Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

OBJECTIVES

1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya.

DESIGN

Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya.

RESULTS

Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/μl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants.

CONCLUSION

This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

Cardiotocography and perinatal outcome in women with and without meconium stained liquor

BACKGROUND

There is little evidence linking meconium stained liquor to poor perinatal outcome and clear amniotic fluid is frequently considered a reassuring sign during labour.

OBJECTIVE

To determine whether there are any differences in cardiotocography (CTG) tracings and perinatal outcomes in women with meconium stained compared with those with clear liquor in labour.

DESIGN

A prospective cohort study.

SETTING

The Aga Khan University Hospital, Nairobi.

SUBJECTS

Seventy seven women presenting in labour were studied. Thirty six had meconium stained liquor and 41 had clear liquor.

MAIN OUTCOME MEASURES

Initial and intrapartum CTG was done. Perinatal and maternal outcomes determined were birth weights, Apgar scores, admission due to foetal indications and puerperal sepsis. CTG interpretation was based on RCOG/NICE guidelines-2001. SPSS 12.0.1 was used for all analyses.

RESULTS

Variable decelerations were the most common foetal heart rate patterns. In the initial CTG, suspicious (RR 1.033, 95% CI: 0.515 - 2.073), and pathologic (RR 1.490, 95% CI: 0.928-2.393) patterns were increased in the meconium stained group. In the intrapartum CTG, pathologic pattern was increased in women with meconium stain liquor (RR 1.096, 95% CI: 0.650-1.847). Apgar score of <7 was likely if the initial base line rate was abnormal (RR 1.357, 95% CI: 0.139 -1.009, irrespective of the state of liquor. Meconium staining of liquor was associated with Caesarean delivery (RR = 1.357, 95% CI: 1.010-1.823; P-value 0.042). There was no significant difference in the mean birth weights of the infants born to women in both groups (3359.72 grams and 3260.24 grams respectively, P = 0.282). One minute Apgar score in both groups was not significantly (RR 0.390, 95% CI:0.131-1.1611).

CONCLUSION

The suspicious and pathologic tracings were increased in the meconium stained liquor group. There was no significant difference in the Apgar scores in both groups of women. Meconium staining of liquor was significantly associated with Caesarean delivery.

Symptom screen: diagnostic usefulness in detecting pulmonary tuberculosis in HIV-infected pregnant women in Kenya

OBJECTIVE

To determine the diagnostic usefulness of tuberculosis (TB) symptom screening to detect active pulmonary TB among human immunodeficiency virus (HIV) infected pregnant women in two PMTCT (prevention of mother-to-child transmission) clinics in western Kenya that are supported by the United States Agency for International Development-Academic Model Providing Access to Healthcare partnership.

DESIGN

Cross-sectional study. Participants were interviewed for TB symptoms with a standardized questionnaire (cough >2 weeks, fever, night sweats, weight loss or failure to gain weight). Those with cough submitted sputum specimens for smear microscopy for acid-fast bacilli and mycobacterial culture. Women at >14 weeks gestation underwent shielded chest radiography (CXR).

RESULTS

Of 187 HIV-infected women, 38 (20%) were symptom screen-positive. Of these, 21 had a cough for >2 weeks, but all had negative sputum smears and mycobacterial cultures. CXRs were performed in 26 symptomatic women: three were suggestive of TB (1 miliary, 1 infiltrates and 1 cavitary). Of 149 women with a negative symptom screen, 100 had a CXR and seven had a CXR suggestive of TB (1 cavitary, 2 miliary and 4 infiltrates).

CONCLUSION

This study did not support the utility of isolated symptom screening in identification of TB disease in our PMTCT setting. CXR was useful in identification of TB suspects in both symptomatic and asymptomatic women.

Bone metabolism in healthy ambulatory control premenopausal women and in epileptics on anti-convulsant drugs

BACKGROUND

Long term anti-epileptic drug use causes multiple abnormalities in calcium and bone metabolism that have been documented in both institutionalised and ambulatory patients.

OBJECTIVE

To assess bone metabolism in ambulatory females of reproductive age, on antiepileptic drugs.

DESIGN

Cross sectional comparative study.

SUBJECTS

Ambulatory females in reproductive age group with epilepsy and on regular follow up were compared to healthy females of similar ages not on any treatment.

RESULTS

The mean duration of treatment for epilepsy was eight years (+/- 6.3). Majority of the patients were on enzyme inducing drugs like phenobarbital, phenytoin, carbamazepine and valproate, either alone or in combination with non-enzyme inducers like lamotrigine (98.2%). There was a significantly lower mean serum calcium and a higher alkaline phosphatase level among the patients (P = 0.002 and 0.0001 respectively) than among the comparators. The urinary marker of bone loss (mean urine calcium excretion) was also significantly raised among the patients (P=0.003). The mean lumbar BMDT-score results were not significantly different in the two groups.

CONCLUSIONS

Long-term anti-epileptic drug use significantly affects biochemical parameters of bone metabolism. These effects on bone biochemistry markers were not reflected in lumbar spine BMD in this study.

Quality of record keeping in the intrapartum period at the Provincial General Hospital, Kakamega, Kenya

OBJECTIVE

To assess the quality of recording critical events in the intrapartum period in Kakamega Provincial General Hospital (PGHK).

DESIGN

Retrospective comparative study.

SETTING

Provincial General Hospital, Kakamega, the referral hospital for Western Province, Kenya.

PARTICIPANTS

Two hundred women admitted at the labour ward during the six-month period between 1st September 2000 and 28th February 2001 were compared to two hundred women admitted between 1st July 2001 and 31st December 2001.

INTERVENTION

The Safe Motherhood Demonstration Project (SMDP) was introduced in four districts of Western Province, Kenya, in which PGHK is located. It included on job training in Safe Motherhood which emphasised, among others, collection and utilisation of maternal health care services data.

MAIN OUTCOME MEASURES

Comprehensiveness of recording of biodata, history taking and examination findings were assessed for women in labour before and during the implementation of the SMDP. The proportion of cases in labour managed by use of partograph and its appropriate use were also determined.

RESULTS

Retrieval rate of patients' notes was 86.9% and 89.6% before and during SMDP respectively. Information on sociodemographic characteristics, history taking, general and obstetric examination had a near universal recording in both groups but data on alcohol consumption, smoking, menarche, previous pregnancies and contraceptive use was poorly recorded. There was a significant improvement in recording of diagnosis and plan of management during the SMDP (p = 0.037). The partograph was used in only 11% of patients before SMDP as compared to 85% during SMDP (p = 0.000). Record on foetal condition and progress of labour were significantly improved during the SMDP (p = 0.000). Records on summary of labour likewise significantly improved during the SMDP (p = 0.02).

CONCLUSION

The quality of record keeping in the intrapartum period at the PGHK greatly improved during the implementation of the SMDP. It would be worthwhile to assess the sustainability of quality of intrapartum records and care a year or so after the SMDP ended.

Socio-demographic characteristics of patients admitted with gynaecological emergency conditions at the provincial general hospital, Kakamega, Kenya

OBJECTIVE

To determine the magnitude of gynaecological emergencies and the socio demographic characteristics of patients admitted at Provincial General Hospital Kakamega (PGHK).

DESIGN

Retrospective cross-sectional study.

SETTING

Provincial General Hospital Kakamega, the referral hospital for Western Province, Kenya.

SUBJECTS

Four hundred patients admitted at the gynaecological wards during the period 1st January 2002 to 31st December 2002.

RESULTS

In this study 80% of gynaecological patients admitted at PGH Kakamega were of an emergency nature with 45% being teenagers. The mean age was 17 +/- 3 (mean +/- SD). The majority had primary level of education or below (69%), unemployed (87%) and were rural residents (71%). Patients with abortion formed about 43% of the study group while those with inflammatory disease, pelvic abscess and ectopic pregnancy formed about 24%, 10% and 8% respectively.

CONCLUSION

Most gynaecological admissions in PGH Kakamega are of acute nature, with abortion being the most common diagnosis. Hence, trained staff, equipment, supplies and drugs for management of acute gynaecological conditions should be available in hospitals in Western Kenya.