This study was conducted among women attending for antenatal care at a district hospital in Entebbe, Uganda. The study was reviewed and approved by the ethics committees of the London School of Hygiene and Tropical Medicine and the Uganda Virus Research Institute and by the Uganda National Council for Science and Technology.
All pregnant women attending for their booking visit were eligible to enrol. The greatest limitation on the rate of recruitment was the availability of study staff to counsel antenatal attenders regarding the study and so at busy clinic times eligible women were selected to receive counselling according to convenience. After obtaining written informed consent, a standardised questionnaire was completed by one of four clinic midwives experienced in research techniques, who gathered information on obstetric history and treatments taken during this pregnancy. Women were asked if they had experienced any abnormal vaginal discharge or genital itch within the past 2 weeks.
Following routine obstetric examination, the midwife took four blind high vaginal swabs by inserting two swabs deeply into the vagina and gently rotating them for 5 seconds, this being repeated once. The first swab was rolled on a glass slide, fixed with ethanol, and Gram stained for the diagnosis of BV according to the morphological scoring system described by Nugent et al
A score of 7–10 was used to define a diagnosis of bacterial vaginosis and a score of 4–6 that of intermediate flora. Scores of 3 or less were defined as consistent with normal vaginal flora. Five per cent of slides were re‐evaluated by an external independent expert slide reader and were consistently within a Nugent score of plus or minus 1 with none requiring re‐classification. The second swab was inoculated into a culture media kit for Trichomonas vaginalis
(InPouch, BioMed Diagnostics, San Jose, CA, USA) and was incubated at 37°C for up to 5 days and examined by light microscopy daily for the presence of motile trichomonads. The third swab was taken using the Roche Amplicor collection kit (Roche Diagnostics, Branchburg, NJ, USA) for the detection of Neisseria gonorrhoeae
and Chlamydia trachomatis
by polymerase chain reaction (PCR); the fourth swab was inoculated onto blood agar, MacKonkey agar, anaerobic blood agar, and Sabauraud agar (Oxoid, Basingstoke, UK) for aerobic, anaerobic, and candidal culture. All microbiology investigations were performed at the MRC/UVRI microbiology laboratory and were used as gold standard for the evaluation of the syndromic diagnosis of RTIs. Quality assurance at the laboratory is maintained through participation in a scheme of the American College of Pathologists with consistently good results.
A venous sample was taken from participants for syphilis serology using a specific treponemal antibody test (Treponema pallidum haemagglutination assay, TPHA) and rapid plasma reagin (RPR) test (both Biotec Laboratories, Ipswich Suffolk, UK). RPR titres were determined where RPR was found to be positive. A diagnosis of active syphilis was defined as serology positive for both TPHA and RPR for any titre. Affected women were treated with benzathin penicillin (2.4 MU intramuscular single dose) weekly for 3 weeks. Participants were offered voluntary counselling and testing for HIV as part of the hospital prevention of mother to child transmission programme. HIV testing was performed using rapid antigen tests; an initial screening test was performed (Determine, Abbott Laboratories, Abbott Park, IL, USA) followed by a confirmatory test in those found to be HIV positive (UniGold, Trinity Biotech Plc, Ireland). In the event of discordant results a third test (InstantScreen, Gaifar GmbH, Biotech Campus Potsdam, Germany) was performed to confirm HIV status.
Clinical study staff were trained in the syndromic management of RTIs in line with local guidelines (Ugandan Ministry of Health24
), which do not include risk score assessment or cervical examination (fig 1). According to these guidelines women of any gestation, complaining of vaginal discharge and/or itch (defined here as vaginal discharge syndrome (VDS)), are treated in the first instance with single dose (2 g) oral metronidazole and clotrimazole pessaries. Partners of affected women are not offered treatment at this stage. Women in whom symptoms persist are treated with antibiotics to cover cervical infections (erythromycin 500 mg four times daily for 7 days and cotrimoxazole 2.4 mg twice daily for 3 days) and are counselled with regard to partner notification and treatment. Women presenting with signs and symptoms suggestive of an upper genital tract infection were to be referred for further management and excluded from the study: however no such women presented during the study. All participants were evaluated and treated for infections on the day of screening. Participants found later, on laboratory testing, to have an untreated infection were given specific treatment at the next follow up visit and where appropriate were counselled with regard to partner notification and treatment.
Figure 1Algorithm for the management of vaginal discharge in pregnancy. *Partners are not referred for treatment at this stage.
The principal outcome in this study was the presence of BV and/or TV. A sample size of 250 women was required to estimate the prevalence of these infections with a 95% confidence interval of plus or minus 5% if the prevalence of each was 20%. Data were entered using Excel (Microsoft) and analysed using Stata software (version 8: StataCorp). Prevalence of vaginal infections were calculated and compared using Fisher's exact test, χ2 and χ2 for trend as appropriate. Sensitivity, specificity, and positive and negative predictive values were used to assess the effectiveness of syndromic management guidelines and practice.