenya, reports on prevalence of diabetic vascular amputations are conflicting. Kikuyu Hospital has a high incidence of diabetic foot complications whose relationship with amputation is unknown. This study aimed to describe causes of limb amputations in Kikuyu Hospital, Kenya. Records of all patients who underwent limb amputation between October 1998 and September 2008 were examined for cause, age and gender. Data were analysed using the statistical package for Social Sciences (SPSS) for Windows Version 11.50. One hundred and forty patients underwent amputation. Diabetic vasculopathy accounted for 11.4% of the amputations and 69.6% of the dysvascular cases. More prevalent causes were trauma (35.7%), congenital defects (20%), infection (14.3%) and tumours (12.8%). Diabetic vasculopathy, congenital defects and infection are major causes of amputation. Control of blood sugar, foot care education, vigilant infection control and audit of congenital defects are recommended.