1. For Lab personnel Tuesday, 10 August 2010
Orientation on New Protein Test for Detection of Pre-eclampsia/eclampsia (PE/E): A Study at Maternity Hospital
For Lab personnel
Tuesday, 10 August 2010

2. 1. Objectives of this Orientation
To explain why this study is important
To familiarize lab personnel throughout the hospital with the study testing protocol
To explain how the study team can use their help in identifying protein-positive samples for the study (Step One)

3. 2. Orientation Overview Objectives Purpose of the study
Introduction to new point of care diagnostics
Urine samples
Study design
Sample collection points
Sample transportation
Ethical aspect
Procedure of the tests

4. 3. Purpose of the Study
To test the validity and specificity of this new Point of Care (PoC) test
To detect any presence of protein in urine
To help early detection and management of pre-eclampsia and eclampsia (PE/E)
Second leading direct cause of maternal death in Nepal and other developing countries
Currently, women rarely are tested for proteinuria during pregnancy in Nepal

5. 4. Common Urine Protein Tests in Nepal
Dipstick
Sulphosalicylic acid
Acetic acid
Esbach test (occasionally)

6. 5. New Point of Care (PoC) Diagnostics for Urine Protein Detection
Developed at Johns Hopkins University Biomedical Engineering Department with Jhpiego
Color-based qualitative measurement
It has the reagent (tetrabromophenol blue) and acid buffer
Applied to filter paper. Put urine on it and it identifies changes color if there is protein
Low cost—10 times cheaper than dipstick
Already proven in US lab setting

7. 6. Type & Amount of Urine Required
At least 10–15 mL urine (midstream urine)
10–15 mL urine specimen after catheterization (if in critical condition/or unable to go to lavatory)

8. 7. Study Design Two-step study STUDY STEP SAMPLES TESTING STEP ONE
200 protein positive samples from ANC OPD, emergency lab and parasitology department
Hospital dipstick result recorded
Additional testing: Dipstick, PoC test, Esbach test
STEP TWO
300 urine samples from ANC OPD, all pregnant women

9. 8. Sample Collection STEP One= KEEP/COLLECT IN RED TRAY
ANC OPD lab where dipstick is done
Emergency laboratory
Parasitology lab
Wards (MICU, ANC A and ANC B) if any protein positive samples found there
STEP Two=KEEP/COLLECT IN BLUE TRAY

10. 9. Step One Sample Collection: Emergency LabOR
On duty
Dr or
nurse
examine
Emergency Patient
Emergency
Lab for urgent need
Sample and form
Gynecology
Ward
Inpatient Obstetric Ward
provide free
recycle
bottle or
Go to
pharmacy
and buy
bottle
or bag
for urine
Parasitology
Lab for
normal
process
Result
+ ive and
-ive urine sample
(-) Sample Discard
Handover to Sean / Britni
(+ ive) Sample
Transport to new testing room
Remove the label
For detail see next Slide
Provide sample bottle to PW
Record and code the sample
Collect + ive samples in red tray

11. 9. Step One Sample Collection: Parasitology Lab
collect + ive sample in red tray
Emergency
Inpatient Obstetric Ward
Parasitology lab
Sample arrives coded together with form
Urine comes here for variety of test i.e, protein, sugar and other microscopic examination
Sample Collection Center
ANC OPD
Gynecology
Ward
OPD
Result
+ ive urine protein
- ve urine sample
Fill Result on form and register
Give form to patient or family member
Discard samples
Handover to Sean / Britni
(-) Sample
(+) Sample
Transport to new testing room
Lab Tech/Asst tests urine using one of the
Record and code the sample

12. 9. Step One Sample Collection: Inpatient Departments
Provide large sample bottle to PW
(-) Sample Discard
Result
+ ive and
-ive urine sample
Staff collect
and test
urine
protein
ANC A
(+ ive) Sample
remove the label
ANC B
Transport to new testing room
Record and code the sample
MICU
Handover to Sean / Britni

13. 9. Step One Sample Collection: ANC OPD
Provide 20 mL sample bottle to PW
Pregnant women
Screen
BP, ht, wt
Registration
provide free recycle
bottle
Collect positive samples in red tray
Urine Test
with Dip stick
(+) Sample
(-) Sample discard
PW provide
urine for testing
Result + ive / –
ive (record in ANC card )
Transport to new testing room
Handover to Sean / Britni
Record and code the sample

14. 9. Step Two Sample Collection: ANC OPD
Provide 20 mL sample bottle to PW
Pregnant women
Screen
BP, ht, wt
Registration
provide free recycle
bottle
Collect all samples in blue tray
Urine Test
with Dip stick
(+) Sample
(-) Sample
PW provide
urine for testing
Transport to new testing room
Handover to Sean / Britni
Record and code the sample

15. 10. Storage of Samples
Study team will collect urine within hours
Samples can be kept at room temperature

16. 11. Transportation of Samples
Lab support staff will collect samples and bring them for testing:
Every morning from emergency lab and inpatient department
Every hour from ANC OPD lab
Close the lid of the bottle well
Remove any patient identifiers from samples (lab form and ANC card)
Be careful not to spill the samples
Deliver samples trays to new testing room

17. 12. Ethical Aspects
Must remove any patient identifier before providing to Jhpiego/JHU researchers
Study will code samples: S1–D1–1
Study step= S1 or S2
Study day=D1, D2, D3, etc
Sample number
Keep positive samples in red tray and other sample (unidentified) in blue tray

18. 12. Ethical Aspects
Tray labeled according to department and type of sample (e.g., positive sample from ANC OPD lab)
Record in register
STUDY ID #
PLACE OF COLLECTION
HOSPITAL RESULT
LAB DIPSTICK RESULT
POC RESULT
ESBACH RESULT

19. 13. Measurement of Urine Protein: Type of Tests used for the Study
Dipstick test
PoC diagnostics (new test)
Esbach test

20. 14. Study Procedure for PoC
Collect filter paper, reagent solution, 2 mL urine and 5 mL syringe with needle
Use syringe to squirt urine onto filter paper
Shake excess urine off filter paper and allow 10–15 seconds for color change to settle
Record the result in the register

21. 15. Interpreting PoC Results
Test result is interpreted according to color change in the filter paper (special paper used for this test) as below:
Negative +1 +2 +3
Yellow
Yellow–green
Green
Green–blue

22. 16. Procedure for Esbach Test
Pour urine up to the level mark “U” in the albuminometer
Add the esbach reagent up to the mark “R” in the albuminometer
Close the albuminometer with stopper
Invert albuminometer slowly several times to ensure thorough mixing
Keep this at room temperature for 24 hours, then measure the protein precipitate

23. 17. Interpreting Esbach Test Result
Measurement is based on the volume occupied by the precipitated protein in the bottom of the albuminometer.
It is measured as grams protein per liter of urine.

24. 18. Safety Precautions Hand washing—after handling specimens
Gloving—while handling specimens

25. 19. Waste Disposal Discard urine sample after testing
Discard sample bottles
Dispose all used syringes and needles
Place used filter papers in bleach solution for 20 minutes and then discard