Gavin Cobb

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Country: Scotland
Background: Medicine
Research Project:The management of maternal and congenital syphilis in Central Australia

METHODOLOGY: The research involved a retrospective case-note audit that was undertaken onsite in the medical records department of Alice Springs Hospital, Alice Springs, Australia. This reviewed the patient-records of all mothers who were discharged from the hospital during the dates 01/01/06 – 31/12/06 following delivery. Quantitative analysis included patient ethnicity, religion of antenatal care and residence, and maternal age. Further data was collected that examined the extent of maternal screening for syphilis during pregnancy and the management thereof in affected cases in accordance with the Centre for Disease Control (Northern Territory) “Guidelines for the Investigation and Treatment of Infants at Risk of Congenital Syphilis in the Northern Territory, July 2005”. Any affected pregnancies were also reviewed for management of infants born to these women, again in accordance with the guidelines.
A list of all women who met in the inclusion criteria was generated by the hospital records database and these were manually accessed within the records department. Each record was evaluated individually in-line with the CDC guidelines. Evidence of serological screening for syphilis was obtained from the patient records with further cross-referencing from various hospitals a laboratory databases.
Infants who were at risk of congenital infection were identifies through the maternal records and accessed in the records department. Management of these infants was analysed in accordance with the CDC guidelines.
All maternal (and infant where relevant) data was coded and entered onto Microsoft Excel™ spread sheets for standardisation and analysis by groupings as informed above. Paired t-testing and Chi-squared analyses were used for statistical analysis between groupings.
Ethical approval was obtained from Central Australian Human Research Ethics Committee (CAHREC) which serves the Central Australian region, and the Trinity College Faculty Research Ethics Group. Permission to enter the hospital premises and access patient notes was granted by relevant hospital management and administrative staff.

FINDINGS AND CONCLUSION: A positive association was found between Indigenous status and maternal age with the mean age of Indigenous woman being 4 years younger that non-Indigenous women who were also more likely to undertake their antenatal care in an urban rather that a remote setting. Of the 667 women included in the study, 97 were seropositive for indicating previous or current infection. Of these, 12 were found to have active infection. All seropositive cases and cases of active infection were found in Indigenous women. A positive association was found between area of residential/antenatal care and seropositivity, with Indigenous women from remote regions and town camps more likely to be seropositive than Indigenous women from Urban areas. Interestingly, Indigenous women from urban areas were most likely not to complete their antenatal screening for syphilis which could indicate a lower risk of infection for these women.
Syphilis screening was generally good for non-Indigenous women with 95% completing there screening, but was poor for Indigenous women. 70% of Indigenous women completed their screening, and of those who did not, 72% were due to failure of health personnel to collect serology when an opportunity was available, and 25% due to poor antenatal care attendance by the women. It was of concern that 33% of all cases of missed screening was due to failure to obtain serology at delivery, placing the child at increased risk of undiagnosed congenital syphilis obtained late in pregnancy.
Areas in which the guidelines could be improved included clarification of the terminology, inclusion of further screening and management criteria, and removal of sections that were not used or duplicated by other materials. Significant requirements for improvements in communication and documentation were identified, especially with regard to partner tracing and treatment, as were short comings in the delivery of training of health professionals regarding syphilis management. Recommendations for improvements in these areas were put forward.