**3. Outcome of study on abnormal vaginal discharge among pregnant women conducted in Maiduguri, Borno State in North-eastern Nigeria**

#### **3.1. Goal and objectives**

Characteristically, vulvitis is minimal or absent compared with candidiasis. On speculum exam, apart from the discharge, a cervical erosion may be seen, and in severe cases, multiple, small punctuate haemorrhages and swollen papillae may be found on the cervix ("straw berry"

The vaginal pH is usually 5–5.5 in trichomonas infection [17]. Applying litmus to the unlubri‐ cated speculum after it has been withdrawn from the vagina easily tests the pH. A saline wet mount of the swab taken from the vagina or cervix will show motile flagellated protozoa and leucocytes. Wet mount alone detects 64% infection in asymptomatic women, 75% of those with clinical vaginitis and 80% of those with characteristic symptoms [5]. The use of culture (Feinberg-Whittington or Diamond culture) gives a sensitivity of 86–97% [5]. Pap smear has a detection rate of about 50–86% [5]. Monoclonal antibody staining is also used. It is sensitive

Metronidazole is effective in eradicating *T. vaginalis* administered orally in a single 2 g dose [5, 10]. Ootrimazole, which is both a fungicide and trichomonacide, can be used intravaginally usually in pregnancy in the same dosage regime as in candidiasis [5]. In persistent infection,

*Chlamydia* and gonorrhoea can both cause vaginal discharge in pregnancy and a major cause of morbidity among women in developing countries [31]. Both infections have been associated with pregnancy-related complications [32]. These two conditions are prevalent worldwide particularly in Africa [20]. They are a major cause of acute pelvic inflammatory disease,

The prevalence of *Chlamydia* and gonorrhoea among pregnant women in Africa, in several studies, is between 6–13% [4, 33] and 2–8% [4, 34], respectively. According to the WHO, globally new cases of *C. trachomatis* infection have been estimated as 92 million, including 19 million in Sub-Saharan Africa [35–37]. In Maiduguri, North-eastern Nigeria, Amin et al.

*Chlamydia* is characteristically asymptomatic [39, 40]. About one-third of patients may have symptoms including mucopurulent vaginal discharge [5]. The role of *Chlamydia* in infertility is well documented [39–42]. Tubal pathology in *Chlamydia* infection is the cause of infertility in 10–30% of couples in developed countries and in up to 85% in developing countries [36, 37, 43, 44]. The main cause of tubal pathology is PID. Several different methods to diagnose chlamydial infection are available. Great studies have been performed in the areas of reliable methods of diagnosis [40, 45]. *Chlamydia* culture is considered as the gold standard because it has near 100% specificity [40, 45]. Because only viable infectious chlamydial elementary bodies are detected by culture, this is the method of choice for medico-legal issues. The disadvantages of culture include its low sensitivity and is that it depends on the laboratory inter-personal experience [46]. Non-culture methods include enzyme immunoassay (EIA), direct fluorescent staining with monoclonal antibodies (DFA), nucleic acid amplification tests (NAATs) and

and is reported to detect 77% of those missed on wet mount [5].

**2.4. Gonorrhoea and chlamydial infection**

infertility and adverse pregnancy outcomes [20].

reported a prevalence of 9% [38].

it is best to treat the patient and her male sexual partner simultaneously.

cervix) and vagina [17].

52 Genital Infections and Infertility

The general objective of the study is to detect the clinical features associated with abnormal vaginal discharge and antibiotic sensitivity pattern of the causative microorganisms in pregnant women to improve the early diagnosis and prompt treatment. The specific objectives were as follows:


### **3.2. Methodology**

Borno State lies between latitude 10° and 14° north and longitude 14° and 45° east. It is located in the north-eastern part of Nigeria. Maiduguri is the capital city. The University of Maiduguri Teaching Hospital (UMTH) is a tertiary health institution and is the only functional teaching hospital in the north-eastern zone of Nigeria. The 2006 Nigerian provisional census puts the population of Borno State at 4,151,193 with 1,990,036 females [49].

It was a cross-sectional analytical study. The study population consisted of pregnant women presenting to the antenatal clinic with complaint of abnormal vaginal discharge while pregnant women without complaints of abnormal vaginal discharge attending the antenatal clinic of the hospital served as controls. A sample size of 800, consisting of 400 cases and 400 controls, was obtained using Taylor's and Kish's formulas [50]. Information on sexual and reproductive risk factors and symptoms was obtained. Vaginal examination was performed, and discharge was assessed. Endocervical and high vaginal swabs were collected and immediately processed in accordance with microbiological standard. Infection with *Candida* species was diagnosed by microscopy of a saline mount, which showed a highly refractile, round or oval budding yeast cells, and gram-stained smear of material from the vagina showed gram-positive pseudohy‐ phae with budding yeast cells; *T. vaginalis* was diagnosed by microscopy of a saline mount for actively motile, spear-shaped flagellates, whereas bacterial vaginosis was diagnosed using Amsel's criteria [26]. *N. gonorrhoea* was identified by typical colonial morphology, reactions to gram stain, positive oxidase test and sugar fermentation. The antibiotic sensitivity of isolates was tested by the agar diffusion method on chocolate agar plates using oxoid multi discs with standard antibiotic concentration.

The computer program SPSS V 20.0 (2010) Inc., Illinois, United States was used to analyse the results; the association between organisms and studied variables was compared using chisquare (*χ*<sup>2</sup> ) and Fisher's exact tests while *P* value <0.05 was considered significant at 95% confidence level.

#### **3.3. Results**

During the period of study, 1280 pregnant women were seen at the antenatal booking clinic among which 800 satisfied the inclusion criteria. Four hundred of the pregnant women complained of abnormal vaginal discharge (cases), whereas 400 had no complaint of vaginal discharge, giving a prevalence of abnormal vaginal discharge in pregnancy of 31.5%.

Table 1 shows the clinical features associated with vaginal discharge in the study group. Vulval pruritus was present in 266 patients, and 200 (75%) of them complained of vaginal discharge, whereas 66 (25%) were in the control group. There was a significant association between pruritus and vaginal discharge (*χ*<sup>2</sup> = 1.011, *P* < 0.001). As much as 63% of those without itching were in the control group. Dysuria showed statistically significant association with vaginal discharge (*χ*<sup>2</sup> = 44.008, *P* < 0.000) with 74 (83%) of the 89 patients who complained of dysuria having vaginal discharge. There was no statistically significant association between dyspar‐ eunia and vaginal discharge (*χ*<sup>2</sup> = 2.082, *P* = 0.149). The only patient that had vulval wart complained of vaginal discharge, there was, however, no statistically significant association between vulval warts and abnormal vaginal discharge.

**Figure 1.** (Findings from culture of ECS/HVS from pregnant women with abnormal vaginal discharge (N=400)) shows outcome of culture and microscopy from vaginal discharge specimens collected from women with complaint of vagi‐ nal discharge. The prevalence of positive culture was 77% (308) among the cases and 21.3% (85) among the control group. Of the 400 patients with abnormal vaginal discharge, the commonest microorganism found was *C. albicans*, 160 (40%), whereas *N. gonorrhoea* infection was the least, 1(0.2%). *E. coli* was isolated in 20 (5%), *T. vaginalis* in 7 (1.8%), *Staphylococcus aureus* in 36 (9%), *Klebsiella* species in 8 (2%), *G. vaginalis* in 68 (17%) and *Streptococcus* species in 8 (2%) of the pregnant women. Samples from 92 (23%) patients had negative culture.


a Lower abdominal tenderness.

**3.2. Methodology**

54 Genital Infections and Infertility

standard antibiotic concentration.

pruritus and vaginal discharge (*χ*<sup>2</sup>

eunia and vaginal discharge (*χ*<sup>2</sup>

square (*χ*<sup>2</sup>

**3.3. Results**

discharge (*χ*<sup>2</sup>

confidence level.

Borno State lies between latitude 10° and 14° north and longitude 14° and 45° east. It is located in the north-eastern part of Nigeria. Maiduguri is the capital city. The University of Maiduguri Teaching Hospital (UMTH) is a tertiary health institution and is the only functional teaching hospital in the north-eastern zone of Nigeria. The 2006 Nigerian provisional census puts the

It was a cross-sectional analytical study. The study population consisted of pregnant women presenting to the antenatal clinic with complaint of abnormal vaginal discharge while pregnant women without complaints of abnormal vaginal discharge attending the antenatal clinic of the hospital served as controls. A sample size of 800, consisting of 400 cases and 400 controls, was obtained using Taylor's and Kish's formulas [50]. Information on sexual and reproductive risk factors and symptoms was obtained. Vaginal examination was performed, and discharge was assessed. Endocervical and high vaginal swabs were collected and immediately processed in accordance with microbiological standard. Infection with *Candida* species was diagnosed by microscopy of a saline mount, which showed a highly refractile, round or oval budding yeast cells, and gram-stained smear of material from the vagina showed gram-positive pseudohy‐ phae with budding yeast cells; *T. vaginalis* was diagnosed by microscopy of a saline mount for actively motile, spear-shaped flagellates, whereas bacterial vaginosis was diagnosed using Amsel's criteria [26]. *N. gonorrhoea* was identified by typical colonial morphology, reactions to gram stain, positive oxidase test and sugar fermentation. The antibiotic sensitivity of isolates was tested by the agar diffusion method on chocolate agar plates using oxoid multi discs with

The computer program SPSS V 20.0 (2010) Inc., Illinois, United States was used to analyse the results; the association between organisms and studied variables was compared using chi-

During the period of study, 1280 pregnant women were seen at the antenatal booking clinic among which 800 satisfied the inclusion criteria. Four hundred of the pregnant women complained of abnormal vaginal discharge (cases), whereas 400 had no complaint of vaginal

Table 1 shows the clinical features associated with vaginal discharge in the study group. Vulval pruritus was present in 266 patients, and 200 (75%) of them complained of vaginal discharge, whereas 66 (25%) were in the control group. There was a significant association between

were in the control group. Dysuria showed statistically significant association with vaginal

having vaginal discharge. There was no statistically significant association between dyspar‐

= 44.008, *P* < 0.000) with 74 (83%) of the 89 patients who complained of dysuria

= 1.011, *P* < 0.001). As much as 63% of those without itching

= 2.082, *P* = 0.149). The only patient that had vulval wart

discharge, giving a prevalence of abnormal vaginal discharge in pregnancy of 31.5%.

) and Fisher's exact tests while *P* value <0.05 was considered significant at 95%

population of Borno State at 4,151,193 with 1,990,036 females [49].

**Table 1.** Clinical features associated with vaginal discharge in the study group (*N* = 800).

Table 2 shows the association between the bacterial isolates and their antibiotic sensitivity patterns. *G. vaginalis* was sensitive to augmentin and ofloxacin in 64% of cases. *Streptococ‐ cus* sp. was most sensitive to augmentin and erythromycin in 92% (12/13) and 84% (11/13) of cases, respectively. *N. gonorrhoea* was sensitive to augmentin and ofloxacin in 100% of cases but was 100% resistant to other antibiotics. *E. coli* was sensitive to cefuroxime and gentami‐ cin in 62% and 65% of cases, respectively. Most of the microbial isolates were resistant to ampicillin and norbactam. Only augmentin had greater than 60% sensitivity rate to all the isolated microorganisms.


a Amoxicillin-clavulanic acid.

**Table 2.** Antibiotic sensitivity rate (%) of isolated bacteria.

### **4. Conclusion**

Vaginal discharge in pregnancy is common, but distinguishing abnormal vaginal discharge from normal leucorrhoea of pregnancy is challenging. Since findings have showed that the trio of vaginal candidiasis, trichomoniasis and bacterial vaginosis are common causes of abnormal vaginal discharge in pregnancy; efforts must be made to exclude these conditions in pregnant patients presenting with vaginal discharge so that appropriate treatment can be instituted timely. Finally, gonococcal infection must also be excluded since though it is less prevalent than others, it is a major cause of morbidity in women in developing countries.

### **Author details**

Sanusi Mohammed Ibrahim\* , Mohammed Bukar and Bala Mohammed Audu

\*Address all correspondence to: ozovehesan@yahoo.co.uk; smibrahim@unimaid.edu.ng

Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria

### **References**

Table 2 shows the association between the bacterial isolates and their antibiotic sensitivity patterns. *G. vaginalis* was sensitive to augmentin and ofloxacin in 64% of cases. *Streptococ‐ cus* sp. was most sensitive to augmentin and erythromycin in 92% (12/13) and 84% (11/13) of cases, respectively. *N. gonorrhoea* was sensitive to augmentin and ofloxacin in 100% of cases but was 100% resistant to other antibiotics. *E. coli* was sensitive to cefuroxime and gentami‐ cin in 62% and 65% of cases, respectively. Most of the microbial isolates were resistant to ampicillin and norbactam. Only augmentin had greater than 60% sensitivity rate to all the

**Antibiotics** *S. aureus Klebsiella sp. E. coli G. vaginalis Streptococcus sp. N. Gonorrhoea*

Vaginal discharge in pregnancy is common, but distinguishing abnormal vaginal discharge from normal leucorrhoea of pregnancy is challenging. Since findings have showed that the trio of vaginal candidiasis, trichomoniasis and bacterial vaginosis are common causes of abnormal vaginal discharge in pregnancy; efforts must be made to exclude these conditions in pregnant patients presenting with vaginal discharge so that appropriate treatment can be instituted timely. Finally, gonococcal infection must also be excluded since though it is less prevalent

, Mohammed Bukar and Bala Mohammed Audu

than others, it is a major cause of morbidity in women in developing countries.

\*Address all correspondence to: ozovehesan@yahoo.co.uk; smibrahim@unimaid.edu.ng

Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital,

Amoxicillin 16.9 10.5 14.2 35.9 0 0 Augmentina 86 61.5 75 64 92 100 Ofloxacin 75 55 12.5 64 25 100 Ciprofloxacin 64 51 25 9.2 22.5 0 Erythromycin 45 1.2 25 72 84 0 Cefuroxime 50 50 62 26 50 0 Gentamicin 61 64 65 21 30 0 Ampicillin 25 45.5 0 7.2 0 0 Norbactam 17.5 25 4.2 0 0 0

isolated microorganisms.

56 Genital Infections and Infertility

Amoxicillin-clavulanic acid.

**4. Conclusion**

**Author details**

Maiduguri, Nigeria

Sanusi Mohammed Ibrahim\*

**Table 2.** Antibiotic sensitivity rate (%) of isolated bacteria.

a


[29] Wendel KA, Workowski KA. Trichomoniasis: challenges to appropriate manage‐ ment. Clin Infect Dis 2007; 44:S123.

[14] Klufio CA. Prevalence of vaginal infections with bacterial vaginosis, *Trichomonas vag‐ inalis* and *Candida albicans* among pregnant women at the Port Moresby General Hos‐

[15] Puri KJ, Mdan A, Benjal K. Evaluation of causes of vaginal discharge in relation to pregnancy status. Indian J Dermatol Venereol Leport [semal online] 2003; 69:129–130.

[16] Sobel JD. Vulvovaginal candidiasis. In: Sexually transmitted diseases. 3rd edition. Edited by Holwes KK, Mardh PA, Sparling PF, et al. Mc Graw Hill, New York 1999:

[17] Omnia MS, Robert WH. Vulvovaginitis 2005. Retrieved from Emedicine.com. Updat‐

[19] Bornstein J, Lakovsky Y, Lavi I. The classic approach to diagnosis of Vulvovaginitis:

[20] Edward D, Linda M, Maarten S. Bacterial vaginosis, vaginal flora patterns and vagi‐ nal discharge syndrome in the Gambia, West Africa. BMC Infectious Disease 2005;

[21] Joharah MA. Patients with vaginal discharge: a survey in a University Primary Care

[22] Schmid G, Markowitz L, Koumans E. Bacterial vaginosis and HIV infection. Sex

[23] Morris MC, Rogers PA, Kinghorn GR. Is bacterial vaginosis a sexually transmitted

[24] Holzman C, Leventhal JM, Qlu H. Factors linked to bacterial vaginosis in non-preg‐

[25] Edmonds DK. Benign disease of the vagina, cervix and ovary. In: Dewhurst's text‐ book of Obstetrics and Gynaecology. 7th edition. Edited by Edmonds DK. Blackwell

[26] Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenback D, Holmes KK. Non-specific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J

[27] Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is im‐ proved by a standardized method of Gram stain interpretation. J Clin Microbiol 1991;

[28] American College of Obstetricians and Gynaecologists. Assessment of risk factors for

a critical analysis. Infect D Obstet Gynecol 2001; 9:105[PMID: 11495550].

12.DOI: 10.1186/1471-2334-5-12. Retrieved fromwww.biomedcentral.com

pital Antenatal Clinic. PNG Med J 1995; 38: 163–171.

ed 20 July 2005, accessed 11 November 2010.

[18] Sobel JD. Vulvovaginal candidosis. Lancet 2007; 369:1961.

Clinic in Riyadh City. Ann Saudi Med 2000; 20:3–4.

nant women. Am J Public Health 2001; 91: 1664–1670.

Med 1983; 74:14–22. Retrieved from www.sfcityclinic.org

29: 297–301. Retrieved from www.sfcityclinic.org

preterm birth. Practice Bulletin 31, 2001.

infection? Sex Transm Infect 2001; 77: 63–68.

Publishing, Oxford, UK 2007: 606–613.

Transm Infect 2000; 76: 3–4.

629–639.

58 Genital Infections and Infertility

