Pregnancy outcomes in mothers with advanced human immunodeficiency virus disease.

OBJECTIVE: To determine the impact of HIV disease on immediate maternal and foetal outcomes at the Kenyatta National Hospital, Nairobi, Kenya. DESIGN: Prospective cohort study. SETTING: Kenyatta National Hospital, Nairobi, Kenya, between September 2004 and April 2005. SUBJECTS: Sixty eight mothers with advanced HIV disease (WHO clinical stage 3 and 4) and 68 HIV negative pregnant mothers. RESULTS: Mothers with advanced HIV disease were more likely to be anaemic (55% vs. 16% p < 0.001), to have sexually transmitted diseases (56% vs. 15%, p = 0.004), to have chorioamnionitis (14.8% vs. 2%, p = 0.004), to develop preterm premature rupture of membranes (31% vs. 9%, p < 0.001), to have puerperal pyrexia (16% vs. 2%, p = 0.032) an to die (5% vs. 0.5%, p = 0.028) compared to HIV negative mothers. The mean gestational age at deliver was lower in mothers with advanced HIV disease compared to the seronegative counterparts (73% vs. 32%, delivery <37 weeks, p < 0.001). Infants of mothers with advanced HIV disease compared to infants of seronegative mothers were more likely to be low birth weight infants (58% vs. 21%, p < 0.001), stillborn (4% vs. 2%, p = 0.308) and to have low Apgar scores (28% vs. 12%, Apgar score < 4 at 5 minutes p = 0.02). Perinatal sepsis and perinatal deaths were more common in infants born to mothers with advanced HIV disease compared to infants born to HIV negative mothers (8 vs. 3, p = 0.003 and 14 vs. 5, p = 0.025 respectively). External congenital anomalies were similar in the two groups (5.9% vs. 5.9%). CONCLUSION: Pregnancies complicated by advanced HIV disease are more likely to have adverse outcomes, both maternal and foetal. Advanced HIV disease is associated with increased risk of both maternal and fetal mortality. HIV infected mothers should be counselled on the increased pregnancy risks associated with advanced disease.

Embryonal rhabdomyosarcoma with uterine inversion: case report.

Presented here is a 16-year-old nulliparous girl who had embryonal rhabdomyosarcoma causing uterine inversion. She had been referred with a one year history of continuous vaginal bleeding and vaginal swelling. Histology had shown sarcoma botyroides and had received five courses of chemotherapy at the referring hospital. At surgery she was found to have uterine inversion and extended hysterectomy was carried out to be followed by radiotherapy.

Acceptability of human immunodeficiency virus testing in patients with invasive cervical cancer in Kenya.

Invasive cervical cancer (ICC) is common in areas where human immunodeficiency virus (HIV) is also prevalent. Currently, HIV seroprevalence as well as acceptability of HIV testing in ICC patients in Kenya is unknown. The objective of this study was to determine the acceptability of HIV testing among patients with ICC. Women with histologically verified ICC at Kenyatta National Hospital participated in the study. A structured questionnaire was administered to patients who gave informed consent. HIV pre- and posttesting counseling was done. Blood was tested for HIV using enzyme-linked immunosorbent assay. Overall, 11% of ICC patients were HIV seropositive. The acceptance rate of HIV testing was 99%; yet, 5% of the patients did not want to know their HIV results. Patients less than 35 years old were two times more likely to refuse the result of the HIV test (odds ratio [OR] 2.2). Patients who did not want to know their HIV results were three times more likely to be HIV seropositive (OR 3.1). Eighty four percent of the patients were unaware of their HIV seropositive status. The HIV-1 seroprevalence in ICC patients was comparable to the overall seroprevalence in Kenya. ICC patients were interested in HIV testing following pretest counseling. Offering routine HIV testing is recommended in ICC patients.

Knowledge and practice about cervical cancer and Pap smear testing among patients at Kenyatta National Hospital, Nairobi, Kenya.

Invasive cervical cancer (ICC) is the leading cause of cancer-related death among women in developing countries. Population-based cytologic screening and early treatment does reduce morbidity and mortality associated with cervical cancer. Some of the factors related to the success of such a program include awareness about cervical cancer and its screening. The objective of this study was to assess knowledge and practice about cervical cancer and Pap smear testing among cervical cancer and noncancer patients using a structured questionnaire to obtain information. Fifty-one percent of the respondents were aware of cervical cancer while 32% knew about Pap smear testing. There were no significant differences in knowledge between cervical cancer and noncancer patients. Health care providers were the principal source of information about Pap testing (82%). Only 22% of all patients had had a Pap smear test in the past. Patients aware of cervical cancer were more likely to have had a Pap smear test in the past. The level of knowledge is low among ICC and noncancer patients. There is need to increase the level of knowledge and awareness about ICC and screening among Kenyan women to increase uptake of the currently available hospital screening facilities.

Resistance to chloroquine therapy in pregnant women with malaria parasitemia.

OBJECTIVES: The objective of the study was to determine the efficacy of chloroquine in pregnant women with Plasmodium falciparum parasitemia at therapeutic doses of 25 mg/kg body weight divided over 3 days. METHODS: Three-hundred pregnant women in Kilifi Hospital at the coast of Kenya were screened for malaria parasitemia using Giemsa stained thick blood smears. In vivo and in vitro parasite sensitivity to chloroquine was determined. RESULTS: P. falciparum infections were present in 65 (22%) of 300 pregnant women. The in vivo tests showed that 46% of all the P. falciparum infections were resistant to chloroquine predominantly at RI and RII levels. The in vitro tests showed a resistance rate of 35%. CONCLUSIONS: A large proportion of pregnant women with malaria do not respond to chloroquine therapy and alternative drugs are required.

Retrospective study of alleged sexual assault at the Aga Khan Hospital, Nairobi.

A retrospective audit of all the rape cases reported at the Aga Khan Hospital, Nairobi over a two year period was carried out. Out of 37 victims, 86.6% were less than 30 years old and 73.4% did not know who the assailant was. 80% of the victims reported to the hospital within 24 hours of the incident taking place and in 4 (10.8%) of the victims-vaginal swabs grew N. gonorrhoea. None of the victims opted for prosecution and none were referred for further counselling. We recommended that alleged rape victims be seen by a qualified gynaecologist or police surgeon and that they should be examined, investigated and managed by a standard protocol.

PIP: This retrospective study was undertaken to identify the management problems of sexual assault cases as seen at the Aga Khan Hospital, Nairobi where an ongoing quality assurance program attempts to maintain high standards of medical care. The study reviewed all records of sexual assault victims over a 2-year period. The results showed that all 37 victims were females and majority (89.1%) were aged between 19 and 30 years old. About 73.4% did not know their assailants, 80% reported to the hospital within 24 hours of the incident and 10.8% of the victims manifested Neisseria gonorrhea in their vaginal swabs. None of the victims made attempts to bring the assailants to justice. Although rape victims usually suffer from posttraumatic stress, none of the victims in this study were referred for further counseling. Lastly, this study recommended that sexual assault victims should be examined, investigated, and managed by a standard protocol.

A survey of knowledge of family planning (FP) methods among Kenyan medical doctors: secondary data analysis.

PIP: This survey, conducted between October 1989 and March 1990, to determine the knowledge, attitude, practice, and provision of family planning of a sample of 376 Kenyan medical doctors, reports on the aspects of knowledge of family planning (FP) methods. Kenyan medical doctors had low-to-average knowledge of the association between oral contraceptives (OCs) and the risk of various medical conditions and the mechanism of action of steroidal contraceptives. Their knowledge of the effectiveness of various program methods was average to high. There was a linear relationship between monthly income and knowledge of effectiveness of OCs, according to which physicians earning more had less knowledge than their colleagues who earned less (Z = 2.318, p = 0.02). A stepwise unconditional logistic regression model showed that two variables, department where most work is performed and sex, are significantly associated with better knowledge. Use of these operational variables for assessing medical doctors' knowledge of FP methods gave a better resolution of the extent and perhaps the quality of counseling and advice they provided to their FP clients. At the same time, the need for update courses in FP for medical doctors is unquestionable and long overdue.^ieng

A survey of attitude of Kenyan medical doctors on family planning (FP): secondary data analysis.

PIP: This was part of a survey conducted between November 1989 and March 1990 to determine the knowledge, attitude, practice, and provision of family planning (FP) by a sample of Kenyan medical doctors. This part of the survey reports on the attitude as assessed through several attitudinal variables. Medical doctors had an average-to-high (60-98%) positive attitude about the relationship between population/economic growth and the need for FP, the effectiveness of the FP campaign in Kenya, and the ideal family size being 0-4 children. However, the proportion of doctors who considered the ideal family size to be 0-2 children dropped to a mere 23%. In light of the 1993 Kenyan total fertility rate of 5.4, an ideal family size of 0-4 children would be a worthwhile ambition for Kenyans, the majority of whom are of low socioeconomic status. Important covariates were future fertility intentions (desire for children), doctors' place of work, and religion. It is very important that the FP campaign continue to promote small families in Kenya.^ieng

Seventy years of the East African Medical Journal towards safe motherhood.

Obstetrical and gynaecological articles related to safe motherhood published in the East African Medical Journal between 1924 and 1989 were reviewed. A total of 133 topics were published. Out of these, 84 (63.2%) were obstetrical and 49 (36.8%) gynaecological. Out of the obstetrical topics, 66 were pregnancy related, 12 were public health and the rest medical topics. A rapid increase in the number of the relevant topics is seen especially after 1970. This is probably due to the increase in the number of of obstetricians training locally in the African region and the international nature of the Journal during the last two decades.

PIP: A review of all published articles in the East African Medical Journal between 1924 and 1989 was presented. All articles pertaining to obstetrical and gynecological topics related to maternal care were reviewed. The aim was to identify the role the journal has played in distributing information about safe motherhood research. This journal is one of the oldest to present information originating in Africa and recently has gained international recognition. Articles that were studies conducted in other parts of the world are now published. The number of topics devoted to obstetrics and safe motherhood has increased during the past 20 years. Publication by researchers in this journal has contributed to specialists advancement within universities and medical areas. The first maternal-related article was published in 1024 and was devoted to performance of a cesarean section on a woman in Mombasa, an article of particular importance for African countries with high maternal mortality and morbidity from child birth. There have been a total of 133 articles on motherhood since 1924, of which 84 were on obstetrics and 49 on gynecology. World War II probably affected the decline in articles during the period 1940-49. There was a rapid increase in motherhood articles between 1950 and 1989, which also corresponded to an increase in trained obstetricians and gynecologists. Prior to 1970, most specialists were trained outside of Africa and did not publish in this journal. By subject area, there were 12 topics on public health related issues, 43 on prenatal care, 19 on delivery, 4 on postpartum care, and 6 on medically related issues such as infections, diabetes mellitus in pregnancy, hypertension, and heart disease.

Human immunodeficiency virus in gestational trophoblastic neoplasias--is it a poor prognostic risk factor.

Three cases of HIV infection with choriocarcinoma are presented. One case had prolonged chemotherapy without remission, the second had remission only after combining hysterectomy with chemotherapy and the third who had extensively metastatic disease in the presence of other low risk factors are reported. HIV infection may predispose patients to extensive metastatic choriocarcinoma and influence the course of treatment. We propose that HIV infection be considered a poor prognostic risk for gestation trophoblastic neoplasias.

Audit of hysterectomies at the Aga Khan Hospital, Nairobi: justification of operative indications.

An audit of 381 hysterectomies performed over a 5 year period (1986-1990) was carried out. In order to assess justification of the indication for hysterectomy pre-operative diagnoses were divided into two groups: those potentially confirmable by pathologic study and those not potentially confirmable by pathologic study. Out of the 273 cases studied in the first group, 246 (90.1%) were justified, while out of the 108 cases studied in the second group, 82 (75.9%) were justified. An overall 86% justification rate was observed. Adenomyosis as a histopathologic finding was seen more commonly in Asian than African patients (P < 0.005). Morbidity rate was 20% and there were no mortalities. The procedure in general was considered safe and justified.

Management of shoulder dystocia.

Shoulder dystocia is a rare obstetric emergency with which few clinicians have adequate experience. A case which was successfully managed is presented and current management procedures reviewed.

In vivo and in vitro response of Plasmodium falciparum to chloroquine in pregnant women in Kilifi district, Kenya.

In a malaria-endemic area of the Coast of Kenya with chloroquine resistant Plasmodium falciparum, we determined the prevalence and density of falciparum infection in gravid women and assessed the in vivo and in vitro parasite response to a regimen of chloroquine 25 mg/kg body weight divided over three days. P. falciparum infections were present in 65 (21.7%) of 300 pregnant women. The proportion of primigravidae who were parasitaemic was 41.8% which was significantly higher than that of the multigravidae (17.1, P less than 0.01). Primigravidae did not show a significantly higher mean parasite density than the multigravidae. The in vivo tests showed that 45.9% of all the P. falciparum infections were resistant to chloroquine predominantly at RI and RII levels with percentages 36.1% and 8.2%, respectively.

PIP: At the antenatal clinic of Kilifi District Hospital in the Coast Province of Kenya, researchers enrolled 300 pregnant volunteers 15-32 years olds, living in the district to screen and treat then for Plasmodium falciparum infection and to follow those with parasitemia on days 0, 1, 2, 14, 17, 21, and 28. They also conducted in vitro studies to determine resistance to chloroquine. They combined in vivo and in vitro study took place between November 20, 1988 and January 17, 1989. 65 women (21.7%) had P. falciparum in their peripheral blood smear. Primigravidae were more likely to be parasitemia than were multigravidae (41.8% vs. 17.1%; p .001). Their mean parasite density was also higher but not significantly so. Parasite density fell consistently with rising parity. Malaria infections in 54.1% of the women responded to 25 mg/kg chloroquine. the remaining 45.9% (28) of cases exhibited in vivo resistance, especially at RI an RII levels (36.1% and 8.2%, respectively). Primigravidae were more likely to experience failure to clear parasites by day 7 than multigravidae. Further, among women experiencing a parasitemia on day 7, parasites tended to reappear on day 14 and 21 in primigravidae. Initial parasite density did not affect clearance of parasites. Primigravidae continued to have a higher level of parasitemia throughout treatment than did multigravidae. It took at least 24 hours for the chloroquine to be completely absorbed thus the mean level of parasitemia decreased sharply between 0-2 days. Amodiaquine induced a parasitemia in 89.3% (25 cases) of the chloroquine resistant infections. Even though the 3 remaining cases with parasitemia received amodiaquine treatment, clinicians administered Fansidar, resulting in a clearing of parasitemia in 7 days. 34.8% of in vitro parasite cultures were resistant to chloroquine. The reduced ability of pregnant women to clear parasitemia likely explained the lower level of in vitro resistance.

A comparison of organochlorine pesticide residues in maternal adipose tissue, maternal blood, cord blood, and human milk from mother/infant pairs.

A total of 41 samples of maternal blood, milk, subcutaneous fat and umbilical cord blood were collected from mothers giving birth by Caesarean operation at Kenyatta National Hospital in Nairobi in 1986. The samples were analyzed for organochlorine contaminants. The main contaminants found in all the samples were p,p'-DDT (100%), p,p'-DDE (100%), o,p'-DDT (59%), dieldrin (27%), transnonachlor (15%), beta-HCH (12%) and lindane (2%) of all the samples analyzed. Polychlorobiphenyl (PCB) residues were not detected in any of the samples. The mean levels (mg/kg fat) of sum of DDT were 5.9 in subcutaneous fat, 4.8 in mothers milk, 2.7 in maternal serum and 1.9 in umbilical cord serum. There was a significant correlation between the levels of sum DDT in subcutaneous fat and milk fat (r = 0.963), subcutaneous fat and maternal serum fat (r = 0.843), and maternal serum fat and maternal milk fat (r = 0.868), indicating the coherence of DDT in the body. Hexachlorocyclohexane (beta-HCH) was found in subcutaneous fat and milk fat with the mean levels of 0.03 and 0.26 mg/kg fat, respectively. Dieldrin detected in mothers milk and subcutaneous fat could not be quantified.

A survey of the knowledge, attitude and practice of induced abortion among nurses in Kisii district, Kenya.

PIP: A cross-sectional study was carried out in Kisii District in the western part of Kenya between April 1 and April 28, 1991, with the objectives of ascertaining the attitude of nurses towards induced abortion, patients, and their involvement in abortion. Data were collected using a structured, self-administered questionnaire. All nurses present at the various institutions were recruited. A total of 218 nurses were recruited into the study. 75-83% were married, female nurses younger than 40, and therefore in the reproductive age group. 134 (61.5%) nurses were Protestant and 51% worked in the government district hospital. The nurses displayed a deficient knowledge of all aspects of induced abortion. Among clinically safe methods only intraamniotic saline instillation and dilation and curettage were mentioned by 4% and 11%, respectively. This deficiency in knowledge may be explained by the fact that most nurses work in the government hospitals, where induced abortion is not a routine procedure. Only 26-28% of the nurses thought it was safe to induce abortion at 1 and 2 months of gestation. 31-43% either did not know or were uncertain. Abortion is illegal in Kenya except when the life of the mother is in danger. Most nurses seemed to favor the law. A previous study in Nairobi revealed that only 38% of the nurses favored abortion on demand under a liberalized abortion law. 24 (11%) of nurses admitted to have induced abortion before. Their knowledge of induced abortion needs to be improved in order to prevent an increase in mortality and morbidity associated with improperly performed abortions.^ieng

Pseudo-precocious puberty in a Kenyan African child: a case report.

A female Kenyan child with pseudoprecocious puberty due to juvenile granulosa cell tumour is presented. Clinical features in this patient included a mass in the lower abdomen, a growth spurt and appearance of pubic hairs as well as enlargements of the breasts. No similar case has been reported in a Kenyan child. The management and review of literature are discussed.