Results and Discussion
One hundred and twelve (112) of the two thousand and fourteen (2014) mothers screened during the study period were positive for CT, a prevalence of 5.6%. The mean age of the respondents was 24+ 4.3years. The mean birth weight of the neonates was 2.98+ 2.2 kg. There were one hundred and one (101) live births and eleven (11) stillbirths. Two (2) out of the one hundred and one (101) live births had CT DNA positive cord blood, an indication of transplacental transmission of CT . Eleven (11) neonatal cord blood were positive for CT DNA. Out of the eleven neonates whose cord blood were CT DNA positive, nine (9) were stillborn. The two neonates whose cord blood were positive for CT DNA and survived at birth developed early onset neonatal sepsis. The finding of the present study showed trans-placental CT infection is associated with stillbirth (p<0.001) OR 38.5, 95% CI (6.91- 412.3). Neonates whose cord blood were positive for CT DNA were more likely to be stillborn than those with cord blood negative for CT DNA.
A prevalence of 5.6% of CT infection among pregnant women in the study area is high but slightly lower than what has been reported from other parts of sub-Saharan Africa. A pooled prevalence rates of 6.9% and 6.1% were reported for East and Southern Africa and, West and Central Africa respectively (5, 6)
Vertical transmission of CT and its consequential impact on the infected mother and the neonate has been reported by some studies (14, 15). Studies on the stages of pregnancy at which vertical transmission of the infection occurs are scarce and not well defined. The present study observed trans-placental transmission of CT from the infected mother to the fetus. Cord blood was positive for CT DNA in 11 out of 112 (10.18%) neonates screened. The findings of the present study is similar to 10.34% reported elsewhere (16).
Maternal infections are important causes of stillbirth, accounting for half of stillbirths in low and middle-income countries and 10–25% in high-income countries. Some studies have suggested that infections in general may account for up to 10–66% of miscarriages and these risks for miscarriages are higher in pregnant women in low- and middle-income countries (15, 17, 18).
Earlier studies reported spontaneous abortion and stillbirth among mothers with CT infection (7). CT DNA was observed to be more common in products of conception and the placenta in women with miscarriage than in their control counterparts (15). Miscarriage, stillbirth and ectopic pregnancy were reported to be higher in CT infected pregnant women than their uninfected counterparts (10, 19, 20). One such study found CT antibodies in 33.3% of mothers with stillbirths in comparison to 10.4% of mothers with live births (𝑝 < 0.05).
The mechanism by which CT infection may lead to adverse outcomes of pregnancy is not clearly understood. It was suggested that CT may infect the fetus, triggering a harmful inflammatory response with cytokine release leading to miscarriage, premature rupture of membranes, or preterm labor. It could also possibly be caused by maternal inflammatory response that induces embryonic rejection due to homology of the chlamydial and human 60 kDa heat shock proteins (21, 22). Some studies have suggested that this pathogenic effect of CT infection may also play an important role in stillbirths (7, 23). CT antibodies were reported to be higher in mothers who had stillbirths compared to mothers with live births(4, 7, 24-26).
Despite substantial burden of CT infection on preterm birth estimated for sub-Saharan Africa and Asia, few published studies of CT infection and related outcomes of preterm labor and/or low birthweight from countries in these regions exist. Among the studies that could be identified, the majority seem to support a role for CT infection in preterm birth and similar pregnancy outcomes (27).
Stillbirth in the present study was 11 out of 112 (10.18%) of which nine(9) were attributable to transplacental transmission of CT from the infected mother to the fetus. Other routes of perinatal transmission: intrapartum or postpartum have been implicated in neonatal morbidity and mortality (28). Earlier studies reported septicemia, conjunctivitis, pneumonia, gastritis and urinary tract infection as documented neonatal sepsis among neonates of CT infected mothers (25, 29) .
Nine (9) out of the eleven (11) neonates whose cord blood were positive for CT DNA were stillbirths. The two live-birth neonates with CT DNA positive cord blood had early onset neonatal sepsis. It is therefore, clear that intrauterine transmission of CT is associated with high perinatal morbidity and mortality.
Prevention of adverse maternal and perinatal outcomes in CT infected pregnant women has been impeded for two primary reasons: lack of an effective human vaccine and progressive targeted screening/treatment recommendations for pregnant women (27).
Risk factors for adverse pregnancy outcome in CT infections have been reported by several studies (4, 15, 24, 30). These risk factors have been used to identify individuals at risk for prophylactic antibiotics (10).
Selection of antibiotics for the management of CT in pregnancy required the use of antibiotics which have proven to be of low toxicity to both the mother and fetus.
The use of such antibiotics in prophylactic management in at-risk pregnant women was reported to reduce the impact of CT infection in pregnancy on both the infected mother and neonate (29).
Earlier studies observed a significantly lower rates of CT infection for neonates born to women who received treatment with erythromycin as opposed to those who were not treated for CT. Antibiotic prophylaxis though effective in preventing adverse effect of CT infection in pregnancy where routine screening is not done, that is not part of the ANC service in Ghana. It will therefore not be out of place, to suggest the inclusion of prophylactic antibiotics in ANC services since the facilities do not have the capacity for routine screening.
Despite the fact that effective diagnoses and management of CT infection in pregnancy is able to reduce the impact of the infection on maternal and perinatal outcomes, CT management in Ghana is syndromic and has the ability to detect between 30 to 80% of infections (31). The low case detection rate is attributable to the fact that most of the cases are asymptomatic and would not present for management. They are most often diagnosed when the individual presents to the health facilities for reasons other than CT infection. The gold standard of routine screening for CT as part of ANC services should be part of the medium to long term plans of maternal and child health goals not only Ghana but other countries in Sub-Sahara Africa. Lack of human resource and equipment has been a major challenge. This therefore, would require a major policy direction at the national level for most developing countries.