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Background: Chlamydia infection has been associated with ectopic gestation, the taking acute gynecological exigency in Kenya. In gestation, it is frequently symptomless yet it is non screened for during prenatal clinic visits.

Aim: To depict and compare the prevalence of Chlamydia infection in patients with ectopic and intrauterine gestation ( uncomplete abortion ) at the Kenyatta National Hospital

Design: Cross sectional prospective survey

Puting: Acute gynecological ward at the Kenyatta National Hospital.

Subjects: Patients with ectopic gestation and uncomplete abortion.

Methods: A cervical swab will be taken from a patient with an ectopic gestation post-operatively. On the same twenty-four hours, another swab will be taken from an age matched client presenting at the acute gynecological ward with an uncomplete abortion. Detection of Chlamydia antibodies in the samples will be done through rapid immunochemical assay. Social demographic profiles of the participants will besides be extracted utilizing a structured questionnaire.

Introduction

Chlamydia trachomatis is an obligate intracellular bacteria that normally attaches to columnar or transitional epithelial tissue. C. trachomatis infections are an tremendous public wellness job throughout the universe, accounting for most bacterial sexually transmitted diseases.1 WHO estimated that there were 16 million new instances of chlamydia in sub-Saharan Africa in 1999 and 70-75 % of septic adult females were symptomless.

A survey in adult females undergoing tubal ligation found chlamydia prevalence to be 14.9 % ,2 while 9 % of adult females aged 18 – 40 old ages go toing an STD clinic in Nairobi, were found to hold Chlamydia.3 E. Lagarde, et Al in a multicenter survey in Kisumu, reported the prevalence of chlamydia to be 4.5 % in adult females selected from the general population.4

Most pregnant adult females have symptomless infection but some present with urethral syndrome, urethritis or Bartholins gland infection.5 Chlamydia prevalence was 29 % after testing 1090 adult females in labor and at 7 and 14 yearss postpartum in a survey in Nairobi,6 while in Durban South Africa, cervical infections were diagnosed microbiologically in 8.2 % of symptomless pregnant black adult females. These were N. gonorrhea in 4.1 % and C. trachomatis in 4.7 % .7 Romoren et Al in a survey among 703 prenatal attention attendants in Botswana found that the prevalence of chlamydia and gonorrhea was 8 % and 3 % respectively.8 Ndinya-Achola et Al found chlamydia in 8 % of pregnant adult females go toing prenatal clinic in Nairobi, Kenya.9

Several surveies found inconclusive or no grounds that Chlamydial infection causes abortion.24,25.26,27

Ectopic gestation is nidation of the blastodermic vessicle anyplace else other than in the endometrial liner of the uterine pit. 95 % of these involve the fallopian tubing. Other sites of nidation are cervix, ovary, wide ligament and intra-abdominal. Racheal E. L. et al detected anti-Chlamydia Ig in 51 % and 67 % of patients with ectopic gestation in the United Kingdom and Trinidad respectively.10

Abortion refers to the expiration of gestation from whatever cause before the foetus is capable of extrauterine life. Spontaneous abortion refers to those terminated gestations that occur without deliberate steps, whereas induced abortion refers to expiration of gestation through a calculated intercession intended to stop the pregnancy11. Another widely used term for self-generated abortion is abortion. By convention, abortion is normally defined as gestation expiration prior to 20 hebdomads ‘ gestation or less than 500-g birth weight.

Qualitative sidelong flow immunochemical assay is a method of finding the presence of an antigen ( or antibody ) in blood sample when the specimen is exposed to the specific antibody ( or antigen ) labelled with a fluorochrome and detecting the antigen-antibody reaction of precipitation. During the trial, a solution extracted from the cervical swab will be applied to the trial devise. If Chlamydia antigen is present in the solution, it will respond with antibodies at the trial part of the devise and bring forth a colored line ( the trial line ) . Another colored line will look at the control part of the devise bespeaking equal volume of specimen ( the control line ) . Chlamydia antigen may prevail even after appropriate intervention ; therefore the trial will be positive in instances of past infection.

The DiaspotTM Chlamydia Rapid Test Device when comparison to the gilded criterion for sensing of Chlamydia antigens on cervical swabs, Polymerase Chain Reaction, has a sensitiveness of 88.5 % and specificity of 96.7 % . Its comparative truth is 93.7 % .11

LITRETURE REVIEW

Descriptions of a disease of human eyes resembling trachoma ( meaningA ‘rough oculus ‘ ) have been found in ancient Chinese and Egyptian manuscripts. In 1907, Halberstaedter and von Prowazek, working in Java, described the transmittal of trachoma from adult male to Pongo pygmaeuss by inoculating their eyes with conjunctival scrapings. In Giemsa-stained conjunctival epithelial cells, they found intracytoplasmic vacuoles ( chlamydial inclusions ) incorporating legion minute atoms ( little chlamydial simple organic structures and larger chlamydial reticulate organic structures ) which they right inferredA represented the causal agent of trachoma. The freshly discovered beings were called the Chlamydozoa ( from the Greek khlamus, a mantle / cloak ) because of the blue-staining matrix in which the atoms were seemingly embedded [ See: Collier 1990 ] . This was non right, as the chlamydiae are non “ mantled protozoons ” . However, the Greek-derived root remains as a testimonial to these outstanding workers.12

In 1929-30, widespread eruptions occurred of an untypical and frequently terrible pneumonia, acquired from psittacine birds ( budgereegahs, parrots ) , which was termed parrot disease. These eruptions stimulated research, and Levinthal Coles and Lillie independently described infinitesimal basophilic atoms in Giemsa stained blood and tissue from the septic birds and human patients. Bedson and colleagues shortly proved the aetiological relationship of these atoms with parrot disease and went on to specify the characteristicA developmental rhythm that now defines all members of the order Chlamydiales. Bedson referred to this agent as “ an obligate intracellular parasite with bacterial affinities ” , a construct of great penetration that was non by and large accepted for another 30 years.13A

Equally early as 1934, Thygeson, an eye doctor, had drawn attending to the resemblances between the development and morphology of the inclusions seen in trachoma and inclusion pinkeye and of those found in parrot disease. The determination of a common complement-fixing antigen strengthened the thought that these agents and those of lymphogranuloma venereum and of mouse pneumonitis were related within the same alone group. By 1935 the parrot disease agent had been grown in the chick embryo chorio-allantoic membrane.

The trachoma “ virus ” was foremost isolated in the chick-embryo yolk pouch in China in 1957 by T’ang and co-workers and reported in the Chinese Medical Journal.14

The aetiological relationship of this being with trachoma was proved in 1958 by the vaccination of human voluntaries. Their aetiological function in inclusion pinkeye, and besides in venereal piece of land infection was confirmed by inoculating the eyes of voluntaries and baboons

Name callings for these bacteriums included ‘Bedsonia ‘ , ‘Miyagawanella ‘ and ‘Halprowia. The term ‘Chlamydia ‘ appeared in the literature in 1945. That chlamydiae were non viruses became apparent in 1965 with the coming of tissue civilization techniques and of negatron microscopy, when grounds for bacterial rRNA, ribosomes and cell wall structures in chlamydiae eventually became overwhelming.A However chlamydiae were grouped with Rickettsia until the genus Chlamydia was validated by Page in 1966. For old ages, Chlamydiales was the lone bacterial order that had merely one household and one genus ( Chlamydiaceae and Chlamydia, severally ) .13 In the 1990s, with the debut of new diagnostic methods, chlamydiae were described as emerging disease agents.

C. trachomatis is an entirely human pathogen has been recognized as a major cause of sexually transmitted and perinatal infection.15 Worldwide incidence has been estimated at 92 million yearly, with about 16 million happening in sub-Saharan Africa. This is 2nd to South and South-east Asia with 43 million one-year cases.16

C. trachomatis preferentially infects the columniform epithelial tissue of the oculus and the respiratory and venereal piece of lands. The infection induces an immune response but frequently persists for months or old ages in the absence of antimicrobic therapy. Serious sequelae frequently occur in association with repeated or relentless infections. The precise mechanism through which repeated or relentless infection elicits an inflammatory response that leads to tubal scarring and harm in the female upper genital piece of land is non yet clear.17 Natural human infection consequences in strong serological responses to the major outer membrane protein OmpA, but antibodies to outer membrane protein PorB are low or absent.18

In grownups, the clinical spectrum of sexually transmitted C. trachomatis infections parallels that of gonococcal infections. Both infections have been associated with urethritis, proctitis, and pinkeye in both sexes ; with epididymitis in work forces ; and with mucopurulent cervicitis, acute salpingitis, bartholinitis, and the Fitz-Hugh-Curtis syndrome ( perihepatitis ) in adult females. Both infections can be associated with infected arthritis. Generally Chlamydia infections produce fewer symptoms and marks than gonococcal infections at the same anatomic site. Increasing grounds suggests that many Chlamydia infections of the venereal piece of land, particularly in adult females, persist for months without bring forthing symptoms. Coincident infection with C. trachomatis frequently occurs in adult females with cervical gonococcal infection and in heterosexual work forces with gonococcal urethritis.17

Surveies among male and female grownups between 15 and 49 old ages of age in a low to middle category suburb and single female plantation workers in Kenya found prevalence of Chlamydia to be 1.5 to 3.2 % 19,20

Hazard factors: In adult females include age younger than 25 old ages, presence or history of other sexually transmitted diseases and multiple or a new sexual spouse within the last 3 months. Use of unwritten preventive pills and the presence of cervical ectopy besides confer an increased hazard of Chlamydia infection.17

Complications of Chlamydia infection include pelvic inflammatory disease, ectopic gestation, tubal factor sterility and chronic pelvic hurting. Simms, et Al found chlamydia in 27 % of PID instances and none in adult females undergoing bilateral tubal ligation.21 Chlamydia infection besides increases the hazard of transmittal of human immunodeficiency virus.22 Feist A, et Al found no association between abortions and infection with C. Trachomatis.23 Other surveies by Oakeshott, Ostaszewska-Puchalska, Sozio and Osser and their co-workers found no conclusive grounds that Chlamydia causes abortion.24,25,26,27 However. Cohen C, Sinei S, Bukusi E, et Al in a survey at KNH found that more frequent histories of self-generated abortions reported by sterile adult females were besides consistent with untypical upper genital piece of land infection including Chlamydia. They found antichlamydia antibodies in 34 % of adult females with abortions.28

Diagnosis: This is based entirely on research lab trials. N. gonorrhea and C. trachomatis are normally symptomless, among work forces in a rural African population in Tanzania merely 24 of 158 ( 15 % ) infected topics complained of urethral discharge at the clip of interview.29 Cell civilization isolation has specificity of 100 % and sensitiveness of 70 to 90 % but is expensive and extremely specialised and therefore non widely available. Giemsa discoloration of exudations in grownups with venereal infection is merely 40 % accurate. Serologic methods either complement arrested development or microimmunofluorescence trial are positive in 20 to 40 % of sexually active adult females. However, most do non hold a current infection. Moss and co-workers, in a survey among adult females go toing a GU clinic, found that up to 50 % of all chlamydia Ig G-positive instances were due to nongenital chlamydia ( C. pneumoniae and C. psittaci ) .30 In qualitative sidelong flow immunochemical assay, a solution extracted from a cervical swab will be applied to the trial devise. If Chlamydia antigen is present in the solution, it will respond with antibodies at the trial part of the devise and bring forth a colored line ( the trial line ) . Another colored line will look at the control part of the devise bespeaking equal volume of specimen ( the control line ) . Chlamydia antigen may prevail even after appropriate intervention, hence the trial will be positive in instances of past infection.

The DiaspotTM Chlamydia Rapid Test Device when comparison to the gilded criterion for sensing of Chlamydia antigens on cervical swabs, Polymerase Chain Reaction, has a sensitiveness of 88.5 % and specificity of 96.7 % . Its comparative truth is 93.7 % .11

Other research lab trials include direct smear fluorescent antibody proving that has a sensitiveness of 90 % and specificity of 98 % . Polymerase concatenation reaction, ligase concatenation reaction and DNA investigation checks for sensing of C. trachomatis are more rapid and less expensive.

Inoculation against human Chlamydia infections is presently unavailable. However, carnal tests on campaigner vaccinums specifically for adolescent adult females are ongoing. The current challenge is to develop an effectual bringing vehicle for initiation of a high degree of immunological response. When developed, vaccinums could be delivered trans-dermally via a spot, by rhinal spray or vaginal cream.31,32,33,34

Treatment: Doxycycline 100 milligram orally twice daily for 7 yearss for non-pregnant patients or azithromycin 1 g orally as a individual dosage can eliminate Chlamydia from the neck. An alternate regimen is erythromycin ethylsuccinate 800 milligram orally 4 times day-to-day given for a lower limit of 7 yearss. Patients who can non digest Erythrocin should see ofloxacin 300 mg twice daily or levofloxacin 500 milligrams orally one time day-to-day for 7 yearss. Post-treatment civilizations are non normally advised if Vibramycin, Zithromax, or ofloxacin is taken as described above and symptoms are non present ; remedy rates should be higher than 95 % . Retesting may be considered 3 hebdomads after finishing intervention with Erythrocin. A positive post-treatment civilization is more likely to stand for disobedience by the patient or sexual spouse or re-infection instead than antibiotic opposition. It is of import to guarantee that the sexual spouse is treated, as most post-treatment re-infections occur because the sexual spouse was non treated. Clinicians should rede all adult females with Chlamydial infection to be re-screened 3-4 months after treatment.35

Several regimens are used to handle Chlamydia infection in gestation. Drugs of pick are either unwritten Erythrocin 500 milligram four times a twenty-four hours or unwritten Amoxil 500 milligram three times a twenty-four hours both for seven yearss. Alternate therapies are unwritten erythromycin 250 milligrams four times a twenty-four hours for 14 yearss or unwritten Zithromax 1 g individual dosage. Jacobson, Kacmar, Wehbeh and all their co-workers demonstrated the efficaciousness of Zithromax for Chlamydia infection in pregnancy.36,37,38 Adair and associates treated 106 adult females with Erythrocin ( 93-percent remedy ) or azithromycin ( 88-percent remedy ) .39 Tetracyclines are avoided because of concerns sing foetal dental stain.

Ectopic gestation is nidation of the blastodermic vessicle anyplace else other than in the endometrial liner of the uterine pit. 95 % of these involve the fallopian tubing. Other sites of nidation are cervix, ovary, wide ligament and intra-abdominal.40

The fallopian tubing lacks a submucosal bed, therefore the fertilized egg cell quickly burrows through the epithelial tissue, and the fertilized ovum comes to lie within the muscular wall. At the fringe of the fertilized ovum is a capsule of quickly proliferating trophoblast that invades and erodes the subjacent muscularis. At the same clip, maternal blood vass are opened, and blood pours into the infinites lying within the trophoblast or between it and the next tissue. The tubal wall in contact with the fertilized ovum offers merely little opposition to invasion by the trophoblast, which shortly burrows through it. The embryo or foetus in an ectopic gestation is frequently absent or stunted. The invading, spread outing merchandises of construct may tear the Fallopian tube at any of several sites. Tubal rupture in the first few hebdomads, the gestation is situated in the isthmic part of the tubing. When the fertilized egg cell is implanted good within the interstitial part, rupture normally occurs subsequently. Rupture is normally self-generated, but it may be caused by injury associated with sexual intercourse or two-handed examination.40

With intraperitoneal rupture, the full embryo may be extruded from the tubing, or if the rent is little, exuberant bleeding may happen without bulge. If an early embryo is expelled basically undamaged into the peritoneal pit, seldom it may reimplant about anyplace, set up equal circulation, survive, and turn. Normally little embryos are resorbed. Occasionally, if larger, they may stay in the cul-de-sac for old ages as an encapsulated mass, or even go calcified to organize a lithopedion.40

Rachael E. L. , et al detected anti-Chlamydia Ig in 51 % and 67 % of patients with ectopic gestation in the United Kingdom and Trinidad respectively.10

Hazard factors for tubal harm and disfunction are associated with the happening of ectopic gestation. They include tubal disciplinary surgery, tubal sterilisation, presence of intra-uterine prophylactic device and old venereal infection. After one old ectopic gestation, the opportunity of return is 7 to 15 % .41,42 There is strong grounds associating Chlamydia infection and sterility ; chlamydia antibody titres have been associated with tubal occlusion and anterior ectopic gestation and chlamydia trachomatis seropositive serology has been found to be higher in adult females with ectopic gestation compared to controls ( 81 % vs 63 % ) .43,44 Frost E. and co-workers found that Chlamydia infections play a major portion in salpingitis and sterility in cardinal Africa.45 Other hazard factors are multiple sexual spouses, sterility and old pelvic or abdominal surgery.46

Symptoms: These are pelvic and abdominal hurting ( 95 % ) and amenorrhea with some grade of vaginal staining or hemorrhage ( 60 to 80 % ) . With rupture, the adult female all of a sudden is stricken with terrible lower abdominal hurting, often described as crisp, knifing, or rupturing in character. Vasomotor disturbances develop, runing from dizziness to syncope. Tenderness on abdominal and vaginal scrutiny, particularly on gesture of the neck, is incontrovertible in over 75 % of adult females with ruptured or tearing tubal gestations. This may be absent anterior to tear. Identification of non-clotting blood in the peritoneal pit by abdominocentesis or culdocentesis is implicative of a hemorrhage ectopic gestation. Absence nevertheless, does non except an ectopic pregnancy.47

Current serum and urine gestation trials that use ELISAs are sensitive to degrees of chorionic gonadotropin of 10 to 20 mIU/mL, and are positive in over 99 % of ectopic pregnancies.48

In abdominal echography, absence of a uterine gestation, fluid in the cul-de-sac, and an unnatural pelvic mass, ectopic gestation is about diagnostic if a gestation trial is positive.49 There has been much betterment in the early diagnosing of ectopic gestation utilizing vaginal echography which allows supersonic sensing of a uterine gestation every bit early as 1 hebdomad after lost menstruations. When serum I?hCG degrees exceed 1000 mIU/mL, a gestational pouch is seen half the time.50

Treatment: This is either surgical or medical. Surgical therapy is by laparoscopy or laparotomy. Laparoscopy is more cost-efficient and has a shorter recovery time-1.3 versus 3.1 days.51 Procedures include salpingotomy, salpingostomy, salpingectomy and segmental resection and inosculations. Medical therapy is with individual or multiple dose systemic methotraxate at a dosage of 50 mg/m2. The patient must be hemodynamically stable, have a gestation less than 6 hebdomads gestation and a tubal mass smaller than 4 centimeter in diameter. She must avoid sexual intercourse, intoxicant and folic acid addendums until the ectopic gestation has resolved.40

Spontaneous abortion or abortion: This is the most common complication of gestation and is defined as the passing of a gestation prior to completion of the twentieth gestational hebdomad. It implies bringing of all or any portion of the merchandises of construct, with or without a fetus weighing less than 500 g. Threatened abortion is shed blooding of intrauterine beginning happening before the 20th completed hebdomad, with or without uterine contractions, without distension of the neck, and without ejection of the merchandises of construct. Complete abortion is the ejection of all of the merchandises of construct before the 20th completed hebdomad of gestation, whereas uncomplete abortion is the ejection of some, but non all, of the merchandises of construct. Inevitable abortion refers to hemorrhage of intrauterine beginning before the 20th completed hebdomad, with distension of the neck without ejection of the merchandises of construct. In lost abortion, the embryo or fetus dies, but the merchandises of construct are retained in utero. In infected abortion, infection of the womb and sometimes environing constructions occur.53

Bleeding into the decidua basalis, followed by mortification next tissues causes the egg cell to detach, exciting uterine contractions that result in its ejection. In ulterior abortions, the maintained foetus may undergo maceration – the skull castanetss prostration, the venters distends with fluid, the internal variety meats degenerate and skin softens and Peels. Alternatively, amnionic fluid is absorbed, the foetus becomes compressed and desiccated ( fetus compressus ) or resembles parchment ( fetus papyraceous ) .54

More than 80 per centum of abortions occur in the first 12 hebdomads of gestation, and at least half consequence from chromosomal anomalousnesss ensuing in unnatural fertilized ovum development. Assorted infections are uncommon causes of abortion in worlds. In 2002, Oakeshott and associates reported an association between second- but non first-trimester self-generated abortion and bacterial vaginosis.24

Iodine lack, antiphospholipid and antithyroid antibodies and hapless glucose control in diabetes mellitus have been associated with miscarriages.54,55,56,57,58 Tobacco, intoxicant and caffeine have been linked to increased hazard of abortion and foetal anomalies.53 Uterine anatomical defects ensuing from unnatural mullerian canal formation or merger and cervical incompetency consequence in 2nd trimester abortions.

The clinical facets of self-generated abortion separate into five subgroups: threatened, inevitable, complete or uncomplete, missed, and perennial abortion.

In threatened abortion, the neck remains closed and hemorrhage is slight while inevitable abortions present as abdominal or back hurting and hemorrhage with an unfastened neck. In an uncomplete abortion, the merchandises of construct have partly passed from the uterine pit. If less than 10 hebdomads of gestation, the foetus and placenta are normally passed together while in those greater than 10 hebdomads, they may be passed individually, with a part of the merchandises retained in the uterine pit. Spasms are normally present and hemorrhage is relentless and is frequently terrible. Complete abortion is identified by transition of the full embryo. Slight hemorrhage may go on for a short clip, but pain ceases after gestation has traversed the neck. Missed abortion implies that the gestation has been retained following decease of the foetus. Normal progestin production by the placenta may go on while estrogen degrees autumn, which may cut down uterine contractility. A spoilt egg cell or anembryonic gestation represents a failed development of the embryo so that merely a gestational pouch is present.53

Lab trials: These include complete blood count and gestation trials. If important hemorrhage has occurred, the patient will be anaemic. Both the white blood cell count and the deposit rate may be elevated even without infection. Falling or abnormally lifting plasma degrees of I?hCG are diagnostic of an unnatural gestation, either a spoilt egg cell, self-generated abortion or ectopic pregnancy.53

Transvaginal ultrasound: This is helpful in documenting intrauterine gestations every bit early as 4-5 hebdomads ‘ gestation. Fetal bosom gesture should be seen in embryos at least 5-6 hebdomads gestation. 53

Management: In threatened abortion, bed remainder and pelvic remainder are recommended while for inevitable or uncomplete abortion, emptying of the womb by D & A ; C should be considered. Grouping and cross-match for possible blood transfusion and finding of Rhesus position should be obtained. For complete abortion, the patient should be observed for farther hemorrhage and merchandises of construct should be examined.53

Treatment of infected abortion involves hospitalization and endovenous antibiotic therapy. A D & A ; C should be performed, and a hysterectomy may be necessary if the infection does non react to treatment.53

A survey by A. Kaaria showed that patients seen at KNH with abortion were in the same socio-economic category as those with ectopic gestation unlike those go toing prenatal clinic who are in a higher class.59 Hence adult females with abortion are a better control group than prenatal clinic attenders.

Hypothesis

The prevalence of Chlamydia infection is higher among patients of ectopic gestation than those with intrauterine gestation ( showing with uncomplete abortion ) .

Justification

Current local guidelines on the direction of ectopic gestation do non include intervention of Chlamydia infection and this is non common pattern. Previous surveies on STI among patients showing with ectopic gestation have non focussed on Chlamydia and none has used rapid immunochemical assaies such as DiaspotTM the current gold criterion of Chlamydia diagnosing. Previous surveies have besides compared patients with ectopic to patients with on traveling gestations. However this may do prejudice as STIs are likely to take to abortions of intrauterine gestations. Therefore patients seeking abortion services are an ideal comparing group. This survey will be the first done in the Kenyan scene where prevalence of undiagnosed STIs is high.

Aim

Broad aim:

To depict and compare the prevalence of Chlamydia infection in patients with ectopic gestation and abortion at the Kenyatta National Hospital.

Specific aims:

Describe and compare obstetric, gender, clinical and socio-demographic features of patients showing ectopic gestation and abortion at KNH.

Describe and compare prevalence of Chlamydia infection among patients with ectopic gestation and abortion at KNH.

Determine obstetric and socio-demographic factors associated with Chlamydia infection.

Study Design

This will be a instance control survey. An endocervical swab will be taken from a patient with ectopic gestation the twenty-four hours after exigency surgery. Rapid immunoassay trial for antichlamydial antibodies Ig G and Ig M will be done on the sample and a questionnaire on socio-demographic profiles will be filled post-operatively. On the same twenty-four hours, a patient with abortion of the same age plus or minus 5 old ages as the ectopic gestation patient will be recruited. A similar sample will be taken for proving and questionnaire filled. Doxycycline 100 mg twice daily for a hebdomad will be given to all patients with positive antibody trials.

Puting

The survey will be done at the KNH acute gynecological ward. KNH serves the population within and around the metropolis and it is the national referral infirmary. It besides serves as the university learning infirmary for the College of Health Sciences of the University of Nairobi and the Kenya Medical Training College. Several medical fortes are catered for and the Department of Obstetrics and Gynaecology is one of them.

The OBs unit consists of four antenatal/postnatal wards, a labour ward, pregnancy runing theater, prenatal and post natal clinics while the gynecology unit consists of a showing room ( figure 7 ) in the A + E section and ague and elected gynecological wards – 1 D and 1 B severally. Gynecological surgeries are done at the chief theaters every bit good as Trauma theatres at the A + E section.

The Ob/Gyn section is organized into three houses. Each house is headed by a senior adviser obstetrician and gynecologist with a squad of advisers, senior registrars, senior house officers, housemans, nurses and paramedical staff. The senior medical staff is both from KNH and UoN.

The prenatal clinic is located at the infirmaries outpatient section ( clinic no. 18 ) . Each house has its ain specific ANC and gynecology clinic follow-up twenty-four hours i.e. Tuesday, Wednesday and Thursday. Monday has traditionally been reserved for prenatal engagement ; nevertheless prenatal engagement is now done on any clinic twenty-four hours.

The acute gynecological ward admits patients from A+E section and gynecology clinic for all three houses. Each twenty-four hours at least one patient with ectopic gestation is admitted while three with uncomplete abortion are treated by manual vacuity aspiration.

Study population/Study period

The survey population will include patients showing with ectopic gestations and abortions at KNH, from October 2010 to December 2010. The chief research worker will enroll patients with ectopic gestation from Sunday to Saturday and those with uncomplete abortion on the same twenty-four hours. With an norm of one ectopic per twenty-four hours, the sample size shall be achieved in two months.

Sample size

The sample size was calculated utilizing the undermentioned expression [ Fleiss JL Statistical Methods for Rates and Proportions ( 2nd edition ) . Wiley: New York, 1981. ] ,

Factor under consideration ” prevalence of chlamydia ”

1ST GROUP ” Ectopic Pregnancies ”

2ND GROUP ” Abortions ”

Parameter Symbol Value

“ Prevalence of chlamydia ” in “ Ectopic Pregnancies ” group p1 67.0 %

“ Prevalence of chlamydia ” in “ Abortions ” group p2 34.0 %

p1 – p2 d 0.33

Oddss Ratio OR 3.94

Proportion of participants expected in “ Ectopic Pregnancies ” m1 50.0 %

group

Proportion of participants expected in “ Abortions ” group m2 50.0 %

Ratio of ( “ Ectopic Pregnancies ” : ” Abortions ” ) sizes r 1.00

P corrected p-bar 0.505

Power 1-I? 80 %

z-I? 0.84

Confidence level 1-I± 95 %

z-I± 1.96

Number of topics required for “ Ectopic Pregnancies ” n1 ‘ 35

group

Number of topics required for “ Abortions ” group n2 ‘ 35

Continuity rectification for n1 ‘ n1 41

Continuity rectification for n2 ‘ n2 41

Sample size 82

Inclusion Standards

Patients operated at KNH for ectopic gestation

Womans showing with abortion at KNH.

Those who consent.

Exclusion Standards

Womans with other causes of shed blooding in gestation e.g.

-placenta previa / abruptio

-malignancies like cervical carcinoma

Those who decline to give consent.

Survey instruments

A pre-coded questionnaire will be used.

Study process

Recruitment will be done at the acute gynecological ward KNH on all yearss of the hebdomad. The chief research worker will enroll participants from among patients who have undergone surgery for ectopic gestation. Upon written consent, an endocervical swab will be taken and put in an extraction tubing that has 5 beads of reagent A. The underside of the tubing will be compressed and the swab rotated 15 times. After 2 proceedingss, 220 microliters of reagent B will be added into the tubing, the underside compressed and the swab rotated 15 times. After 1 minute, the swab will be withdrawn while squashing the tubing and a dropper tip fitted to the top of the extraction tubing. 3 full beads of the solution will be added to the DiaspotTM Chlamydia Rapid Test Device and the consequence read after 10 proceedingss. The visual aspect of 2 distinct coloured lines indicates a positive consequence while 1 colored line in the control line part denotes a negative consequence. If the control line fails to look, this is an invalid trial and may be due to an unequal specimen volume or wrong process technique. A coded questionnaire will so be administered. On the same twenty-four hours, an abortion patient in the same age group as the ectopic gestation patient will be recruited upon written consent. A similar specimen will be subjected to the rapid trial and a similar questionnaire filled. All patients with a positive chlamydia trial will have unwritten Vibramycin 100 milligram twice daily for a hebdomad.

Data aggregation and direction

Data will be collected utilizing a coded questionnaire. A biostatistician will transport out informations entry and analysis. All the information will later be entered into the computing machine and analyzed utilizing Statistical Package for Social Sciences ( SPSS 12 ) for Windows. Data analysis will affect descriptive statistics like cross tabular matter, frequence scopes and average. Chi-square will be used for proportions and p-value for significance.

Study restrictions

Presence of anti-chlamydia antibodies does non intend there is an on-going active Chlamydia infection. Despite this, all patients with positive serology will be put on Vibramycin 100 milligram twice daily for one hebdomad.

Ethical considerations

Blessing for the survey will be sought from the ethical and research commission of KNH.

Voluntary informed consent will be obtained from every participant prior to aggregation of blood and disposal of the chlamydia rapid strip trial and of the questionnaire.

Consequences of chlamydia rapid trial will be availed to participants. Participants with positive consequences will be treated instantly.

Data and information will be treated with confidentiality. The participant ‘s names and in-/outpatient figure will non look on the questionnaire. A consecutive figure will be used.

Consequences of the survey will be used for academic intents and for betterment of the criterion of attention.

Consequences of the survey will be availed to KNH.

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