Elimination of Congenital Syphilis in Thailand: What can be done during antenatal period?

Congenital syphilis (CS) is an infection in infants born to mothers infected by Treponema pallidum. It is transmitted via placenta or direct exposure to vaginal secretion during vaginal birth. World Health Organization aims to eliminate CS by 2015, which is defined as an incidence of 0.5 cases or fewer per 1,000 births. Thailand has already achieved the goal for many years. However, new syphilis cases have been increasingly reported, especially among young people. The National Guideline on the management for the elimination of congenital syphilis in Thailand, 2015 has been developed to tackle the problem and enhance the healthcare system for this preventable condition. The optimal goal is to reduce the incidence of CS to less than 0.05 per 1,000 livebirths by 2020. For early detection and early treatment, the guideline focuses on the early ANC and the same-day-result testing of syphilis for pregnant women with late or no ANC. We, obstetricians, can play essential roles in this mission

Cefoxitin Plus Doxycycline Versus Clindamycin Plus Gentamicin in Hospitalized Pelvic Inflammatory Disease Patients: An Experience from A Tertiary Hospital

Objective: To compare the length of hospital stay (LOS) and surgical rate in patients hospitalized with pelvic inflammatory disease (PID) who received either cefoxitin plus doxycycline regimen or clindamycin plus gentamicin regimen. Methods: Medical records of patients hospitalized with PID from 2004 to 2011 were reviewed. Study population was women aged 14-40 years old who had a first-time, admitted diagnosis and a discharged diagnosis of PID. Patients who had prior hysterectomy, bilateral salpingectomy and were not sexually active were excluded. The patients received either intravenous cefoxitin (2 grams every 6 hours) plus oral doxycycline (100 mg twice a day) regimen or intravenous clindamycin (900 mg every 8 hours) plus gentamicin (240 mg once daily) regimen. Outcomes of interest were LOS and surgical rate. Results: Of 252 eligible participants, 141 (55.95%) received cefoxitin plus doxycycline and 111 (44.05%) received clindamycin plus gentamicin. The patients receiving cefoxitin plus doxycycline had statistically significant lower age and less number of cases of tubo-ovarian abscess (TOA) (P<0.05). Logistic regression showed the similar LOS and surgical rate in both groups after adjusted with age and TOA. No severe adverse effect was identified in both regimens. Conclusion: Cefoxitin plus doxycycline regimen appears as effective as clindamycin plus gentamicin regimen for treating hospitalized PID patients in terms of LOS, surgical rate and safety profile

Characteristics and Neonatal Outcomes of Teenage Pregnant Women Diagnosed with Syphilis at Siriraj Hospital

Objective: To demonstrate the characteristics of teenage pregnant women diagnosed with syphilis during pregnancy and neonatal outcomes. Methods: This is a retrospective study. Medical records of teenage pregnant women who were diagnosed with syphilis during pregnancy and delivered at Siriraj Hospital and their newborn babies from 2011 to 2016 were reviewed. Demographic data and clinical factors were retrieved. Neonatal outcomes including gestational age at birth, birth weight, and diagnosis of congenital syphilis were recorded. STATA version 12.0 was used to analyze the data and p-value less than 0.05 was considered statistically significant. Results: During 2011-2016, there were 28 eligible women. The mean age was 17.6±1.2 years. Seventy-five percent of them were unemployed and one-fourth had been educated less than or up to primary school level. The median number of partners was 4 and their sexual debut started from the age of 15.3±0.9. A quarter also had other sexually transmitted infections (STIs). Congenital syphilis was diagnosed in 12 newborns (12/28, 42.8%). The mothers of the newborns with congenital syphilis were more likely to be unemployed, had first antenatal care (ANC) after 20 weeks of gestation, had <4 ANC visits, had high initial non-treponemal titer and poor treatment of syphilis before deliveries (p<0.05 for all). Preterm birth and very low birth weight were significantly more common in newborns with congenital syphilis. Conclusion: Some socio-economic factors are associated with the risk of syphilis infection. Almost half of the teenage pregnant women diagnosed with syphilis delivered babies with congenital syphilis. Inadequate antenatal care and poor treatment of maternal syphilis are the predictive factors of congenital syphilis

Prevalence and cumulative incidence of abnormal cervical cytology among HIV-infected Thai women: a 5.5-year retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Cervical cancer is one of the most common AIDS-related malignancies in Thailand. To prevent cervical cancer, The US Public Health Service and The Infectious Disease Society of America have recommended that all HIV-infected women should obtain 2 Pap smears 6 months apart after the initial HIV diagnosis and, if results of both are normal, should undergo annual cytological screening. However, there has been no evidence in supporting whether this guideline is appropriate in all settings - especially in areas where HIV-infected women are living in resource-constrained condition.</p> <p>Methods</p> <p>To determine the appropriate interval of Pap smear screenings for HIV-infected Thai women and risk factors for subsequent abnormal cervical cytology, we assessed the prevalence, cumulative incidence and associated factors of cervical cell abnormalities (atypical squamous cell of undetermined significance or higher grades, ASCUS+) among this group of patients.</p> <p>Results</p> <p>The prevalence of ASCUS+ was 15.4% at the first visit, and the cumulative incidence of ASCUS+ gradually increased to 37% in the first 3.5 years of follow-up appointments (first 7 times), and tended to plateau in the last 2 years. For multivariate correlation analysis, women with a CD4 count <350 cells/μL had a significant correlation with ASCUS+ (<it>P </it>= 0.043). There were no associations of subsequent ASCUS+ with age, pregnancy, contraceptive method, highly active anti-retroviral treatment, assumed duration of infection, or the CD4 count nadir level.</p> <p>Conclusion</p> <p>There are high prevalence and cumulative incidence of ASCUS+ in HIV-infected Thai women. With a high lost-to-follow-up rate, an appropriate interval of Pap smear screening cannot be concluded from the present study. Nevertheless, the HIV-infected Thai women may require more than two normal semi-annual Pap smears before shifting to routinely annual cytologic screening.</p

Reproductive outcomes of patients being hospitalised with pelvic inflammatory disease

This study aimed to investigate the prevalence and the predictors of the adverse reproductive outcomes in patients who had been hospitalised with pelvic inflammatory disease (PID). The retrospective cohort study was conducted by contacting all the patients admitted with PID or tubo-ovarian abscess (TOA) during January 2004 and December 2011. Those who were sexually active and aged 14–40 years were included. The exclusion criteria were no intention to conceive or undergoing hysterectomy, bilateral salpingo-oophorectomy, bilateral complete or partial salpingectomy. At a follow-up duration of 69 [IQR 51–93] months, of 94 eligible participants, 24 (25.5%) met the criteria of infertility, 15 (16.0%) had recurrent PID and 13 (13.8%) reported chronic pelvic pain. Less than half had subsequent pregnancies including 30 live births, seven miscarriages and one ectopic pregnancy. There was no association between the adverse reproductive outcomes and length of hospital stay >6 days, surgical treatment and recurrent PID. After adjusting for age, parity, abortion, hospital stay, surgical treatment, TOA was the only negative predictive factor for live birth (aOR 0.23, 95%CI 0.07–0.79, p = .019). The high prevalence of adverse outcomes following PID or TOA should alert clinicians for proper long-term care

Vaginal Tablets of Metronidazole (750 mg) plus Miconazole Nitrate (200 mg) versus Oral Metronidazole (2 g) for Bacterial Vaginosis: A Randomized Controlled Trial

Objective: To compare the cure rates, side effects, satisfaction, and recurrence rates of bacterial vaginosis (BV) in women having vaginal tablets of metronidazole (750 mg) plus miconazole (200 mg)—the “NPF group”—versus oral metronidazole (2 g)—the “MET group.” Materials and methods: This September 2019–March 2020 trial enrolled symptomatic women aged 18–45 years diagnosed with BV based on Amsel’s criteria. Excluded were women who were immunocompromised; allergic to metronidazole or miconazole; had BV episodes during the preceding 3 months; or had abnormal vaginal bleeding. After randomization with a ratio 1:1, another vaginal swab was done for Nugent scoring. Two weeks later, the evaluation using Amsel’s criteria and Nugent scores was repeated. Also, symptom resolution, side effects and satisfaction were evaluated. Symptomatic resolution referred to 75% improvement in discharge, irritation, itching, odor, and coital pain. At one and three months, subjective symptomatic recurrence was assessed by telephone. Results: Data on 70 participants were analyzed (NPF, N=34; MET, N=36). Their average age was 32.3±7.9 years (NPF, 34.1±8.1; MET, 30.6±7.3). Without statistical significance, NPF had higher symptom resolution (67.7% vs 58.3%; P=0.420), cure rate by Amsel criteria (82.4% vs 77.8%; P=0.632), and cure rate by Nugent scoring (35.3% vs 16.9%; P=0.075). Both groups reported high satisfaction (NPF, 8.5±1.4; MET, 7.9±2.0; P=0.125). Side effects were comparable, including appetite loss, metallic taste, nausea, and dizziness. Conclusion: For BV treatment, both vaginal ovules containing metronidazole (750 mg) plus miconazole nitrate (200 mg) and oral metronidazole (2 g) show comparable efficacy and side effects

The prevalence of bacterial vaginosis in pregnant women during early third trimester and the pregnancy complications

Objectives: To investigate the prevalence of bacterial vaginosis (BV) in asymptomatic pregnant women during early-third trimester and to compare the pregnancy complications between pregnant women with and without BV.Materials and Methods: A total of 270 asymptomatic pregnant women at GA 28-32 weeks without history of preterm birth (PB) or cervical surgery were screened for BV, along with other vaginal infections, using gram stain. Nugent criteria was used to categorize vaginal smears into no BV (score 0-3), intermediate flora (IF, score 4-6) and BV (score 7-10). Fifteen weeks later, their medical records were reviewed. Outcomes of interest were premature rupture of membranes (PROM), preterm birth <37 weeks (PB) and birth weight <2,500 grams (LBW).Results: From 270 participants, 233 who delivered at Siriraj hospital were eligible for the study. The prevalence of BV, vaginal candidiasis (VC) and IF were 19.3%, 21% and 36.5%, respectively. None had trichomoniasis or gonococcal infection. One of BV cases had chorioamnionitis and none of all participants had post-partum infection. Multivariate analysis showed the increasing trend of pregnancy complications: PROM (IF 1.6, 95% CI 0.6-4.5; BV 2.2, 95% CI 0.8-6.2, p= 0.339), PB (IF 1.3, 95% CI 0.3-5.1; BV 2.3, 95% CI 0.6-9.4, p= 0.489) and LBW (IF 1.4, 95% CI 0.5-4.1; BV 1.5, 95% CI 0.5-4.9, p= 0.761). Conclusion: BV during GA28-32 weeks in asymptomatic Thai pregnant women was prevalent at 19.3% and tended to increase in pregnancy complications, including premature rupture of membranes, preterm birth and low birth weight

Sexually Transmitted Infections and Pregnancy Outcomes in Women without Antenatal Care at Siriraj Hospital

Objective: To demonstrate prevalence of sexually transmitted infections (STIs) and pregnancy outcomes in Thai pregnant women without antenatal care (ANC) who delivered at Siriraj Hospital. Methods: Medical charts of pregnant women without ANC who delivered at Siriraj Hospital during 2010-2014 were reviewed. Data of all deliveries during the same time period were used for the comparison. Results: During 2010-2014, out of 46,486 deliveries, 1,057 had no ANC, ranging from 197 to 229 / year. The average age was 25.5 ± 6.5 years and 85% were married. Prevalence of HIV infection, hepatitis B and other STIs in patients without ANC were 5.9% (62/1,057), 3.3% (35/1,057) and 1.4% (15/1,057), respectively. One third had consumed recreational drugs and urine amphetamine was positive in 20.8% of patients. The frequency of current smokers and current alcohol consumers were 14.6% (154/1,057) and 3.8% (40/1,057). Compared with all deliveries, those without ANC had significantly higher adverse pregnancy outcomes, including preterm birth (39.1% vs 14.0%, RR 2.29, 95%CI 2.10-2.49), birthweight < 2,500 gms (25.9% vs 12.6%, RR 1.84, 95%CI 1.65-2.05) and birthweight < 1,500 gms (4.1% vs 1.3%, RR 3.08, 95%CI 2.28-4.18). Teenage pregnancy significantly increased risk of preterm birth (aOR 1.86, 95%CI 1.36-2.55) and being separate doubled the risk of birthweight < 1,500 gms (aOR 2.13, 95%CI 1.02-4.46) after adjusting for history of recreational drug use, urine amphetamine, smoking, marital status, maternal age and concurrent STIs. Conclusion: STIs and adverse pregnancy outcomes were highly prevalent among deliveries without ANC. Teenage pregnancy and lack of family support appears to increase the risk of poor pregnancy outcomes

Miconazole for the treatment of vulvovaginal candidiasis. In vitro, in vivo and clinical results. Review of the literature

At concentrations achieved following systemic administration, the primary effect of imidazoles and triazoles on fungi is inhibition of 14-α-sterol demethylase, a microsomal cytochrome P450 (CYP) enzyme. Imidazoles and triazoles impair the biosynthesis of ergosterol for the cytoplasmic membrane and lead to the accumulation of 14-α-methyl sterols. The synthetic imidazole miconazole is additionally able to increase intracellular reactive oxygen species, at least in part through inhibition of fungal catalase and peroxidase. This unique feature of miconazole is probably the basis for its fungicidal activity in C. albicans, in addition to the fungistatic mode of action. Studies show that miconazole is superior to nystatin treatment and demonstrate its impact as one of the best options in managing vulvovaginal candidiasis. Regarding recurrent vulvovaginal candidiasis, several new drugs are currently developed to ensure effective treatment also for this group of patients

A Survey of Daily Genital Care Practices among Reproductive-aged Female Personnel at Siriraj Hospital

Objective: To demonstrate the genital cleansing habit and associating factors among reproductive-aged Thai women. Materials and Methods: The survey was conducted at Siriraj Hospital between June and September 2022 (COA no. Si 370/2022). Twenty patient unit wards and 20 office units were randomly selected. Only active Siriraj female staff aged 18-50 were approached. The exclusion criteria included medical students and doctors, pregnant women, incomplete questionnaires, and women with immunocompromised conditions. Twenty sets of questionnaires, together with an information sheet as well as a box to return the questionnaire, were left at each unit. The primary outcome was the frequency of daily genital cleansing done outside of shower time. Associating factors and other genital care practices were secondary outcomes. Results: Of the 800 distributed questionnaires, 611 were returned (response rate of 76.4%) and 504 were eligible for the study. The participants were 32.7±7.3 years old and most were in the 25-40 age group. Up to 90% reported genital cleansing outside shower time and 74.2% (374/504) of all respondents and 74.7% (236/316) of those with sexual experience cleansed >2 times daily. Twenty-four participants (4.8%) practiced vaginal douche. Water without genital care products is the most common method of cleansing. There was no association between sexual health risks and frequency of cleansing. Conclusion: Three fourths of reproductive aged Thai women practice genital cleansing >2 times per day. Water without genital care products is the most common method of cleansing. There is no association between the habit and any demographic data and sexual health risks