Journal of Clinical Research and Case Studies

Clinical Epidemiological Characterization of Vaginal Infection in Pregnant. “Orlando Matos Mosquera” Polyclinic 2019-2021

Elisa Puentes Rizo M¹, Alejandro Aguilar Puentes², Ruben Aguilar Puentes³, Mariam Machado Tejeda⁴, Pedro Rolando López Rodríguez^5*

¹First and second degree specialist in comprehensive general medicine, assistant professor, associate researcher and master’s degree in comprehensive care for women.

²Second-year resident in comprehensive general medicine.

³Second-year resident in comprehensive general medicine

⁴Second-year resident in pediatric surgery.

⁵First and second degree specialist in general surgery, assistant professor, consulting professor and assistant researcher.

*Corresponding author
Pedro Rolando López Rodriguez, Continental Street No.152, Sevillian cast, Havana. Cuba.

ABSTRACT
Introduction: Vaginal infection is a disease with a high incidence in pregnancy. It is associated with maternal-fetal complications, being early diagnosis and fundamental treatment. 

Objective: To clinically and epidemiologically characterize pregnant women with vaginal infection belonging to the “Orlando Matos Mosquera” Polyclinic in the period 2019-2021. 

Method: Observational, descriptive and cross-sectional study of pregnant women with vaginal infection. The arithmetic mean and standard deviation of the quantitative variables and the absolute frequencies and percentages in qualitative variables whose association was obtained through the Chi-square with 5% significance were obtained. 

Results: 245 pregnant women were analyzed. The mean age was 25 years. 42.4% were mestizo, 56.4% accompanied or single, 41.2% had an upper secondary level, and 12.7% were housewives. At least 7 out of 10 smoked or had unprotected sex. 80.8% of the examined had vaginal discharge. 75 pregnant women suffered infection by Candida albicans and the average gestational age was 18.58 ± 8.48 weeks of pregnancy, with 37.6% of vaginal infections occurring in the first trimester. 73.0% of the mixed infections had vaginal changes and 66.7% of the infections due to infrequent germs were complicated. 3 out of 10 presented premature rupture of membranes, abortion or preterm delivery.

Conclusions: Adolescents and young adults, mestizos, accompanied and with a higher secondary level prevailed. Vaginal discharge as a symptom and Candida albicans infection predominated. There was an association between the variables analyzed and complications. 

Keywords: Vaginal Infection, Pregnancy, Primary Health Care

Introduction
Reproductive system infections are caused by changes in the vaginal flora, 50% of these infections go unnoticed by women and are only diagnosed during gynecological examination [1]. Pregnancy is an event that is traditionally celebrated around the world. However, for many families, the reproductive process can be grim and dangerous, with morbidity, sequelae, and ultimately death for the mother, her child, or both [2,3]. Multiple complications may appear during pregnancy, including vaginal infection, which has a worldwide distribution and constitutes a health problem due to its high incidence and health consequences [4]. These infections have increased in recent years, since they went from having a prevalence of less than 5-10% to 7-20% of cases per year. This type of disease affects women of reproductive age, without discrimination of race, state socioeconomic, educational level or others. Being the lack of knowledge of the subject an influential factor in the increase in the frequency observed [5]. The normal discharge from the vagina is white, odorless, and not homogeneous, which is generally found in the entire vaginal fornix, where numerous concomitant microorganisms of the usual flora in that region. However, when the secreted volume increases and is accompanied by irritative symptoms, unpleasant odors and discomfort, a vaginal infection has occurred, which tends to occur with marked frequency in pregnant women [6-8]. Vaginal infection can be present in women of any age, whether or not they are sexually active. Most have had a vaginal infection at least once in their lives [9]. Pregnancy is a period in which women are not exempt from suffering from a vaginal infection; Several investigations declare that pregnancy is a factor for the appearance of vaginal infections. Some women live with these and sometimes go unnoticed, but during pregnancy this is a serious problem, since they represent a risk factor for the production of complications such as premature rupture of the membrane (PROM), preterm labor and its consequences, including birth of a low-weight product [10]. The World Health Organization (WHO) estimates that annually 333 million new cases of curable sexually transmitted diseases in people aged 15 to 49, the majority in developing countries, which include member countries of the European community [11,12]. On the other hand, recent calculations report that each year more than 340 million cases of curable sexually transmitted infections (STIs) occur in the world (they include only fungal and parasitic bacterial infections), which manifest as vaginal discharge syndrome, susceptible to effective treatments and that at least one million infections occur every day [3]. Infections of the vulva and vagina are a frequent reason for consultation in Primary Care, Specialized and Hospital Emergencies, representing 20% of the queries gynecological [13,14]. In the United States it is the most frequent cause of infectious pathologies with an estimated 5 to 7 million cases per year. One in three women in this nation have bacterial vaginosis. While, in Sub-Saharan Africa it registers the highest prevalence, especially in the areas affected by the human immunodeficiency virus (HIV) [4]. In Cuba, cervicovaginal infections represent 80% of the reasons for gynecological consultations, so these Pathologies constitute a priority health problem [10]. The Island is no exception to this situation and reports approximately 831,787 consultations by these entities annually. In Havana, this entity behaves with 227,292 patients assessed by gynecology consultation. According to reports from the National Statistics Office, infections by fungi, protozoa, parasites, and bacteria represent between 40,000 and 50,000 cases annually, with a marked trend toward increase [11]. Epidemiological studies conducted in Cuba agree stating that the three most common types of vaginal infections are bacterial vaginosis (40-50%), followed by candidiasis (20-25%), and trichomoniasis (15-20%). Vaginal discharge may also occur if you have an infection of the cervix with gonorrhea or Chlamydia (sexually transmitted diseases). There are also other causes of vaginal infections that are less common [12]. The Cuban health program and the development of preventive medicine, with the participation of the family doctor and nurse in gynecologic and obstetric care, together with the substantial technical and organizational changes to improve the quality of care for the mother-child pairing, have made it necessary to seek more dynamic ways that favor the performance of the health team, among which is the early detection of vaginal infections in pregnant women, whose control is decisivo para mejorar la salud reproductiva y de toda la población, lo que constituye uno de los mayores desafíos de la salud pública contemporánea [13]. Teniendo en cuenta lo anterior y la observación del incremento de la incidencia de infección vaginal en las embarazadas del área de salud Párraga y la repercusión que puede tener en el desarrollo del proceso gestacional y su producto, se tardará en realizar esta investigación.

Methods
Between September 2019 and September 2021, an observational, descriptive and cross-sectional study was carried out on 245 pregnant women with positive microbiological studies registered in the obstetric card belonging to the health area of the “Orlando Matos Mosquera” Polyclinic of the Arroyo Naranjo Municipality in Havana, Cuba.

Inclusion Criteria
Pregnant patients with a positive microbiological study registered in the obstetric card belonging to the aforementioned Polyclinic

To agree to participate in the study, an attitude that must be expressed by signing the informed consent, with stable residence in the health area.

Exclusion Criteria
Presenting a mental disability that prevents them from performing adequately in the Obtaining the information.

Theoretical Methods
Induction-Deduction: Facilitated typifying the processes of reading and interpreting theoretical and empirical data, to arrive, following the logic of scientific thought, to generalizations and conclusions. Historical-Logical: It made it possible to approach the theoretical references of the subject and the analysis of the different criteria consulted by other authors with an approach adjusted to the time and space of its emission and to the corresponding level of scientific-technical development.

Statistical Method
Calculation of absolute frequencies, percentages, arithmetic mean, standard deviation. Chi Square test of independence with a significance of 5%. Preparation of statistical and contingency tables he study.

Results
Table 1 summarizes the sociodemographic characteristics of the pregnant women studied.

A total of 245 pregnant women with vaginal infection at the defined time and place were analyzed. The average age of the patients was 25.01 ± 8.75 years. The majority age group was 15 to 24 years old with 43.7% of the total (107 pregnant women). The extreme ages (less than 15 years and 45 or more years) represented in each case less than 10%. Most of the patients were mestizo (104 cases; 42.4%). The percentage of whites and blacks was quite similar (28.1% and 29.5% respectively

The most frequent marital status was accompanied (94 pregnant women for 38.4%), followed by single women (at least 3 out of 10 studied). Only 8 pregnant women were divorced (3.2%). 41.2% of those analyzed (101 pregnant women) had a higher average level. Following them in frequency were those with completed secondary school (66 cases; 26.9%). More than 80% of the pregnant women were linked to some activity (studying or working).

Table 2 lists the symptoms reported by pregnant women with vaginal infection at the polyclinic and in the period analyzed.

El flujo vaginal fue el síntoma más frecuente en 178 pacientes (72,6%), seguido del prurito vaginal y la fetidez (65 casos; 26,5% y 60 casos; 24,5% respectivamente). El dolor abdominal bajo se presento en menos del 10% de las analizadas. El porcentaje individual de los incluidos en Otros no superó el 5%.

En la tabla 3 se resumen los resultados microbiológicos y la relación con el gestacional de las embarazadas.

The average gestational age of the patients studied was 18.58 ± 8.48 weeks of pregnancy, with 37.6% of all vaginal infections occurring in the first trimester of pregnancy (92 of the pregnant women). Candida albicans was the most prevalent etiological agent (75 pregnant women; 30.6%) among all those studied. While 46.7% of pregnant women with candidiasis were in the second trimester of pregnancy, 53.6% of those infected with Trichomonas were in the third trimester and 46.8% of those infected with Gardnerella vaginalis were found. in the first trimester. Mixed infections predominated in the first trimester (16 pregnant women; 43.23%) and those caused by other germs such as Escherichia coli, Group B Streptococcus or Streptococcus agalactiae (which were the least frequent in general with only 15 pregnant women and 6 0.1% of the total) prevailed in the second trimester of pregnancy. The association between these variables was notorious with a statistical significance level of 5%.

Table 4 relates the microbiological result with the presence of cervical changes in the pregnant women studied.

Modifications cervicals: g (4); x2=46.31. Others: Escherichia coli, Streptococcus Group Bo Streptococcus agalactiae. Source: data collection form

A total of 113 pregnant women (46.1%) presented cervical modifications. 73.0% of pregnant women with Mixed infections had cervical modifications. Also 62.9% of those infected by Gardnerella vaginalis and 6 out of 10 with Escherichia coli, Group B Streptococcus or Streptococcus agalactiae. There was an association between these variables at the statistical analysis with a high level of significance.

The complications of pregnant women with vaginal infection were summarized in Table 5. It can be seen that of the 104 pregnant women with complications, the

33.7% presented PROM, this being the most frequent, followed by abortion or preterm delivery (32 pregnant women; 30.8%) and low weight or CIUR (18 cases; 17.3%).

Discussion
The development of a community medicine that focuses its axis on prevention and timely diagnosis characterizes primary health care today. Likewise, the care of the pregnant woman and the product of conception are fundamental pillars in the programs of the Ministry of Public Health of Cuba. Since the introduction of the Maternal and Child Care Program (PAMI), the monitoring of this population group has benefited in various ways. The recognition of the same, as a vulnerable group and susceptible to preventable diseases, led to the standardization of strategies in the care of pregnant women that involve not only a multidisciplinary team of health professionals, but also social actors from governments at all levels. Infectious diseases are becoming more frequent in the general population, displacing chronic non-communicable diseases as the fundamental cause of morbidity and mortality and often with an unfavorable impact on those who are affected. Pregnancy is a situation that modifies the physiology of different organs and systems. The appearance of concomitant diseases or the presence of these prior to pregnancy makes it necessary to know these modifications and their influence on the disease, as well as the repercussion of the disease and of the diagnostic and therapeutic means in the pregnant woman and the fetus. In the course of a normal pregnancy, vulvovaginal infections are among the most common, often because their existence was ignored until the moment when the changes typical of pregnancy favor the course, sometimes florid, symptomatic and unfavorable. of this type of illness [14]. The sociodemographic characterization regarding the age of the patients analyzed showed, in the current study, an average of 25.01 ± 8.75 years, prevailing patients between 15 and 24 years (43.7%). Vidal Borras and Ugarte Rodríguez found that the age group that predominated in their study was that of 25 to 29 years, with 22.6% of their studied [15]. While, Mendoza A, Sánchez J and Montes E others showed a mean age of 23 and 24 years respectively and a predominance of adolescents [16,17]. Results that correspond to that of the current series. Several studies have shown that younger women have a greater tendency to have pathological vaginal discharge during pregnancy. Furthermore, adolescence is considered the most difficult stage of life where drastic changes occur in the sexual sphere and their inexperience makes them more prone to infections of this type [18,19]. The data correspond to those published by López Torres L. and another in the Peruvian Journal of Medicine Experimental and Public Health where an analysis of the association of several risk factors in vaginal infections was carried out in 20 cities of the Latin American country [20,21]. One of the results was that single women suffer 1.23 times more vaginal infections than married women. Although it was not a significant factor (lower limit of the confidence interval less than 1), the result was relevant. In the same way, and with statistical impact, the age of the pregnant woman turned out, since when it comes to single adolescents the risk multiplied considerably. There are several factors that predispose to the acquisition of vaginal infections and the more is known about the host factors that condition the appearance of these infections and the more attention is paid to them, the frequency and complications will tend to decrease. There are risk factors that trigger or precipitate the appearance of changes in the normal vaginal flora of pregnant women, and others considered individual factors -personal hygiene and obstetric history- and social factors -sexual conduct [22].  Castillo Pacheco MC. indicates that 86.30% of women who reported systematic condom use did not present vaginal infection, this can be explained by the protective effect Condoms are contraceptives that reduce the risk of STIs and prevent unwanted pregnancy. Also, Navarro García YE and others explain that currently it is related to PROM (the most frequent complication in this series) with multiple causes, but mainly vaginal and cervical sepsis is the most relevant factor [22-25]. Vaginal infection is currently maintained as an obstetric problem that makes pregnancy difficult and sometimes produces fatal outcomes. Among the limitations of the study, it is worth mentioning the biases inherent in its methodological design. of condoms on various Sexually Transmitted Infections (STIs) such as vaginal infections. Above all, when compared with research that, even addressing the same subject, focuses on designs that are generally quite heterogeneous [26]. However, this work provides local institutions with a characterization of pregnant women with vaginal infections, which allows long-term identification of term strengths and weaknesses in relation to its diagnosis and management, in addition to facilitating the generation of strategies aimed at improving maternal and fetal health care, based on the results of new studies.

Conclusions
Adolescent and young adult patients predominated. Vaginal discharge and stench appeared as the predominant clinical symptoms and findings among those studied. Candida albicans was the most frequent etiological agent, as well as early infections. The minority presented cervical modifications and complications and these were mainly associated with mixed infections or by infrequent germs such as Escherichia coli, Group B Streptococcus or Streptococcus agalactiae. There was a statistically significant relationship between the microbiological results and the trimester of pregnancy, cervical changes and complication.

Conflicts of Interest: There are no conflicts of Interest.

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