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International Journal of Health Sciences & Research (www.ijhsr.org) 18
Vol.7; Issue: 11; November 2017
International Journal of Health Sciences and Research
www.ijhsr.org ISSN: 2249-9571
Original Research Article
Prevalence and Aetiology of Pathological Vaginal Discharge among Third-
Trimester’ Women Attending Antenatal Care at Kampala International
University Teaching Hospital
Dr. Bwaga Ibrahim1, Dr. Nzabandora Emmanuel1, Prof. Ubarnel Almenares1, Prof. Ivan Bonet Fonseca1,
Mr. Echoru Isaac2, Mr. Atuhaire Collins4, Prof. Ssebuufu Robinson3
1Department of Obstetrics and gynecology, Kampala International University Teaching Hospital
2Department of Human Anatomy, Kampala International University, Western Campus
3Department of Surgery, Kampala International University Teaching Hospital
4Department of Public Health, Kampala International University Teaching Hospital
Corresponding Author: Dr. Bwaga Ibrahim
ABSTRACT
Background: A vaginal discharge means any secretion originating from the vagina except blood.
Pathological vaginal discharge predisposes to preterm labor and prematurity which is a leading cause
of infant mortality in the world.
Objectives: To determine prevalence and aetiology of pathological vaginal discharge among women
in third trimester who attend Antenatal Care (ANC) at Kampala International University Teaching
Hospital (KIUTH).
Research methods: A cross-sectional study was carried out from February through April, 2017. 394
of the women in third trimester who attended ANC at KIUTH during the study period were recruited,
and data was collected using structured interviewer-administered questionnaire and laboratory
investigation on the vaginal discharge specimen. The data was analyzed with the use of SPSS
software.
Results: 45.2% of participants had pathological vaginal discharge. Vaginal Candidiasis largely
contributed to pathological vaginal discharge (37.1%) while Trichomoniasis contributed the least
(2.2%). Bacterial Vaginosis caused 10.1% of the pathological vaginal discharge while 50.6% was due
to bacterial infections (of the total of 178 participants, 34.3% had Staphylococcus Species infection,
Streptococcus infection at 1.7%, Klebsiella species at 3.4% and mixed infections at 1.1%).
Conclusion: Some pregnant women in third trimester who attend ANC at KIUTH actually harbor
pathogenic organisms (Trichomonas spp, Candida spp, Staphylococcus spp, Streptococcus spp, E. coli
and Bacterial vaginosis) and these organisms put them at risk of poor perinatal outcomes like
premature rupture of membranes, chorioamnionitis, etc. Some pregnant women in third trimester have
pathogenic bacterial colonization that requires detection and necessary care given.
Key words: Pathological Vaginal Discharge, Antenatal Care
INTRODUCTION
According to Omole, 2011, a vaginal
discharge means any secretion originating
from the vagina except blood. Vaginal
discharge may be normal (physiological) or
abnormal (pathological). Physiological
vaginal discharge normally increases in
pregnancy. Pathological vaginal discharge
can present with variable colors including
brown, yellow, green, white or red in color,
sometimes with an itchy sensation of
genitals and a foul smell or may be
asymptomatic. Vaginal discharge normally
results from secretion arising from cervix
and Bartholin’s glands; and shedding of
epithelial cells of the vagina which results
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 19
Vol.7; Issue: 11; November 2017
from bacterial action in the vagina (Spence
and Melville, 2007 ; Fettweis et al., 2012;
Doerflinger et al., 2014). Identification of
microbial causes of pathological vaginal
discharge which occurs among pregnant
women dates from the twentieth century but
majorities of the studies were conducted
during the twenty first century (Andrea Seils
et al., 2005). Pathological vaginal discharge
predisposes to preterm labor and
prematurity which is a leading cause of
infant mortality in the world. Identification
of the aetiology of pathological vaginal
discharge helps to reduce on prematurity
hence reducing infant mortality. Globally,
studies on prevalence of pathological
vaginal discharge among pregnant women
have revealed varying results; according to
the study conducted by da Fonseca et al.,
(2013), 43% of participants had pathological
vaginal discharge during pregnancy. Many
studies have been conducted in Africa about
pathological vaginal discharge in pregnancy
especially in West Africa. One of the latest
studies was conducted by Sanusi and
Mohammed, (2016), about treatment of
abnormal vaginal discharge among pregnant
women, 31.5% of study participants were
found to have pathological vaginal
discharge while Abdelaziz et al., (2014),
reported pathological vaginal discharge to
have a prevalence of 63% in the third
trimester. In Uganda, literature search has
revealed scarce information on pathological
vaginal discharge during pregnancy. In a
study named ―Lack of effectiveness of
syndromic management in targeting vaginal
infections in pregnancy in Entebbe,
Uganda‖, Tann et al., (2006), concluded that
Bacterial vaginosis (BV) affects 47.7%;
Trichomonas vaginalis (TV) affecting
17.3%; Candida affecting 60.6%; and
gonorrhoea affecting 4.3% of pregnant
women. Normal vaginal discharge has been
said to occur in pregnancy, during sex or at
some period in menstrual cycle (Dawson et
al., 2012; Bossio et al., 2014). During
pregnancy, consistence of vaginal discharge
changes, most women produce more
discharge while pregnant. Pathological
vaginal discharge during pregnancy may be
due to infection mainly BV, vaginal
candidiasis, Trichomonas vaginalis
(Donders, 2010; Waters et al., 2008). Other
causes include Group B Streptococcus
(GBS) and other bacteria. In pregnancy, the
lower genital tract changes with
hypertrophy of the vaginal walls and
increase in blood flow and temperature, and
vaginal acidity which is common in this
period. These changes protect the uterus,
fetus and pregnancy but they predispose to
vaginal infection, which requires special
attention to prevent vertical transmission.
There is evidence that Trichomonas
vaginalis increases risk of having preterm
labor, premature rupture of
membranes(PROM) (Choi et al., 2012;
Silver et al., 2014; Nakubulwa et al., 2015)
and low birth weight infant. The number of
women affected by pathological vaginal
discharge increases during pregnancy
because of increase in estrogen and
deposition of glycogen (Hay and Czeizel,
2007; Moaiedmohseni et al., 2012).
Bacterial Vaginosis (BV) during pregnancy
is a risk factor to Intra-uterine fetal death.
According to Brotman, 2011, 10%–30% of
pregnant women with BV have preterm
labor; however, there is no evidence that
treating women with BV helps to reduce the
risk of preterm delivery (Hendler et al.,
2007). BV is diagnosed basing on clinical
criteria (Amsel) or the Nugent criteria which
involves Gram stain; both methods are
subjective, although the Nugent criteria
require a highly skilled personnel and more
time (Martínez et al., 2011; Chawla et al.,
2013), while organisms can be identified.
Lactobacilli bacteria are protective in the
vagina because they produce lactic acid,
which is produced by fermentation
accumulates and decreases the pH to a
protective level of 4.5 or lower ( O’Hanlon
et al., 2013; Mendes-Soares et al., 2014).
MATERIALS AND METHODS
Study design
A descriptive and analytical cross-
sectional study was conducted to study
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 20
Vol.7; Issue: 11; November 2017
prevalence and aetiology of pathological
vaginal discharge among third- trimester
women attending antenatal care at Kampala
International University Teaching Hospital.
Study population
The study population was obtained
using selection criteria i.e. inclusion and
exclusion criteria. The study population
involved women in third trimester who
attend Antenatal care at Kampala
International University Teaching Hospital.
Selection criteria
Inclusion Criteria: Third trimester’
pregnant women attending ANC at KIUTH
who had vaginal discharge were included in
the study. Gestation age was calculated
from the first day of the last menstrual
period and early ultrasound scan; those
found to be beyond 28weeks and above are
taken to be in third trimester. The research
participants were those who attended
Antenatal care at KIUTH during the study
period. Only those women that consented
were included in the study.
Exclusion Criteria: Those who had
unprotected sex in the previous 24 hour
were also excluded because this would alter
the pH of the vaginal discharge. Those
women who did not consent were excluded
from the study
Sample size
A sample size of 394 Human research
participants was targeted.
Sample size determination
The sample size was achieved at a 5% level
of precision at 95% confidence level and
calculated using the Keish and Leslie (1965)
formula shown below;
N= (Z)²p(1-p)/d². N=Number of participants
Z=1.96
P-prevalence=63% (0.63) (Abdelaziz et al.,
2014). D= 0.05
N= (1.96)²*0.63(1-0.63)/ (0.05)²
N=358.
Adjusting for non- response, incomplete
data; we added 10% to arrive at an
estimated sample size of 394 Human
research participants.
Sampling techniques
Pregnant women in the third
trimester who attended ANC at KIUTH
during the study period, and were found to
have vaginal discharge on examination were
recruited into the study by consecutive
sampling. This was done to ensure that the
sample size was realized faster because not
all pregnant women are in third trimester.
Data collection instruments
Structured interviewer-administered
pre-tested questionnaire was used to collect
data on demographic profile and relevant
clinical complaints. The questionnaire
involved the following; serial number, date,
age, address, educational status, telephone
contact, occupation, LNMP, EDD,
gravidity, gestation age, religion, ethnicity,
marital status, number of sexual partners,
practice of orogenital sex, whether they
smoke, douching, statement of their
monthly income, about assets that they own
at home, whether they rent, number of
children in the family, HIV status, Diabetes
mellitus, history of abortion or vaginal
discharge in the previous pregnancy, history
of preterm labor in the current pregnancy,
history of Urinary tract infection and history
of hospitalization in the current pregnancy .
A detailed history was elicited (English),
translated where necessary for women who
did not understand English; and a vaginal
examination using a sterile cusco’s
speculum was performed. Presence or
absence of vaginal discharge was noted. The
amount, odour, colour and consistency of
vaginal discharge were noted. The pH of the
discharge was also taken in the same setting.
Swabs (3) (high vaginal swab) were taken
using sterile swab sticks and labeled.
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 21
Vol.7; Issue: 11; November 2017
Sample collection and transportation
Vaginal swab specimens were
obtained from each subject through a sterile
speculum examination and swabbing. Three
vaginal swabs were obtained from each
participant and placed into vaginal swab
containers. Once specimens were obtained,
they were transported immediately to the
Microbiology Laboratory Department of
KIUTH. Speculum examination and
specimen collection was performed by the
principle investigator, and some by the
midwives employed by KIUTH in ANC
section. Consent was obtained and the
questionnaire was subsequently filled by the
one who examined and obtained specimen.
The principle investigator also checked the
questionnaires for completeness before and
after use in the laboratory.
Specimen processing
After specimen submission to the
laboratory, it was processed immediately to
identify pathogenic microorganisms
according to established methods below for
diagnosis in this study.
Method of diagnosis of Bacterial
Vaginosis
Bacterial vaginosis was diagnosed
using the Amsel's clinical criteria and
standard microbiological techniques
according to U.S. Preventive Services
TASK FORCE, 2006. The Amsel’s clinical
diagnosis requires three of four criteria to be
met: the first is a vaginal pH greater than pH
4.5; the second is the presence of clue cells;
the third is a milky, homogeneous vaginal
discharge; and the fourth is the release of
amine (fishy) odour after addition of 10%
potassium hydroxide to the specimen.
The pH was determined directly by
applying a swab on a pH paper in the range
covering pH 4.0 to pH 6.5. The swab was
then inserted into 0.2 mL of normal saline in
a test tube; a drop of this extract was placed
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 22
Vol.7; Issue: 11; November 2017
on a glass slide. A 10% potassium
hydroxide drop was put on another glass
slide. The swab was then stirred in the 10%
potassium hydroxide and immediately
evaluated for the presence of a fishy odour.
Both drops were then covered with a
coverslip and examined at 400x
magnification under a light microscope.
Clue cells were identified as vaginal
epithelial cells with a heavy coating of
bacteria that the peripheral borders are
obscured. Amsel’s criteria has sensitivity of
91%, specificity of 91%, positive predictive
value of 86%, negative predictive value of
94%, and accuracy of 91%
(Mohammadzadeh et al., 2015).
Wet mount
Microscopy was performed
according to procedure described by Kelly,
1990, using sterile swabs; secretions were
obtained from the posterior fornix. We
placed the sample in 1 ml of saline and
shook to mix, then took a drop of this
mixture and placed it on a slide. We then
covered with a cover slip. The slide was
looked at promptly under a microscope.
Culture
Methods used
Isolation of E. coli
Isolation and identification of
bacteria was done by streaking sample on
blood agar, chocolate agar, Eosin Methylene
blue (EMB) agar and MacConkey agar.
Inoculated plates were incubated at 37º C
for 24 hours. Single well defined colony
was further sub-cultured on nutrient agar
and pure culture obtained. Identification of
bacteria was performed on the basis of
cultural characteristics; Gram’s staining
reaction, and biochemical tests.
Gram’s staining
Gram’s staining of the pure culture
was done according to the method described
by (Cheesbrough, 2006). Briefly, a single
colony was picked up with a bacteriological
wire loop, smeared on separate glass slide
and fixed by gentle heating. Crystal violate
was applied on each smear to stain for two
minutes and then washed with running tap
water, treated with lugols iodine, decolorize
with acetone alcohol and counterstained
with Safranin. The slides was washed with
water and allowed to air dry. It was
examined by a light microscope under oil
immersion lense (100X). Gram negative
rods observed as they appear red or pink in
colour.
BIOCHEMICAL TESTS
Sugar fermentation test (TSI agar)
The sugar fermentation test was
performed by inoculating isolated colonies
on slant TSI culture of the organisms into
each tube containing three basic sugars
(e.g., sucrose, lactose, and glucose) and was
incubated for 24 hours at 37º C. Acid
production was indicated by the color
change from reddish to yellow in the
medium and the gas production was noted
by the appearance of gas bubbles. TSI agar
with the above mentioned characteristics
were considered presumptive for E. coli.
Indole test
Two ml of peptone water was
inoculated with the 5 ml of bacterial culture
and incubated at 37 ℃ for 24-48 hours.
Kovac’s reagent (0.5ml) was added, shaked
well and examined after 1 minute. A red
color in the reagent layer indicated indole
positive test suggestive of E. coli.
Isolation of Klebsiella species
Cultural characteristics of Klebsiella
species colonies appeared pink (lactose
positive colonies) and mucous on
MacConkey’s agar, morphologically gram
stain showed gram negative rods.
Identification
Triple sugar iron agar indicated
sucrose, glucose and lactose fermentation
(butt and slant yellow), with gas production,
urea positive, indole negative, and citrate
positive.
Isolation of Staphylococcus species and
Streptococcus species: Samples collected
were inoculated on blood agar, chocolate
agar and MacConky agar and incubated at
37ᴼC for 24-48hrs and chocolate agar plates
were placed in candle jar which provide
10% carbon dioxide.
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 23
Vol.7; Issue: 11; November 2017
Identification
Colony morphology was observed
morphologically, organisms isolated were
determined by gram staining which gram
positive cocci were observed. Catalase test
was performed on the Gram positive
organisms and those found positive were
sub-cultured in mannitol salt agar (MSA)
and incubated at 37ᴼC for 18- 24hrs.
Staphylococcus aureus produced golden
yellow colonies. This was followed by
coagulase test which confirmed
Staphylococcus aureus. Non- coagulase
positive Staphylococcus spp did not ferment
mannitol. Catalase negative test was
indicative of Streptococcus species and this
was further confirmed by subculturing on
blood agar to differentiate Streptococci
species by type of hemolytic reaction
produced.
Isolation of Candida spp
Samples from blood and chocolate
agar suspected to be fungi were stained with
gram stain and positive yeast Gram stain
slides were sub-cultured on Sabouraud
dextrose agar (SDA) and incubated
aerobically at 37ᴼC for 24-48hrs.
Direct Microscopy: Potassium hydroxide
preparation of the sample was made on
microscope slides which revealed non-
pigmented septate hyphae with dichotomous
branching.
Colony from SDA was picked and smeared
on a microscope slide and then stained with
Gram stain which revealed the presence of
Candida hyphae and Yeast seen as dark
blue.
Identification
Germ tube test was done to identify C.
albican by the induction of hyphal
outgrowths (germ tube).
Method of diagnosis of trichomoniasis.
Identification of trichomonas was by wet
slide preparation using normal saline, then
microscopy carried out to identify motile
trichomonads.
Other bacteria: BA/ MacConkey agar and
Eosin Methylene blue agar for gram
negatives. Gram positives like
staphylococcus species were isolated by
culturing on Mannitol-salt agar (MSA). The
specimens were also isolated by culturing
on Chocolates and blood agar.
Quality assurance
Every twentieth specimen was taken
to two different laboratories, one a control
laboratory to ensure that reliable results
were being obtained in the study laboratory.
The microbiology laboratory of Kampala
International University (university section)
was used as a control laboratory because it
is near to the study site and it is an
independent laboratory from the Kampala
International University Teaching Hospital
laboratory.
Data management
Raw data was obtained, entered in
Microsoft Excel Worksheet. The coded data
was exported and inserted into SPSS
software for analysis.
Data analysis
All data analysis was carried out in
SPSS Version 20. The socio-demographic
and clinical characteristics of study
participants were summarized descriptively
using means, medians (for non-normally
distributed variables) and
frequencies/proportions for categorical
variables. The prevalence of Pathological
vaginal discharge was summarized as
percentages depicted in a pie chart. 95% CI
was obtained for positive pathological
discharge for inferential purposes. The
causes of pathological discharge were
summarized as frequencies and percentages.
Ethical Considerations
Informed consent
Adequate explanation was made to
the study participants in English and the
local language (Runyankole). Sterile
speculum examination was performed using
a cusco’s speculum before obtaining
consent from the study participants and
vaginal discharge (if present) specimen was
obtained by use of swab sticks. All pregnant
women who came to KIUTH for ANC were
examined vaginally for presence of vaginal
discharge. Informed consent was sought
from those women who were found to have
vaginal examination during speculum
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 24
Vol.7; Issue: 11; November 2017
examination. For women who did not allow
to consent, the specimen that had been
obtained was discarded. It was emphasized
that they could withdraw from the study at
any stage without compromising the quality
of care they deserved thereafter.
Confidentiality was ensured as only the
principle investigator together with the
research assistants had access to the results
and there was no unauthorized access to
such information by any other parties. The
risks anticipated in the study included
accidental injuries during examination but
none happened. Those women participating
had access to screening for infections which
can predispose to poor perinatal outcome.
Those women who were found to have
infection were offered treatment.
Recruitment was after voluntary acceptance
and a consent form had to be signed.
Pregnant minors (emancipated minors or
those under the age of 18 years) did not
require presence of their guardians to
consent; these procedures were approved by
the Mbarara University of Science and
Technology- Institutional Review and
Ethics Committee. All women had the right
to opt out at any stage without questioning.
Approval to carry out the study was sought
from the department of Obstetrics and
Gynaecology of Kampala International
University Teaching Hospital and the
Institutional Research Ethics Committee of
Mbarara University of Science and
Technology. This approval letter was
presented to the hospital administration.
Consent of the pregnant mothers to take part
in this study was sought and patients who
agreed were assured of strict confidentiality
about their information. The consent form
included the objectives of the study, how
this study would benefit the individual
participating, the potential risks/hazards and
measures taken to counter these hazards,
how confidentiality was ensured, and the
freedom to leave the study whenever they
wished without compromising any services
they may have needed afterwards.
RESULTS
Socio-demographic, medical and obstetric characteristics of study participants
Table 1: Distribution of characteristics of study participants
Variable
Summary measure
Median age (IQR)
25 (22-29)
Median gravidity (IQR)
2 (1-3)
Median parity (IQR)
1 (0-2)
Education n (%)
None
5(1.3)
Primary
156(39.6)
Secondary
161(40.8)
Tertiary
72(18.3)
Total N
394 (100%)
Religion n (%)
Anglican
170(43.1)
Catholic
148(37.6)
Muslim
44 (11.2)
Born again
20 (5.1)
SDA
7 (1.8)
Other
2 (0.5)
Not stated
3 (0.7)
Total N
394(100%)
Occupation n (%)
Saloon
14 (3.6)
farmer/peasant
174 (44.2)
Business
47(11.9)
Teacher
35 (8.9)
Nurses/midwives
6 (1.5)
Other
118 (29.9)
Total
394 (100%)
Income in UGX n (%) per month
< 0.5 million
287 (72.8)
>0.5million
74(18.8)
Not stated
33(8.4)
Total N
394 (100%)
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 25
Vol.7; Issue: 11; November 2017
Table 1 to be Continued…
Marital status n (%)
Married
357 (90.6)
Single
32 (8.1)
Cohabiting
5 (1.3)
Total N
394 (100)
Vaginal douching n (%)
No
183 (46.4)
Yes
211 (53.6)
Total N
394 (100)
Mean Vaginal PH (Sd)
4.26 (0.2)
Smell of Vagina discharge (%)
Offensive
30 (7.6)
Non-offensive
364 (92.4)
Total N
394 (100)
Mean number of sexual partners (Sd)
1.02 (0.1)
Orogenital sex n (%)
No
360 (91.4)
Yes
18 (4.6)
Not stated
16 (4.0)
Total
394 (100)
HIV status n (%)
Negative
349 (88.6)
Positive
32 (8.1)
Not stated
13 (3.3)
Total N
394 (100%)
History of STI n (%)
No
313 (79.4)
Yes
74 (18.8)
Not stated
7 (1.8)
Total N
394 (100%)
Diabetes Mellitus n (%)
No
385 (97.7)
Yes
1 (0.3)
Not stated
8 (2.0)
Total N
394 (100%)
History of miscarriage n (%)
No
324(82.2)
Yes
70 (17.8)
Total N
394 (100)
Vaginal discharge in previous pregnancy n (%)
No
312 (79.2)
Yes
82 (20.8)
Total N
394 (100)
History of disease in current pregnancy n (%)
No
337 (85.5)
Yes
57 (14.5)
Total N
394 (100%)
Hospitalization in current pregnancy n (%)
No
359 (91.1)
Yes
35 (8.9)
Total N
394 (100%)
Pathological discharge n (%)
No
216 (54.8)
Yes
178 (45.2)
Total
394 (100)
The median age of participants was
25 years with lower quartile and upper
quartile of 22 years and 29 years
respectively. Over 40% of the study
participants had attended secondary
education. The majority of study
participants were Anglicans, 43.14%
(170/394). About 3.55% (14/394) of the
study participants were saloon workers and
over 70% of the women had monthly
income of not more than 500,000 Uganda
shillings. Approximately 54% of the
participants practice vaginal douching. The
mean PH of the vagina was 4.3 with 0.2
standard deviations. Approximately 8% of
the participants had offensive vaginal
discharge. Approximately 19% of the study
participants had history of STI’s as shown
in table 1 above.
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 26
Vol.7; Issue: 11; November 2017
The prevalence of pathological vaginal
discharge among pregnant women in third
trimester attending ANC at KIUTH.
Figure 1: Prevalence of pathological vaginal discharge among
third trimester’ women attending antenatal care at
Kampala
International University Teaching
Hospital
A total of 394 research participants were
recruited in the study and 178 of this total
sample size were found to have pathological
vaginal discharge. The prevalence of
pathological vaginal discharge was 45.2%
with 95 % confidence that the true
proportion of pathological discharge ranges
from 40 – 50% as shown in figure 1 above.
Aetiology of pathological vaginal
discharge among pregnant women in
third trimester attending ANC at
KIUTH.
Table 2 : Aetiology of pathological vaginal discharge
Cause
Frequency
Percent
Bacterial vaginosis
18
10.1
Trichomoniasis
04
2.2
Candidiasis
66
37.1
Other bacteria†
90
50.6
Total N
178
100%
†Others: E. coli (n(%)=18(10.1%); Staphyloccocus spp
(n(%)=61(34.3%); Streptococcus spp (n(%)=03(1.7%); Klebsiella
(n(%)=06(3.4%); E. coli & Staphylococcus aureus (n(%)=2(1.1%)
From the total sample size of 394
recruited participants, 178 were found to
have pathological vaginal discharge
(45.2%). Of the 178 participants, 18
participants were found to have Bacterial
Vaginosis (10.1% of pathological vaginal
discharge), 4 (2.2%) participants were found
to have Trichomonas Infection, 66 (37.1%)
participants were found to have Vaginal
candidiasis and 90 participants (50.6%)
were found to have bacterial causes which
included E. coli, Staphylococcus species,
Streptococcus species, Klebsiella. Simple
tabulation of aetiology of vaginal discharge
suggests that Candida infection at 37.08% is
the major cause of pathological vaginal
discharge followed by bacteria
(Staphylococcus species) at 34.3%.
Streptococcus spp contributed the least
percentage towards occurrence of
pathological vaginal discharge at 1.7%. The
results of proportions of aetiological causes
of pathological vaginal discharge are as
shown in table 2 above.
DISCUSSION
Prevalence of pathological vaginal
discharge among pregnant women in the
third trimester who attend Antenatal Care at
Kampala International University Teaching
Hospital.
The prevalence was found to be 45.2% (95
% confidence that the true proportion of
pathological vaginal discharge ranges from
40 – 50%). This was slightly similar to 43%
and 40% obtained by Fonseca et al. (2013)
and Cesar et al. (2009) in Brazil.
The study findings are not in
agreement with similar studies that reported
lower prevalence of 31.5% (Sanusi and
Mohammed, 2016) and 35.5%
(Moaiedmohseni et al., 2012). Additionally,
Abdelaziz et al. (2014) reported a
prevalence of 63% in Khartoum, Sudan
which was higher than that obtained in the
present study. The relatively high
prevalence of pathological vaginal discharge
in the current study is probably because of
poor health seeking behavior coupled with
inadequate knowledge about perineal
hygiene among women who seek health
care at Kampala International University
Teaching Hospital.
5.1.2 Aetiology of pathological vaginal
discharge among third trimester’ women
who attend antenatal care at Kampala
International University Teaching
Hospital
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 27
Vol.7; Issue: 11; November 2017
The etiological causes of
pathological vaginal discharge reported in
this study included; Candidiasis with
prevalence rates (37.1%), bacterial
vaginosis (10.1%), trichomoniasis (2.2%)
and bacterial infections (50.6). These causes
were similarly reported by Aboud et al.
(2008), Larsson et al. (2007) and Tann et al.
(2006) during the third trimester of
pregnancy, although the prevalence are
different.
Bacterial infections were the most
prevalent causes of pathological vaginal
discharge with Staphylococcus spp being
highest followed by E. coli, Klebseilla spp,
and streptococcus spp. This was in
agreement with several studies that
highlighted these bacteria as predominantly
isolated from pathological vaginal
discharges (Tann et al., 2006; Kirakoya-
Samadoulougou et al., 2008; Akerele et al.,
2002). The study obtained a lower
prevalence of Staphylococcus spp compared
to 51% reported by Akerele et al., 2002);
however, the prevalence of bacterial causes
was higher than 14.5% reported by Andrews
et al. (2008). Bergeron et al. (2000) and
Kennedy et al. (2009) reported a prevalence
of 17.9% and 20 to 30% group B
Streptococci respectively in vaginal
discharges which was higher than that
reported in the present study. The low
prevalence of Group B Streptococcal
infection in the current study might be
because of environmental/climatic
differences from that in which other studies
were conducted.
Vaginal candidiasis was the second
most common cause of pathological vaginal
discharge among the study participants.
These findings were in agreement to those
by Olowe et al. (2014) in Nigeria where
they reported 37.4% pathological vaginal
discharge, however, it was higher than
prevalence found in Accra, Ghana (34.2%)
(Apea-Kubie et al., 2006), 30% in South
India (Deepa et al., 2014) and 20% in
Nigeria (Nurat et al., 2015). The high
prevalence of vaginal candidiasis among
study participants may be a result of
insufficient knowledge, poor hygiene,
limited diagnostic centres, poor diet, lack of
effective treatment, wearing of tight-fitting
underclothing, prolonged antibiotic use
which kill the good and beneficial bacteria.
Still, it was slightly higher than the findings
of Yadav and Prakash, (2016) and Guzel et
al. (2011) in Nigeria who reported a slightly
lower rate of 36.5%, 35% and 36%
respectively compared to the present study.
Furthermore, the prevalence of
vaginal candidiasis obtained was much
lower than that of other related studies
which reported 60% in Uganda (Tann et al.,
2006), 54% in Nigeria (Ibrahim et al.,
2016), 42.37% in India (Kanagal et al.
2004). Nelson et al. (2013) reported that the
third trimester has the highest prevalence of
candidiasis (68.09%) (Which is greater than
the current study). Still, these findings were
in concurrence with the study by Alo et al.
(2012) who reported that 40% of pregnant
women worldwide might be harboring
candida species in their vaginas.
According to studies by Mitchell,
(2004) showed that recent antibiotic intake
and douching have a positive correlation to
vaginal candidiasis. This has been reported
to cause suppression of the lactobacillus
species which serves as a protective
organism making way for the yeast to thrive
and colonize the vagina (Kennedy et al.,
2009). The study reported Trichomonas
vaginalis (2.25%) as a potential cause of
pathological vaginal discharge which was
lower than Tann et al. (2006), Romoren et
al. (2007) and Sutton et al. (2007) who
reported higher prevalence rates of vaginal
discharge due T. vaginalis as 17.3%, 19%
and 8.7% respectively compared to the
present study. This low prevalence may be
attributed to the method of diagnosis of
Trichomoniasis used in this study (wet slide
preparation) which has a relatively lower
sensitivity. The low prevalence of T.
vaginalis obtained in the present study is
also be related to the less risky sexual
behavior and vaginal hygiene of the
participants since high risk sexual behavior
Bwaga Ibrahim et al. Prevalence and Aetiology of Pathological Vaginal Discharge among Third- Trimester’
Women Attending Antenatal Care at Kampala International University Teaching Hospital
International Journal of Health Sciences & Research (www.ijhsr.org) 28
Vol.7; Issue: 11; November 2017
and poor hygiene were reported to
predispose to occurrence of trichomoniasis
by da Fonseca et ai.,(2013), however, other
studies reported lower rates of 1.5%, 2.1%
(Kirakoya-Samadoulougou et al., 2008;
Matini et al., 2012). This signifies that the
prevalence of trichomonas infection varies
with geographical location, because of
difference in climatic conditions. In
addition, majority of the participants were
married (90.6%) while very few did
cohabiting (1.27%). Married couples may
be practicing better hygiene practices
compared to those who are cohabiting.
Married women may also have better
supportive partners compared to those who
cohabit. The parasite has been reported to
increase the risk of having premature
rupture of membranes and preterm labor
(Nakubulwa et al., 2015, Choi et al., 2012;
Silver et al., 2014).
The prevalence of bacterial
vaginosis obtained in this study was slightly
higher (10.1%) than 6.4% reported by
Kirakoya-Samadoulougou et al. (2008) in
Burkina Faso. Additionally, the results were
not parallel to similar studies which reported
higher prevalence rates of 47.7% in Uganda
(Tann et al., 2006) and 38% (Romoren et
al., 2007).
CONCLUSION
significant proportion of pregnant
women in third trimester who attend ANC
at KIUTH actually harbor pathogenic
organisms (Trichomonas spp, Candida spp,
Staphylococcus spp, Streptococcus spp, E.
coli and Bacterial vaginosis) and these
organisms put them at risk of poor perinatal
outcomes like premature rupture of
membranes, prematurity, chorioamnionitis,
etc. Some pregnant women in third trimester
have pathogenic bacterial colonization that
requires detection and necessary care to be
given.
Recommendation
Equipping health facility and
training of medical personnel to perform
routine screening for pathological vaginal
discharge for all women during third
trimester. Wide screening of infections in
the laboratory with adequate media variety
so that the different organisms can be
identified; also to educate and sensitize
women about the risk factors to occurrence
of vaginal candidiasis.
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How to cite this article: Ibrahim B, Emmanuel N, Almenares U et al. Prevalence and aetiology of
pathological vaginal discharge among third- trimester’ women attending antenatal care at
Kampala international university teaching hospital. Int J Health Sci Res. 2017; 7(11):18-31.
