PREVALENCE AND ASSOCIATED RISK FACTORS OF HYDATIDIFORM MOLES AMONG PATIENTS WITH INCOMPLETE ABORTION EVACUATED

PREVALENCE AND ASSOCIATED RISK FACTORS OF HYDATIDIFORM MOLES AMONG PATIENTS WITH INCOMPLETE ABORTION EVACUATED AT BUGANDO MEDICAL CENTRE AND SEKOU TOU...
Author: Molly Payne
1 downloads 3 Views 217KB Size
PREVALENCE AND ASSOCIATED RISK FACTORS OF HYDATIDIFORM MOLES AMONG PATIENTS WITH INCOMPLETE ABORTION EVACUATED AT BUGANDO MEDICAL CENTRE AND SEKOU TOURE HOSPITAL IN MWANZA CITY, NORTH-WESTERN TANZANIA

By: BERNARD HENRY KITANGE (MD)

A DISSERTATION TO BE SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF DEGREE OF MASTER OF MEDICINE IN OBSTETRIC AND GYNAECOLOGY OF THE CATHOLIC UNIVERSITY OF HEALTH AND ALLIED SCIENCES CUHAS-BUGANDO 2013

DECLARATION AND COPYRIGHT I, Bernard Henry Kitange declare that the work presented in this thesis is my original work. The contribution of other people that collaborated in the preparation of this work are duly quoted and acknowledged. This dissertation has not been submitted for the award of any degree in any other University. Signed …………………………..

Date ………………………

i

CERTIFICATION The undersigned certify that they have read and hereby recommend for examination of thesis/dissertation entitled PREVALENCE AND ASSOCIATED RISK FACTORS OF HYDATIDIFORM MOLES AMONG PATIENTS WITH INCOMPLETE ABORTION EVACUATED AT BUGANDO MEDICAL CENTRE AND SEKOU TOURE HOSPITAL IN MWANZA CITY, NORTH-WESTERN TANZANIA in fulfillment of the requirements for the degree of Master of Medicine (Obstetrics and Gynecology) of Catholic University of Health and Allied Science (CUHAS-Bugando) …………………………………………

Date ………………………….

Dr. Anthony N. Masinde, M.D, M.MED Lecturer Department of Obstetrics and Gynecology Catholic University of Health and Allied Sciences

…………………………………………..

Date …………………………

Dr. Peter Rambau, M.D, M.MED Senior Lecturer Department of Pathology Catholic University of Health and Allied Sciences

………………………………………….

Date ………………………….

Evelyn Konje, B.Stat, MSc Lecturer Department of Epidemiology and Biostatistics Catholic University of Health and Allied Sciences

ii

DEDICATION This work is dedicated to my brilliant wife Mrs. Yusra Salim Said and our wonderful kids Henry-Beniah and Princess-Hanan for everlasting moral and material support throughout my post-graduate training. May the Almighty God bless them in all days of life.

iii

ACKNOWLEDGEMENTS I wish to thank the Almighty God for keeping me strong and healthy and for overseeing me going through this physically and mentally rigorous but emotionally rewarding course. I am also very grateful to my supervisors, Dr. Masinde, Dr. Rambau, and Ms. Konje for their guidance and the relentless encouragements they have given me during the proposal’s development, the course of my research work and finally during the preparation of this book. I am obliged to Dr. Gaspar J. Kitange (Mayo Clinic, Rochester, MN, USA) and Dr. Fadhili M. Lyimo (Department of Human Resources Development, Ministry of Health and Social Welfare) for their assistance and support in designing the research proposal. Many thanks to the senior members of the department of Obstetrics and Gynecology who enriched my proposal and to the institutional Research and Ethics Board for its invaluable input and for granting me the necessary approvals to embark on my study. My sincerest gratitude also goes to all residents and registrars for being very supportive during my data collection. Finally, but not least, I wish to thank my family members (Dr. Henry M. Kitange and Dr. Modest H. Kitange of SHALOM MEDICAL CENTRE) and friends for their moral support and constant prayers.

iv

TABLE OF CONTENTS DECLARATION AND COPYRIGHT................................................................................ i  CERTIFICATION .............................................................................................................. ii  DEDICATION ................................................................................................................... iii  ACKNOWLEDGEMENTS ............................................................................................... iv  TABLE OF CONTENTS.................................................................................................... v  LIST OF FIGURES ......................................................................................................... viii  LIST OF TABLES ........................................................................................................... viii  LIST OF ABBREVIATIONS ............................................................................................ ix  OPERATIONAL DEFINITION ......................................................................................... x  ABSTRACT ....................................................................................................................... xi  CHAPTER ONE ................................................................................................................. 1  INTRODUCTION .............................................................................................................. 1  1.1. BACKGROUND ..................................................................................................... 1  1.2. PROBLEM STATEMENT ...................................................................................... 3  1.3. RATIONALE OF THE STUDY ............................................................................. 3  1.4. RESEARCH QUESTION........................................................................................ 4  1.5. OBJECTIVES .......................................................................................................... 4  1.5.1. Broad objective ................................................................................................. 4  1.5.2. Specific objective .............................................................................................. 4  CHAPTER TWO ................................................................................................................ 5  2.0. LITERATURE REVIEW ............................................................................................ 5  v

CHAPTER THREE ............................................................................................................ 9  3.0. METHODOLOGY .................................................................................................. 9  3.1.0. Study design .......................................................................................................... 9  3.2.0. Study duration ....................................................................................................... 9  3.3.0. Study setting.......................................................................................................... 9  3.4.0. Study population ................................................................................................... 9  3.5.0. Selection criteria ................................................................................................. 10  3.5.1. Inclusion criteria ............................................................................................. 10  3.5.2. Exclusion criteria ............................................................................................ 10  3.6.0. Sample size estimation ........................................................................................ 11  3.7.0. Sampling procedure ............................................................................................ 11  3.8.0. Study variables .................................................................................................... 12  3.8.1. Independent variables ..................................................................................... 12  3.8.2. Dependent variables ........................................................................................ 12  3.9.0. Data collection methods ...................................................................................... 12  3.10.0. Data processing and analysis ............................................................................ 13  3.11.0. Ethical considerations ....................................................................................... 14  3.12.0. Study limitation................................................................................................. 14  vi

3.13.0. Dissemination of the findings ........................................................................... 15  CHAPTER FOUR ............................................................................................................. 16  4.0. RESULTS .................................................................................................................. 16  CHAPTER FIVE .............................................................................................................. 22  5.0. DISCUSSION ............................................................................................................ 22  CHAPTER 6 ..................................................................................................................... 25  6.0. CONCLUSION AND RECOMMENDATIONS ...................................................... 25  REFERENCE .................................................................................................................... 26  APPENDIX I: Consent information and form for cases (English version) .................. 29  APPENDIX II: Consent form (Swahili version) .......................................................... 32  APPENDIX III: Data collection form........................................................................... 36 

vii

LIST OF FIGURES Figure 1: The prevalence of HM and its pattern ............................................................... 18 

LIST OF TABLES Table 1: Social demographic characteristics of the study population............................... 17  Table 2: Prevalence of HM by maternal characteristics for 180 participants at BMC and Sekou Toure Regional hospital ......................................................................................... 21 

viii

LIST OF ABBREVIATIONS BMC

Bugando Medical Centre

CHM

Complete Hydatidiform Mole

CI

Confidence Interval

CUHAS

Catholic University of Health and Allied Science

GA

Gestation Age

GTD

Gestational Trophoblastic Disease

GTN

Gestational Trophoblastic Neoplasia

HCG

Human Chorionic Gonadotropin

HIV

Human Immunodeficiency Virus

HM

Hydatidiform Mole

LNMP

Last Normal Menstrual Period

OR

Odds Ratio

PHM

Partial Hydatidiform Mole

RPOC

Remain Products of Conception

STRH

Sekou Toure Regional Hospital

ix

OPERATIONAL DEFINITION Abortion: Is defined as termination of pregnancy before the gestational age of 28 weeks. Hydatidiform mole: Refers to the spectrum of abnormal gestations arising from villous trophoblast associated with pregnancy Advanced maternal age (upper extreme age): Refers to the age above 30 years Very young maternal age (lower extreme age): Refers to the age between15-20 years Risk factors for hydatidiform mole: refers to age, parity, previous history of abortion, cigarette smoking, blood group, contraceptive use and the type of previous abortion.

x

ABSTRACT Background: Hydatidiform mole (HM) is one of the causes of spontaneous abortion and its prevalence is not clearly defined, partly because most studies have reported different prevalence rates from different regions of the world. The risk factors for the development of HM include: history and spontaneous type of abortion, blood group, previous history of HM, family history of HM, history of hormonal contraceptive use, extremes of maternal age, parity and history of cigarette smoking. At Bugando Medical Centre (BMC) and Sekou Toure Regional Hospital (STRH), abortion is the leading cause of admission to the gynecological ward. However, there is no previous study that has determined the prevalence and associated risk factors of HM among patients with incomplete abortion evacuated at these centers. Methods: This was a descriptive hospital-based study involving patients with diagnosis of incomplete abortion who were undergoing uterine evacuation at BMC and STRH, Mwanza City, North-Western Tanzania (February-April) 2013. A total number of 180 eligible candidates were enrolled in the study. Convenient sampling method was used, and patients who met the inclusion criteria were enrolled consecutively until the required sample size was reached. Results: A total of 180 women with incomplete abortion who were scheduled for uterine evacuation were recruited. The overall prevalence of HM was 12.8%. Women under the age of 20 years appeared to be more (27.5%) affected. Other risk factors (parity,

xi

contraceptive use, previous abortion, type of abortion and blood group) were found to have no significant association with HM. Conclusion: In this study the prevalence of HM (12.8%) was high and age between 1520 years was the only risk factor found to have significant association with the development of HM. Therefore, we recommend submission of evacuated RPOC for histopathological analysis of all cases with and without risk of HM. Being a hospital base study; these findings might not reflect that of the general population.

xii

CHAPTER ONE

INTRODUCTION 1.1. BACKGROUND Hydatidiform mole (HM) is a spectrum of abnormal gestations arising from villous trophoblast associated with pregnancy (1). HM has two histological types, including partial hydatidiform mole (PHM) and complete hydatidiform mole (CHM) (2). HM is among gestational trophoblastic disease (GTD) and others include choriocarcinoma and placenta site trophoblastic tumors that arise from villous trophoblast and interstitial trophoblast respectively (1). The prevalence of HM varies widely in different regions of the world. Studies conducted in the developed countries (North America, Australia, Newzeland and Europe) show a prevalence of HM ranging from 0.5-1.1 per 1000 pregnancies whereas the higher prevalence is seen in Asia and Japan, accounting for 2 per 1000 pregnancies (2). The prevalence of HM in Brazil is 2.2%, South Africa 1.2 per 1000 deliveries and Nnewi, Southeast Nigeria is 0.3 per 1000 deliveries (3-6). Together, these findings show that the prevalence of HM is not universally similar and that in some countries the prevalence may be very high. In Tanzania, the prevalence of HM is not known due to the lack of studies investigating this problem. HM has several etiological risk factors and the most established are extreme of maternal age and prior molar pregnancy (7-9). For instance, the risk of complete mole increases

1

three fold for women older than forty years and is much higher in patient with previous history of molar pregnancy (10, 11). Several studies have shown a significant association between HM and abortion. Acaia et al reported that among 93 studied women with repeated abortions 9 were found to have HM (12). Moreover, another study by Horn et al evaluating the histology of placenta tissues, reported HM specifically CHM to account for 5.1% of the causes of spontaneous abortion (13). Initial clinical findings are commonly not suggestive of the possibility of HM in patients with abortion. The routine histopathological analysis of the evacuated products of conception is often not performed. This may lead to the possibility of mismanagement of the patients with HM if this condition is unrecognized as the cause of abortion. Therefore, this study was designed to determine the prevalence and associated risk factors of HM among patients with incomplete abortion evacuated at BMC and STRH in Mwanza City, North Western Tanzania.

2

1.2. PROBLEM STATEMENT Hydatidiform mole remains an important risk factor responsible for abortion in many women of reproductive age, while abortion is currently a leading cause of admission to the gynecological wards at BMC and STRH (14, 15). The prevalence of HM in our setting is not known, because the majority of patients with abortion are managed by surgical evacuation and the products of conception are not routinely subjected to a histopathological examination. This may lead to the mismanagement of the patients in terms of unnecessary hysterectomy and improper follow-up of the patients who experience spontaneous abortion. 1.3. RATIONALE OF THE STUDY While abortion remains a leading cause of admission at BMC and STRH, it is ethically inappropriate to ignore the remains products of conception (RPOC) since an accurate knowledge on the pathology of the previous aborted conception may be of prognostic value in the event of a subsequent abortion. This study will help to find out how common HM is amongst the patients with abortion undergoing evacuation at BMC and STRH. This will further emphasize the need for expansion of the histopathological examination services to the health care centers, and eventually, becoming a routine component for the standard of care of patients with abortion. Furthermore, our data will provide a basis for further future studies involving a larger cohort of abortion patients.

3

1.4. RESEARCH QUESTION Are hydatidiform moles among the possible causes of abortion at Bugando Medical Centre and Sekou Toure Hospital? 1.5. OBJECTIVES 1.5.1. Broad objective To determine the prevalence and associated risk factors of HM among patients with incomplete abortion evacuated at BMC and STRH in Mwanza City, North-Western, Tanzania 1.5.2. Specific objective 1. To determine the prevalence of HM among patients with incomplete abortion evacuated at a BMC and STRH in Mwanza City, North-Western, Tanzania. 2. To determine the associated risk factors of HM among patients with incomplete abortion evacuated at a BMC and STRH in Mwanza City, North-Western, Tanzania.

4

CHAPTER TWO

2.0. LITERATURE REVIEW Hydatidiform mole (HM) is one among the causes of the spontaneous abortion, a condition accounting for 19% of the direct causes of maternal death worldwide (16). In the United States, nearly one fifth of all pregnancies end in abortion (17). In 2008, estimated number of abortion in Eastern Africa was 2.4 million (18), and in Uganda occurs at a rate of 54 per 1,000 women aged 15–49 and account for one in five pregnancies (19). Moreover, childbearing age in Tanzania is between 15-19 years, median age at first delivery ranges from 19-20 years and forty eight percent of delivery occurs at home (20). The prevalence of HM is not universally similar and in some countries the prevalence was found to be very high. For instance, in the developed countries, which includes North America, Australia, New Zealand, and Europe, studies have shown a prevalence of HM ranging from 0.57–1.1 per 1000 pregnancies, whereas studies conducted in Southeast Asia and Japan showed a higher prevalence of 2.0 per 1000 pregnancies (2). The prevalence of HM in Southeast region of Nigeria is 0.3 per 1000 deliveries (4) while in Uganda, the prevalence of HM specifically CHM was found to be 3.42 per 1,000 deliveries (21). Since such studies have not been conducted in Tanzania, the prevalence of HM is not known.

Clinically patients with HM frequently present with vaginal bleeding, uterine fundus large for gestational age, pelvic pressure or pain and hyperemesis gravidarum (2, 22). 5

However, this presentation is not invariably observed in all patients since a study by Khoo et al revealed an evidence that 59.8% of patient with HM had no clinical symptoms (22). Moreover, a study by Kumar et al showed that about 6.5% of patient who underwent routine antenatal ultrasonography had asymptomatic HM (23).

HM has two histological distinct types, which include PHM, and CHM (24, 25). These conditions have been shown to have positive association with abortion. A study by Horn et al evaluating the histology of placenta tissues shows CHM to account for 5.1% of the causes of the spontaneous abortion (13). On the other hand, Acaia et al showed that about 10% of women with repeated abortion were found to have HM (12)

Hydatidiform mole can be detected early by using ultrasound and serial monitoring of the serum Human Chorionic Gonadotropin (HCG) hormones. Furthermore, there is a strong indication for ultrasonography evaluation of patients presenting with abortion. However, HM and the RPOC can be difficult to distinguish sonographically despite the presence of some specific sonographic features that can differentiate HM and RPOC (26). Thus, to meet the gold standard for the diagnosis of HM, RPOC must be submitted for further histopathological analysis (13, 27).

Uterine suction and curettage is the safe surgical step in the management of patient presenting with abortion accompanied with excessive uterine bleeding (28). Moreover, if the patient present with life threatening hemorrhage and all possible measure have been done to control and failed hysterectomy can be performed as an emergency regardless of the parity of the patient (29). Follow up of patients after evacuation is mandatory through serial measurement of serum beta HCG in patients with confirmed HM, mainly because 6

about 68% were found to be cured without any chemotherapy (30). Moreover, Bianconi et al shows that among 340 patients with HM 223 (66%) experienced spontaneous remission after evacuation (31). Based on these findings, it is highly possible that many patients are under-reported and this could explain, at least in part, the low prevalence of HM observed in some studies. Histopathological examination of products of conception is critical integral and routine component of the management of patients with abortion. This view is supported by Romero Gutierrez et al, who evaluated the histopathology findings of all patients with spontaneous abortion and unsuspected HM and found that 12.1% had HM, (32). Moreover, Dauda et al reported HM in 10.4% of patients whom their endometrial biopsies were taken for histological analysis. (33). Therefore, histopathological analysis of RPOC could further help to distinguish between different types of HM (34). Many risk factors have been associated with the HM and the common ones include increased number of spontaneous abortion, previous history of HM, family history of HM, extremes of maternal age (< 20 or >35 years) and history of contraceptive use (8, 35-38). Furthermore, data by Parazzini et al showed that HM was common in nulliparous women, which contrasted the findings by Kumar et al that showed HM to be more common in multigravida (8, 23). Blood group ‘B’ and Cigarette smoking was found to be another risk for HM however, for cigarette smoking risk was greater for patients who smoked more cigarettes and for longer periods (39, 40). Hydatidiform mole can be a fatal condition in which most patients who die do so, due to late diagnosis, HIV co-infection in whom patients with low CD4 count (

Suggest Documents