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ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 33-37

The prevalence of genital Candida species among pregnant women attending antenatal clinic in a tertiary health center in North-west Nigeria


Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication11-Apr-2017

Correspondence Address:
Daniel Chukwunyere Nnadi
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.204333

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  Abstract 


Background: Vulvovaginal candidiasis (VVC) is a common genital tract infection that affects the quality of life in many women. It is more prevalent in pregnancy and may lead to complications. Aims and Objectives: The study aimed to determine the prevalence of VVC among pregnant women attending the antenatal clinic of a tertiary health institution in North-West Nigeria and to emphasize the need for accurate diagnosis and adequate treatment. Subjects and Methods: This is a 2-month cross-sectional study performed at the Department of Obstetrics and Gynaecology in association with the Department of Medical Microbiology of the Usmanu Danfodiyo University Teaching Hospital, Sokoto in North-Western Nigeria. It involved pregnant women at various periods of gestation presenting with vaginitis and selected by simple random sampling. A pair of high vaginal swabs was collected aseptically from the study subjects which was used for Gram's staining and inoculation into Sabouraud's dextrose agar (SDA). The samples were then cultured according to standard procedures on sterile SDA. Infection with Candida species was diagnosed by microscopy of a saline wet mount, Gram-stained smear and colony growth on SDA. Results: Of the 288 pregnant women sampled, 175 were positive for candidiasis giving a prevalence rate of 60.8%. The ages of the women ranged from 16 to 45 years with a mean of 26.8 (standard deviation ± 4.93). Pregnant women aged 26–30 years recorded the highest prevalence of 37.1% (65/175). The multigravidae were more affected 41.7% (120/288) than the primigravidae 19.1% (55/288). VVC showed a progressive increase with trimester of pregnancy. Candida albicans was the most prevalent species isolated in 73.7% of the women. Conclusion: There is a high prevalence of VVC among pregnant women in our institution. There is need to educate the women on genital hygiene and practice of regular screening for candidiasis in our antenatal program.

Keywords: Candidiasis, Nigeria, pregnancy, prevalence


How to cite this article:
Nnadi DC, Singh S. The prevalence of genital Candida species among pregnant women attending antenatal clinic in a tertiary health center in North-west Nigeria. Sahel Med J 2017;20:33-7

How to cite this URL:
Nnadi DC, Singh S. The prevalence of genital Candida species among pregnant women attending antenatal clinic in a tertiary health center in North-west Nigeria. Sahel Med J [serial online] 2017 [cited 2020 Nov 29];20:33-7. Available from: https://www.smjonline.org/text.asp?2017/20/1/33/204333




  Introduction Top


The presence of any genital tract infection during pregnancy raises a lot of concerns because of the threat to the well-being of the mother and child. Early detection is thus important because maternal physiological alterations may hamper the diagnosis and management of the infection, and the presence of the fetus may limit treatment.[1] Vaginal discharge is a common symptom of genital tract infection in women. Identifying its source can be very challenging because a large number of pathogens may be responsible and several infections may co-exist. Vulvovaginal candidiasis (VVC) is an inflammation of the vagina and/or vulva in the presence of Candida species and in the absence of any other etiological agent.[1] It is a common infection affecting the quality of life of many women. It is estimated to be the second most common cause of vaginitis after bacterial vaginosis.[1],[2] It is estimated that around 75% of all women experience at least one episode of VVC during their childbearing years, of which about half have at least one recurrence.[3] Symptoms are thought to be caused by an overgrowth of yeast and its penetration of vulvovaginal epithelial cells.[4] The signs and symptoms of uncomplicated VVC include a thick cheese-like discharge associated with vaginal and vulvar pruritus, pain, burning, erythema, and/or edema. Dysuria and dyspareunia may also occur and may result in marital and sexual disharmony. The vaginal pH is usually normal and budding yeast cells, and pseudohyphae may be seen on wet mount. Asymptomatic prevalence has been reported in 10% of women.[5] VVC is most often caused by Candida albicans, however, other species of Candida such as Candida glabrata, Candida parapsilosis, and Candida tropicalis are emerging.[3],[4],[5] With the introduction of antifungal agents, the causes of Candida infections shifted from an almost complete predominance of C. albicans to the common involvement of non-albicans species listed above.[6],[7] These non-albicans Candida (NAC) species tend to be resistant to conventional anti-fungal drugs and are thus responsible for persistent infections.[3],[7],[8]

Risk factors for VVC include sexual activity, recent antibiotic use, pregnancy, and immune-suppression from such conditions as poorly controlled HIV infection or diabetes.[6] The main reservoir for Candida is thought to be the rectum, but vaginal colonization is also common.[9] The factors associated with evolution from colonization to symptomatic infection are multiple and involve a combination of host susceptibility, host inflammatory responses, and Candida virulence factors. VVC is not a reportable disease and is often diagnosed without confirmatory tests and most often treated empirically, and thus the exact incidence is unknown.[3]

The relationship between pregnancy and VVC indicates that increase in gestational hormones results in alteration of the pH of the vagina and increases a woman's risk of developing VVC. The high estrogen levels result in higher glycogen content in vaginal secretions which acts as a nutrient for Candida organisms.[3] The vagina shows an increased susceptibility to infection by Candida species resulting in both a higher rate of vaginal colonization and a higher rate of symptomatic vaginitis. It is also said that estrogen enhances adherence of yeast cells to the vaginal mucosa.[10] Thus, in pregnancy, VVC can be prolonged and associated with more severe symptoms, and resolution of symptoms typically requires longer courses of therapy. Unfortunately, only topical azoles are recommended in pregnancy.[11] Oral fluconazole is usually avoided as it may increase the risk of tetralogy of Fallot in the fetus.[11] Complications of untreated VVC in pregnancy include chorioamnitis, abortion, preterm delivery and congenital infection in the neonate. Other complications in the nonpregnant woman include pelvic inflammatory disease, infertility, pelvic abscess, and menstrual disorders.[12]

A prevalent rate of 31.5%, 41%, and 56.3%, respectively among pregnant women with vaginal discharge has been reported from Northern Nigeria.[6],[13],[14] No previous studies to the best of our knowledge have been done on the prevalence of vaginal candidiasis among pregnant women in our institution. We undertook this study to determine the prevalence of VVC among pregnant women to underscore the importance of accurate diagnosis and prompt treatment of the condition.

Aims and objectives

The study aimed to determine the prevalence of VVC among pregnant women attending the antenatal clinic in a tertiary health institution in North-West Nigeria and emphasize the need for accurate diagnosis and adequate treatment.


  Subjects and Methods Top


This is a cross-sectional study that spanned over a period of 2 months. The study was performed in the Department of Obstetrics and Gynaecology in collaboration with the Department of Medical Microbiology of the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. It was conducted between June 1, 2012, and July 31, 2012; a period of 2-month. The hospital has 600-bed spaces and provides tertiary and secondary health care services to neighboring states and also runs a residency training program for doctors in the various subspecialists including Surgery, Obstetrics and Gynaecology, Internal Medicine, Paediatrics, Pathology among others. The study population consisted of pregnant women who were attending the antenatal clinic of UDUTH with of vaginitis and were recruited into the study by simple random sampling. A convenient sample size was generated using the formula N = Z2 (P (1 − P)/d2), where N is the minimum required sample size, Z = 1.96 at 95% confidence interval, P = estimated population proportion, which was 30% (from a previous work),[9]q = proportion of failure (=1 −P) and d = absolute precision required on either side of the proportions = 5%. This generated a convenient sample size of 288. Prior verbal and written consent was obtained from the women before sample collection, and the study was approved by the ethical committee of the hospital. The sociodemographic data of the patients were obtained and entered into a study proforma. A pair of high vaginal swabs was obtained from the posterior vaginal fornix of the subjects aseptically with the help of a vaginal speculum. One swab was used for Gram's staining, and the other was inoculated on Sabouraud's dextrose agar (SDA). The specimens were labeled, marked and were immediately transported to the microbiology laboratory for processing. The samples were then cultured according standard procedures on sterile SDA and chocolate agar and were incubated aerobically at 37°C for 18–48 h. Infection with Candida species was diagnosed by microscopy of a saline wet mount (which showed multiple pseudohyphae), Gram-stained smear of material from the vagina and colony growth on SDA and chocolate agar. Yeasts are identified in Gram-stained smears as Gram-positive cells. Isolates on the SDA plates were identified and speciated using conventional methods, i.e. germ tube test, sugar assimilation test among others. Statistical analysis of the collected data was performed using the SPSS IBM version 20 (IBM Corp., Armouk, NY, USA). The results were expressed in frequencies, means, percentages, tables, figures and charts. The Chi-square test was used for association at P = 0.05 at 95% confidence interval. The hospital's ethical and research committee approved the study.


  Results Top


Of the 288 pregnant women sampled, 175 were found to be positive for candidiasis while 113 were negative thus giving a prevalence rate of 60.76% in the study population. The ages of the women ranged from 16 to 45 years with a mean of 26.8 (standard deviation [SD] ±4.93). VVC was most prevalent within the age group of 21–30 years 43.1% (124/288) and declined after the age of 35 years as shown in [Table 1]. Pregnant women aged 26–30 years recorded the highest prevalence 37.1% (65/175). The parity distribution showed that 86 (29.9%) were primigravidae while 202 (70.1%) were multigravidae. There was no significant relationship between the parity of the study subjects and the prevalence of VVC as shown in [Table 2] even though. The multigravidae were more affected 41.7% (120/288) than the primigravidae 19.1% (55/288), χ2 = 0.523, df = 1, P = 0.469.
Table 1: Prevalence of vulvovaginal candidiasis in relation to age

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Table 2: Relationship between vaginal candidiasis with the parity and the trimesters of pregnancy of the study subjects

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Similarly, VVC prevalence was affected by the trimester of pregnancy, as it shows a progressive increase with the duration of pregnancy. A very high prevalent rate of 52.7% (152/288) was observed in the 3rd trimester of pregnancy compared to a rate of 0.69% (2/288) and 6.94% in the 1st and 2nd trimesters, respectively, as shown in [Table 2]. However, this was not found to be statistically significant at χ2 = 2.89, df = 2, P = 0.235.

Previous antibiotic treatment during pregnancy was not significantly related to a higher prevalence of VVC (χ2 = 2.453, df = 1, P = 0.117) as shown in [Table 3].
Table 3: Vulvovaginal candidiasis in pregnancy in relation to previous antibiotic therapy

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C. albicans was the most prevalent species isolated in 73.7% (129/175) of the women while the rest 26.3% (46/175) were NAC species as shown in [Table 4].
Table 4: Speciation of candida isolates using germ tube test

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  Discussion Top


The prevalence of Candida species among pregnant subjects in this study was 60.76%. This is higher than the 56.3%, 41% rates observed from studies from North-Eastern Nigeria and far higher than the 30% reported from South-Eastern Nigeria.[9],[13],[14] The major reason for the difference is due to the fact that we sampled both symptomatic and asymptomatic pregnant women in this study. The prevalence of vaginal candidiasis among pregnant women varies among different countries. Reports from several countries indicate the prevalence hovers around 20%.[15],[16],[17] Prevalence rates of 38.5–46.2% has been observed in pregnant women of Havana, Cuba, Papua New Guinea (PNG), and Poland, respectively.[15],[16],[17]

The mean age of the pregnant women in this study was 26.8 (SD 4.93) years. The age range of 26–30 years was more affected 37.1% (65/175). This is consistent with reports from other studies.[9],[13],[18] This age group represents the active reproductive period and the peak childbearing in the Nigerian society.[1],[18] There is intense sexual activity and thus high tendency to acquire some sexually transmitted infections which may subsequently predispose the woman to VVC. Similarly, it has been observed that there is a high concentration of reproductive hormones during pregnancy which provides a favorable environment for the growth of Candida species.[9] There was a consistent increase in the incidence of VVC from the second to the third decade which was followed by a sharp decline in the fourth decade of life. In a similar study in India, the increase in the frequency of VVC persisted up to the fourth decade before declining.[3]

The rate of infection with Candida appears to increase with the duration of pregnancy. In this study, the highest prevalence of candidiasis in pregnancy was observed within the 3rd trimester of gestation 52.7% (152/288). This is comparable to the observation from Nnewi in South-Eastern Nigeria, and also from studies from Australia and Brazil.[9],[19],[20] This could be attributed to higher levels of placental estrogens, progesterone and corticosteroids in advanced pregnancy which reduce the vaginal defense mechanisms and encourage the growth of yeast cells.[17] There is a relative decrease in cell-mediated immune response in pregnancy and thus, pregnant women are prone to fungal, viral and protozoa infections. Similar findings have been reported from Nnewi in South-East Nigeria and in Brazil.[19] However, a study from North-Eastern Nigeria and Port Moresby in PNG found that the trimester of pregnancy did not have any influence in the prevalence of candidiasis in pregnancy.[14],[16]

About 31.4% (55/175) of the women who tested positive for Candida organisms were asymptomatic at presentation. This is hardly surprising because the diagnosis of VVC requires pelvic examination and laboratory support. The combination of thick white discharge and vulvar pruritus is neither sensitive nor specific on its own for diagnosis. On the contrary, some symptomatic women tested negative to Candida infection. This suggests that other causes of vaginitis in pregnancy other than candidiasis may be responsible.[9] These may include Trichomonas vaginalis, bacteria vaginosis,  Neisseria More Details gonorrhoea among others. That these organisms were not sought for constitutes some of the limitations of this study.

There was no relationship between the prevalence of candidiasis and the use of systemic antibiotics in pregnancy in this study (χ2 = 2.453, P = 0.117). This is may be due to the fact that the study was performed in a tertiary health institution where antibiotics tend to be administered cautiously because of the risk of teratogenicity. Studies in nonpregnant subjects have reported a high prevalence of VVC among those women using vaginal or systemic antibiotics.[20]

C. albicans was the most frequent species isolated in 73.8% (129/175) from the pregnant women in this study while the rest were NAC species 26.3% (46/175). Studies from Maiduguri and Jos in Northern Nigeria, have reported prevalence rates of C. albicans in 41% and 60% of high vaginal smears, respectively.[6],[13] Studies from India indicated that C. albicans was present in 74.4% while 25.6% were NAC species.[3]C. albicans adheres to vaginal epithelial cells in significantly higher numbers than do other Candida species.[20],[22] This could explain the relative infrequency of the later in vaginal candidiasis. Studies from India have reported a rising trend in the isolation of NAC vaginitis, which was attributed to the indiscriminate use of anti-mycotic agents which eliminates the more sensitive C. albicans and selects resistant NAC species.[21] In a study from Melbourne Australia, utilization of molecular methods such as the polymerase chain reaction, improved the rate of detection of C. albicans and provided a more accurate means for identification of NAC species.[22] Such methods are not performed routinely in our center and should be a topic for further research.


  Conclusion Top


There is a high prevalence of VVC among pregnant women in our institution. It is common within the age group of 26–30 years. Women of higher parity and those in advanced pregnancy are disproportionately affected. Considering this high prevalence of 60.7% of VVC among pregnant women in this study, there is a need to educate the women on genital hygiene, and incorporate routine screening for candidiasis in our antenatal program to identify and treat symptomatic women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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