Adejo, D S. & Randawa, A J.
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital Zaria, Nigeria
Aguoru, C U. & Ega R A I.
Department of Biological Sciences, Federal University of Agriculture, Makurdi, Nigeria
Maryam M, & Adeyanju D.
Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital Zaria
All correspondence to: firstname.lastname@example.org
Vaginal infections in pregnancy are associated with considerable discomfort and adverse pregnancy outcomes including preterm delivery, low birth weight and increased infant mortality. This study evaluated the prevalence of vulvovaginal candidiasis and the effects of the infection on pregnancy outcome among women attending antenatal clinic in Ahmadu Bello University Teaching Hospital Zaria. A semi-structured questionnaire was administered and high vaginal swab samples were obtained from consenting pregnant women. The samples were processed following standard protocols. The prevalence of vulvovaginal candidiasis was 20.2%. Infections were higher in the third trimester and many women admitted to practices that increase risk of these infections. There was no statistically significant relationship vaginal candidiasis and pregnancy outcome or foetal complications at P=0.05. However, over 50% of the population had abnormal vaginal discharge with more than 30% of them suffering from various degrees of vaginal itching and erythema. Adequate investigation and prompt treatment will improve the quality of life and health of mother and feotus.
Key words: Vulvovaginal candidiasis, Pregnancy, Preterm, Candida albicans.
Pregnancy is a physiological state, which produces several normal and expected changes in all the maternal organ systems. It is believed that higher estrogen levels and higher glycogen content in vaginal secretions during pregnancy increase a woman’s risk of developing vulvovaginal candidiasis (Pratibha et al., 2013). Vaginal candidiasis is one of the most common forms of fungal diseases, that are usually reported in pregnant women which may cause systemic infections in neonate particularly with low birth weight and prematurity after delivery (Mendling, and Brasch, 2010). Although colonization of the maternal genital tract by specific organisms has been inconsistently associated with spontaneous preterm birth and/or preterm premature rupture of the membranes, some infections have been consistently associated with preterm delivery (Gibbs et al., 1992).
It has been hypothesized that screening for and treatment of common vaginal infections would reduce the rate of preterm birth among affected women (Hollier, 2005). There is a possible link between the presence of vaginal Candida and premature birth. Researchers are currently investigating whether treating women with asymptomatic vaginal thrush is effective in reducing spontaneous preterm birth. Hopefully, these studies will show if eradicating Candida in pregnancy helps to reduce the rate of preterm
birth and late miscarriage.
In a related study in Oyo, 33.3% of the 135 women had candidiasis in pregnancy according to Adeyeba et al., (2003). Akinbami et al., 2015 and Anorlu et al., 2004 reported a prevalence of vulvocandidiasis in pregnancy to be 25% and 26% in their respective studies conducted at Ogbomosho and Lagos, Nigeria. Rasti et al. (2014) found that the prevalence of vaginal candidiasis in pregnant women in Iran was 49 (32.7 %). 35% of the patients with preterm labour and 31.8 % with term labour were infected with C. albicans. Out of 12 pregnant women with premature rupture of membrane (PROM), four women (33.3%) were showed positive results of C. albicans infection, while in 138 of the mothers without PROM , C. albicans was found in 45 (32.6%) (Rasti et al., 2014). Candida is an important risk factor of systemic infections in low birth weights infants and the related mortalities (Kaufman, et al., 2006). Neonatal septicemia produced by Candida in the premature infants with low birth weight has been reported to be successfully treated with amphotericin B (Baradkar, et al., 2008). Most fungal infections in preterm neonates are due to Candida species; a much smaller number of infections may be attributed Malassezia, Zygomycetes, or Aspergillus pathogens. Candida species are commensal organisms that colonize the skin and mucosal surfaces and adhere to catheter surfaces. Candida albicans and parapsilosis account for 80-90% of infections. Candida can invade the bloodstream and disseminate in these infants because of their immature immune systems, complicated by the inevitable need to compromise their developing skin and mucosal membrane barrier defenses. For these reasons, fungal infections are often difficult to eradicate in the preterm infant (Kaufman et al., 2006).
The risk for invasive fungal infections is high in very low birth weight (VLBW) infants (< 1500 g) and highest for infants born at the youngest gestational ages who survive past the immediate postnatal period (Kaufman, 2014). There was a tendency towards spontaneous preterm birth reduction among women with asymptomatic candidiasis treated with clotrimazole (Rasti et al., 2014). Screening for eradication of infection during pregnancy may reduce the risk of preterm delivery (Kufman et al., 2006). The objectives of this study were to determine the prevalence of C. albicans in pregnant women referred to obstetrics clinics at Ahmadu Bello University Teaching Hospital Zaria and also to find the effects of infection on the pregnancy including birth weight the children delivered by the women.
MATERIALS AND METHODS
Study Area: This study was carried out on 238 pregnant women in all. 121women presenting with symptoms of vaginal discharge, itching and erythema were recruited as cases. The controls were 117 pregnant women who are asymptomatic. All the women had pregnancies with single fetus of gestational age of > 16weeks with term or preterm delivery referred to Ahmadu Bello University Teaching
Hospital Zaria, from September 2015 to January 2016.
Sampling Technique: Convenience sampling techniques was used in which women who consented, and met the inclusion criteria were recruited consecutively during the period of the study. A questionnaire was provided based on a secure database including demographic data, medical history, symptoms of disease, pregnancy complications and postnatal data.
Sample collection: High Vaginal Swabs were collected with the assistance of health professionals. Cusco vaginal speculum was inserted into the vagina for the visualization of the vaginal wall. A swab stick was inserted through the speculum into the vaginal canal and rotated. This permitted acquisition of vaginal fluid, columnar and or cuboidal epithelial cells which are the main reservoir of pathogenic organisms. The swabs were transported promptly to the laboratory and processed within 30 minutes of collection. The swabs were cultured on Sabaroud agar for isolation of Candida Sp, and vaginal smears were Gram-stained and microscopically evaluated.
Data analysis: The data were analyzed by SPSS version 20 using chi square and Fischer exact tests.
Table 1 shows that Forty eight, 48 (20.2%) pregnant women had Candida infection, of which 33(68.7%) and 15 (31.3%) were isolates from cases and control groups respectively. The prevalence of vaginal candidiasis in pregnant women was 20.2%. There were 18 (7.6%) preterm deliveries among patients who participated in the study, 15 (83.3%) were among women who had vaginal
discharge while 3 (1.3%) had no symptoms. Out of the women who had preterm births, five (5) had Candida albicans infection.
There was no growth in 63 (54%) swabs out of the 117 control samples while 33 (28.2%) had normal vaginal flora isolated. Only 17 of the controls had pathogenic isolates and 15 were Candida albicans as indicated on Table 2. Table 3 shows the distribution of various complications observed during the study. In all, 39 women had babies with complications. Eleven 11 (28.2%) of these complications were Jaundice, 6 (15.3%) early neonate death, 4 (0.1%) fresh still birth and 18 (46.2%) had conjunctivitis respectively. Among the 121 cases who had vaginal discharge, 3 (2.5%) had early neonatal death 2 (1.7%) had fresh still birth and 1 (0.8%) had miscarriage. Other complications observed in the two weeks old infants delivered of women who had abnormal vaginal discharge during post natal clinics include jaundice 4 (3.3%) and Conjunctivitis 11 (9.1%). In the control group, 7 (6.0%) babies born had conjunctivitis, 2 (1.7%) babies had jaundice and 2(1.7) women had fresh still births. There was no record of miscarriages among them. A significant higher frequency of preterm delivery was found in the cases group than in the controls however; only 5 of the women had candidiasis.
In Table 4, 136 (56%) of the study population had abnormal vaginal discharge at various degree and more than 30% suffered vaginal itching and discomfort during pregnancy. The table revealed that women who complained of abnormal discharge consist of 84 from the cases category and 53 from the controls. 52 of the cases group had vaginal itching and discomfort while among the controls, they were 20.
The study also showed that 17.1% of the pregnant women who enrolled for the study had adequate knowledge of vulvocandidiasis in pregnancy and 29.6% has a history of the infection in the past.
The result of the study showed that vaginal yeast infections are a common problem during pregnancy and the prevalence of vulvocandidiasis in pregnancy is 20.2% in Zaria. This is similar to studies conducted in Nigeria by Akinbami et al., 2015 at Ladoke Akintola University of Technology (LAUTECH) in Ogbomoso who reported the prevalence of vulvovaginal candidiasis to be 25%. Anorlu et al. 2004, in another studies documented a prevalence rate of 26% in Ibadan (Anorlu et al., 2004).
Vaginal secretions during pregnancy fall from a pH of greater than 7 (an alkaline pH) to 4 or 5 (an acid pH). This change in pH also unfortunately, favors the growth of Candida albicans. Vaginal infection during pregnancy may be caused by high estrogen levels (Pratibha et al., 2013). These infections are not risky to the pregnancy, but they can cause uncomfortable symptoms and severe fatigue among pregnant women.
This study revealed that 27.7% of the patients with preterm labour and 34.3 % of mothers with appropriate gestational age were infected with C. albicans. Out of 121 pregnant women with abnormal vaginal discharge, 16 (13.2%) mothers had preterm births but only 5 of them had Candida infection. The remaining eleven swabs from the pregnant women consist of 1 normal flora, 6 bacterial isolates and 4 sterile swabs. Our findings did not show any statistical significance effect of vaginal C. albicans infection on pregnancy outcome at P < 0.05 as shown in Table 2
The difference between cases and controls was clinically significant. The study suggests increased risk of vaginal infection during pregnancy among the study population. However, no statistically significant relation was found between C. albicans infections and preterm birth. The prevalence of vaginal candidiasis in the study was 20.2 %. Five 5 (10.4%) of the patients infected with Candida had preterm births and forty three 43 (89.5%) had term deliveries.
The prevalence of vulvovaginal candidiasis in this study is significantly lower than a similar study among pregnant women in Gboko, Nigeria which gave of 47.7% higher than that of the control (20.3%). The rate of symptomatic candidiasis among the pregnant women was significantly high compared to those without symptoms (Jombo et al., 2011). Olugbenga et al., (2014) found that at least one in every three women is infected. This is similar to many reports including 30% by Okonkwo and Umeanaeto (2010) and 37.4% by Guzel et al.,(2011). In Iran prevalence of vaginal candidiasis in 150 pregnant women was 32.7 %. The study showed that the patients with preterm labour were 35% compared to those with term labour (31.8%) were infected with C. albicans (Rasti et al., 2014).
The incidence of yeast infections has greatly increased in recent times especially with the widespread use of broad-spectrum antibiotics and immunosuppressive treatment. Candidiasis is an important yeast infection that is especially common in pregnancy with the risk of the woman harboring Candida spp. and infecting their babies during the perinatal period. Pregnancy, diabetes mellitus, and antibiotic treatment are the most common predisposing factors (Cohen et al., 2012). Some studies have shown that vulvovaginitis has increased in the past three decades due to antifungal resistance to Candida species and a change in women’s health quality (Olugbenga et al., 2014).
Vulvovaginal candidiasis had been noted to be more common in pregnancy, and pregnant women have been reported to have higher rates of recurrent infections. According to the results of Kaufman (2006), Candida is a risk factor for both systemic infections in low birth weight infants and mortality which was not in consistence with the results of this study. Among 48 mothers who had C. albicans infection, 5 (10.4%) were delivered of preterm babies while of 120 mothers with appropriate gestational age newborns, 33 (68.7 %) were shown to have C. albicans infections and this was not statistically significant (P>0.05).
The study also exposed the urgency and need of educating the study population on vaginal infection and its risk on the fetus despite the fact that most of the participants reside in urban and semi urban area. Only 17% of the pregnant women who took part in the study had previous knowledge of the infection as most women claim it is a toilet infection with little or no information of the cause of infection. This is in agreement with the study Jombol et al, (2011) who found that 94.1% of the pregnant women were ignorant of the disease. About 54% of the pregnant women complained of abnormal vaginal discharge with many of them presenting with various degree of itching and erythema.
In this study, the prevalence of Candida infection in pregnancy among the study population was 20.2%. More
than 20% of women had culture-positive Candida albicans vaginal infection during pregnancy, which represents a very high rate of infection of the lower genital tract of pregnant women. However, there was no significant relationship between vulvovaginal candidiasis with pregnancy outcome and foetal or neonatal complications. The rate of symptomatic and asymptomatic vulvovaginal candidiasis among pregnant women in Zaria is high with a corresponding low level of awareness and care about the disease.
Health education should be instituted at ante-natal clinics so as to raise the knowledge and level of awareness of pregnant women towards seeking prompt and appropriate treatment. Routine screening and consequent treatment for vaginal candidiasis could improve pregnancy outcomes. In women with persistent discharge, screening for lower genital tract infections (vaginal and cervical) is recommended. If vulvovaginal candidiasis is diagnosed in a symptomatic pregnant woman, treatment is indicated.
Pregnant women are at high risk of vaginal infections, thus adequate investigations and prompt treatment will improve the quality of lives and prevent adverse effects on mother and fetus. Adequate laboratory facilities should be provided and laboratory personnel should be trained in the diagnosis of vulvovaginal candidiasis.
1. Adeyeba,O.A. Adeoye,M.O. and Adesiji, Y.O.(2003). Bacteriological and Parasitological Assessment of Vaginitis in Pregnant Women in Iseyin, Oyo State, Nigeria. African Journal of Clinical Experimental Microbiology, 4 (2):112-125.
2. Akinbami NA, Babalola OG, Shittu OM, Tijani MA and Adekola AS (2015). Detection and Epidemiology of Vulvovaginal Candidiasis among Asymptomatic Pregnant Women Attending a Tertiary Hospital in Ogbomoso, Nigeria International Journal of Biomedical Resources. 6(07): 18-23.
3. Anorlu R, Imosemi D , Odunukwe N , Abudu O , and Otuonye M (2004). Prevalence of HIV among women with vaginal discharge in a gynecological clinic. National Medical Association. 96(3): 367–371.
4. Baradkar, V.P. Mathur, M. and Kumar, S. (2008). Neonatal septicaemia in a premature infant due to Candida du bliniensis. Indian Journal of Medical Microbiology. 26(4):382.’Retrieved from’: 10.4103/0255-0857.43574.
5. Cohen, C.R. Lingappa, J.R. Baeten, J.M. Ngayo, M.O. Spiegel,.CA. Hong, T. Donnell, D. Celum, C. Kapiga, S. Delany, S. and Bukusi, E.A. (2012). Bacterial Vaginosis Associated with increased risk of Female-to-Male HIV-1 Transmission: a prospective Cohort Analysis among African couples. PLoS Med 9: e1001251.
6. Gibbs, R.S. Romero, R. Hillier, S.L. Eschenbach, D.A. and Sweet, R.L. (1992). A review of premature birth and Subclinical Infection. American Journal Obstetrics & Gynaecology. 166:1515–1528.
7. Hollier, L.M. (2005).Preventing preterm birth: what works, what doesn’t. Obstetrics and Gynecology Survey. 60:124–131.
8. Jombo, G.T. Akpera, M.T. Hemba, S.H. and Eyong, K.I. (2011). Symptomatic Vulvovaginal Candidiasis: Knowledge, Perceptions and Treatment modalities among Pregnant women of an Urban Settlement in West Africa. African Journal of Clinical and Experimental Microbiology 12 (1) 32-37.
9. Kaufman, D.A. Gurka, M.J. Hazen, K.C. Boyle, R. Robinson, M. and Grossman, L.B.(2006). Patterns of Fungal Colonization in Preterm Infants weighing Less Than 1000 Grams at Birth. Pediatrics Infectious Disease Journal 25(8):733–7.
10. Kaufman, D.A (2014). Clinical microbiology of Bacterial and Fungal Sepsis in very-low-birth-weight infants. Clinical Microbioliology Reviews Jul. 17(3):638-80
11. Mendling, W. and Brasch, J.(2010). Guideline Vulvovaginal Candidosis. Mycoses. 55:1–13.
12. Ogbonna, C.I. Ogbonna, I.B. Ogbonna, A.A. and Anosike, J.C. (1991). Studies on the incidence of Trichomonas Vaginalis Amongst Pregnant Women in Jos area of Plateau State, Nigeria. Angew Parasitology. 32(4):198–204.
13. Okonkwo, N. J and Umeanaeto, P.U (2010). Prevalence of Vaginal Candidiasis among Pregnant Women in Nnewi Town of Anambra State, Nigeria. African Research Review, 4(4) Pp. 539-548.
14. Olugbenga, A. O. Olufunmilola, B. M. Olowe, R. and Adekanle, D. (2014). Prevalence of Vulvovaginal Candidiasis, Trichomoniasis and Bacterial Vaginosis Among Pregnant Women Receiving Antenatal Care in Southwestern Nigeria. European Journal of Microbiology and Immunology 4(4): 193–197.
15. Pratibha Kamath , Maria Pais and Malathi.G.Nayak (2013) Risk of vaginal candidiasis among pregnant women. International Journal of Current Microbiology and Applied Science 2(9): 141-146.
16. Rasti, S. Asadi, M. A. Taghriri, A. Mitra, B. M. and Mousavie, G. (2014). Vaginal Candidiasis Complications on Pregnant Women. Jundishapur Journal of Microbiology. 7(2): e10078