EFFECTIVENESS AND SAFETY OF 2-HOURLY 20 MCG ORAL MISOPROSTOL SOLUTION COMPARED TO STANDARD INTRAVENOUS OXYTOCIN IN LABOUR INDUCTION DUE TO PRE-LABOUR RUPTURE OF MEMBRANES AT TERM: A RANDOMISED CLINICAL TRIAL AT KENYATTA NATIONAL HOSPITAL

BACKGROUND

Pre-labour rupture of membranes (PROM) at term is a common event whose management varies from centre to centre. The practice at the Kenyatta National Hospital (KNH) for patients with PROM at term is to initiate delivery of the patient soon on admission with intravenous oxytocin, if there are no contraindications to vaginal delivery. However, in PROM at term, if the cervix is not ripe, vaginal administration of prostaglandin pessaries for cervical ripening is not possible when there is active draining of liquor, thus use of intravenous oxytocin may take a very long time or fail all together. Oral misoprostol at low doses has been found to be a safe and effective agent for labour induction in numerous studies carried out in the developed world, where there are better resources for monitoring of labour. None of the studies has been carried out in Kenya, a limited resource country. Therefore, there is a need to determine the effectiveness and safety of oral misoprostol solution at the KNH, a limited resource set up.

OBJECTIVE

To determine the effectiveness and safety of 2-hourly 20 mcg oral misoprostol solution compared to the standard intravenous oxytocin in labour induction in mothers with pre-labour rupture of membranes at term at the Kenyatta National Hospital.

DESIGN

An unblinded randomised clinical trial.

SETTING

Kenyatta National Hospital Labour Ward Unit.

PARTICIPANTS

Eighty three pregnant women with pre-labour rupture of membranes at term without an indication for Caeserian section were consented and randomised for labour induction with either oral misoprostol at a dose of 20mcg 2-hourly up to a maximum of 4-doses, or with intravenous oxytocin according to the WHO protocol.

MAIN OUTCOME MEASURES

Induction to delivery interval; maternal complications and early neonatal outcomes.

RESULTS

The overall induction success rates in the misoprostol arm was 81% versus 83% in the oxytocin arm (P = 0.447). The mean induction to vaginal delivery interval in the misoprostol arm was 8.4 hours as compared to 9.45 hours in the oxytocin arm (P = 0.116). The induction to active labour interval was similar in the two study arms. The mean induction to active labour in the misoprostol arm was 4.02 hours as versus 4.51 hours in the oxytocin arm (P = 0.223 ). Two women who had failed induction with misoprostol were augmented with oxytocin and delivered vaginally. The Caesarean section rates were 19% in the misoprostol arm and 17% in the oxytocin arm (P = 0.447), which was not statistically significant. The maternal outcomes were similar in the two study arms. Four women had tachysystole in the misoprostol arm, compared to three in the oxytocin arm (P = 0.253). In the misoprostol arm two women had hypertonus compared to three in the oxytocin arm (P = 0.322).There was one case of hyperstimulation in the misoprostol arm and two in in the oxytocin arm. There were no differences in the foetal/neonatal outcomes. No baby had an Apgar score of less than seven at one or five minutes. No baby was admitted to the New Born Unit in either of the two arms. There was no case of a still birth in either of the study arms. There was no significant difference in the passage of meconium between the two arms, 39% in the misoprostol arm and 35.7% in the oxytocin arm (P = 0.755). The passage of meconium did not impact on the neonatal outcomes.

CONCLUSION

Oral misoprostol solution 20mcg 2-hourly is as safe and effective as the standard intravenous oxytocin for labour induction in women presenting with prelabour rupture of membranes at term at the Kenyatta National Hospital.

Blood donors in Kenya: a comparison of voluntary and family replacement donors based on a population-based survey

BACKGROUND AND OBJECTIVES

Blood safety and sufficiency are major challenges in Kenya and other sub-Saharan African countries forcing many countries to rely on family replacement donors (FRD). We analysed data from a national AIDS indicator survey to describe blood donors in Kenya and potential risks of transfusion transmissible infections (TTI) comparing voluntary donors and FRD.

MATERIALS AND METHODS

A population-based, cross-sectional survey was conducted in 2007 among 15- to 64-year-olds. Consenting participants were interviewed about blood donation history and were tested for HIV, HSV-2 and syphilis.

RESULTS

Of the 17,940 people surveyed, 445 (2·3%) reported donating blood in the prior 12 months. Sixty-four per cent were voluntary donors, and the rest were FRD. Compared to FRD, the majority of voluntary donors were <25 years old (59% versus 18%), from the highest wealth quintile (57% versus 42%) and single (64% versus 23%). In addition, voluntary donors were less likely to have been sexually active than replacement donors (43% versus 13%). HIV prevalence was lower among voluntary donors than among FRD (2·6% versus 7·4%, P-value=0·07).

CONCLUSIONS

The majority of blood donors in Kenya are voluntary with lower potential risk of TTI.

Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2

BACKGROUND

Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1.

METHODS

We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses.

RESULTS

A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed.

CONCLUSIONS

Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

Primary intracerebral haemorrhage complicated by cerebral abscess: case report

A case of primary intracerebral haemorrhage complicated by cerebral abscess is presented with a review of the literature.

Increased interleukin-10 in the the endocervical secretions of women with non-ulcerative sexually transmitted diseases: a mechanism for enhanced HIV-1 transmission?

OBJECTIVE

Although non-ulcerative sexually transmitted diseases (STD) and bacterial vaginosis are implicated as cofactors in heterosexual HIV-1 transmission, the mechanisms have not been defined. Recent in vitro data suggest that interleukin (IL)-10 may increase susceptibility of macrophages to HIV-1 infection. Therefore, we performed this study to assess whether non-ulcerative STD are associated with detection of IL-10 in the female genital tract.

METHODS

Women with clinical pelvic inflammatory disease with or without cervicovaginal discharge were recruited from an STD clinic in Nairobi, Kenya. Endocervical and endometrial specimens were obtained for Neisseria gonorrhoeae and Chlamydia trachomatis DNA detection, Trichonomas vaginalis culture, and CD4 and CD8 T-cell enumeration. Bacterial vaginosis was diagnosed by Gram stain. IL-10 was detected in endocervical specimens using enzyme-linked immunosorbent assay. Blood was obtained for HIV-1 serology.

RESULTS

One hundred and seventy-two women were studied. N. gonorrhoeae, C. trachomatis, bacterial vaginosis, and T. vaginalis were detected in 38 (21%), 17 (9%), 71 (43%), and 22 (12%) women, respectively. Cervical IL-10 was detected more often in women with N. gonorrhoeae [adjusted odds ratio (AOR), 3.4; 95% confidence interval (CI), 1.4-8.4], C. trachomatis (AOR, 4.4; 95% CI, 1.2-15.6), and bacterial vaginosis (AOR, 3.1; 95% CI, 1.4-6.9) than in women without these infections.

CONCLUSIONS

The association of non-ulcerative STD and bacterial vaginosis with increased frequency of IL-10 detection in endocervical secretions suggests a potential mechanism through which these infections may alter susceptibility to HIV-1 infection in women.