A flowchart for managing sexually transmitted infections among Nigerian adolescent females.

OBJECTIVE: To devise a flowchart suitable for assessing risk of trichomoniasis, chlamydia and gonorrhoea in an adolescent population, not all of whom will be sexually experienced or currently in a relationship. METHODS: The data used to derive the flowchart were generated from cross-sectional microbiological surveys of girls aged 14-19 years in Port Harcourt, Nigeria. The flowchart screened on the basis of: (i) sexual experience; (ii) recent sexual activity; (iii) a positive urine leukocyte esterase (LE) test; and (iv) among LE negatives, a history of malodorous/pruritic discharge. FINDINGS: Using this flowchart, we found that 26.2% of all adolescents screened would receive treatment for cervicitis and vaginitis. Chlamydial, gonococcal, and trichomonal infections were correctly diagnosed in 37.5%, 66.7%, and 50% of the cases, respectively. CONCLUSION: Although the flowchart is more suitable for an adolescent population than the vaginal discharge algorithm used in syndromic management protocols, it still lacks precision and needs adapting to local settings.

A birthweight nomogram for Africa, as a malaria-control indicator.

Low birthweight (LBW) attributable to malaria in pregnancy is a significant risk for millions in Africa. Infants born to primigravidae are at greatest risk and it is proposed that this excess risk can be used as a simple indicator of malaria transmission and exposure in pregnant women in Africa. Birthweight data from different regions in 11 malarious and three non-malarious African countries were investigated. A regression analysis of the excess risk of low birthweight in first pregnancies, compared with later ones, was completed and interpreted in relation to malaria-transmission intensities. The aim was to develop a simple birthweight chart (nomogram) as a tool for monitoring malaria transmission or malaria control in pregnancy. Low-birthweight risk in first pregnancies was associated with levels of malaria-transmission intensity amongst different African countries. The nomogram distinguished longitudinal changes in malaria exposure, related to season and changes in antimalarial-drug policy. Malaria is one of the most important causes of LBW in first pregnancies in Africa. As birthweight and parity are routinely recorded in many delivery centres across Africa, the nomogram provides a simple, available and inexpensive tool for monitoring malaria transmission and exposure in pregnant women and the effectiveness of malaria-control activities for this high-risk group.

Protecting adolescent girls against tetanus.

PIP: An estimated 8 million infants and 2 million children and adults may die from tetanus during the 1990s despite efforts by the World Health Organization (WHO) to eliminate it by 1995. Vaccination to prevent postabortal and maternal tetanus has been neglected. The immunization of preschool children and of pregnant women has omitted adolescent girls, who are therefore at risk. Data collected on 1101 cases of maternal tetanus in developing countries between 1958 and 1990 indicated that 27% were attributed to postabortal and 67% to postpartum sepsis. In southeastern Nigeria where abortion rates are high, a high proportion of girls were also seronegative for tetanus antibodies. Many unvaccinated pregnant women cite the lack of money for obtaining vaccination when obtaining prenatal services. The WHO is promoting vaccination of women of reproductive age by screening their tetanus toxoid status, but adolescents are poorly covered because they are not regular attenders. Expressly targeting girls would be feasible, as it would require 5 injections providing protection for life. Even 4 injections may protect for 20 years if delivered at the end of primary school. Thus a school health service delivering tetanus vaccination may improve the vaccination of adolescent girls. This could be combined with distribution of vitamin A and antihelminthics whereby the response to the vaccine could be improved significantly. In addition, it has also been suggested that a late dose of an acellular pertussis vaccine and a second dose of measles vaccine given in adolescence would reduce the pool of susceptible girls, just as girls have been targeted for rubella vaccination. Implementation of tetanus vaccination would require local schools vaccination days, immunization cards, high potency primary vaccination, and tetanus boosters free of charge with a system to monitor antibody responses.^ieng

Reproductive tract infections and abortion among adolescent girls in rural Nigeria.

Few studies from developing countries have investigated reproductive tract infections or other indicators of sexual health among unmarried adolescent girls in rural areas. We have obtained baseline demographic, clinical, and microbiological data on reproductive tract infections and induced abortion in girls in a rural area of southeast Nigeria, in order to assess the need for health care for adolescents. 868 females attended for interview and examination: 458 aged 20 and above and 410 aged 12-19, the latter representing 93.4%of the adolescent population. 43.6% of those < 17 and 80.1% aged 17-19 years were sexually active and at least 24.1% had undergone an induced abortion; only 5.3% had ever used a modern contraceptive. Vaginal discharge was reported by 82.4%, though few sought treatment. 94.1% of sexually active adolescents and 97.6% of sexually active women 20 years old or over were gynaecologically examined and screened for reproductive tract infections. Of those aged less than 17, 19.8% had symptomatic candida and 11.1% trichomonas infections. Among those aged 17-19 years, chlamydia was detected in 10.5%, and symptomatic candidosis in 25.6%; this was the group most likely to have any infection (43.8%). 42.1% of sexually active adolescents had experienced either an abortion or a sexually transmitted disease. Syphilis was the only infection for which the incidence clearly increased with age. Health-care services for adolescents in this community are needed and should include sex education, contraceptive provision (especially barrier methods), and access to treatment for reproductive tract infections. Investments in health for this age group will have an effect on subsequent reproductive health.

Clinical and pathological features of ovarian tumours in Rivers state of Nigeria.

The pattern and clinical features of 45 ovarian tumours seen in a Southern Nigeria hospital between 1984 and 1987 were examined. The results indicate that germ cell tumours are relatively more common in this part of Nigeria than in North America and Europe. A reduced incidence of surface epithelial tumours was also observed. Most patients with either benign or malignant tumours were less than 40 years old. Two of the five tumours associated with pregnancy were malignant. The ratio of benign to malignant tumours, presenting complaints of the patients and the late stage of most malignant tumours at the time of diagnosis were consistent with what has been observed in other parts of the world.

Pattern of primary gynecological malignancies as seen in a tertiary hospital situated in the Rivers State of Nigeria.

Between January 1984 and December 1987, out of a total gynecological admission of 1706 patients at the University of Port Harcourt Teaching Hospital, 72 had primary cancers of the female genital organs (excluding malignant trophoblastic diseases). Of those, 53 had cervical, 10 ovarian, 6 endometrial and 3, vulval cancers. There were no cases of vaginal or fallopian tubal cancers. Ovarian cancer was the commonest gynecological cancer before the age of 40 while cervical cancer was commonest after 40. Germ cell tumors of the ovary were frequent. Patients with endometrial cancer reported early to hospital for treatment but those with other types of cancers generally reported late. On account of late arrival to hospital, inadequate medical facilities and a high defaulting rate, the outcome of treatment was very poor. Since evidence exists to the effect that cervical cancer may be sexually transmitted, a plea is made for the promotion of the widespread use of condoms in order to reduce the prevalence of invasive carcinoma of the cervix in developing countries.

Outcome of labour in occipitoposterior positions in an African population.

PIP: A prospective study compared 100 consecutive term pregnant women presenting in labor with the fetus in occipito-posterior position at the Ahmadu Bello University Hospital, Zaria, Nigeria, to 100 women arriving immediately after with a fetus in occipito-anterior or -transverse position. The groups were matched for age, height and parity: their mean age was 22 years (20% 16), height 1,55m (34% 1.53), and parity 2- 3 (52% primiparas). Among the study group, labor was shorter and less traumatic in those delivered spontaneously face-to-pubes. Those whose fetal occiput rotated anteriorly and those with low forceps had relatively easy deliveries. Cesarean delivery was performed when vaginal delivery was considered impossible, in 32% of the index group, and 9% of controls. Young, short primiparas predominated in the cesarean group. Those with easy labors, often delivering face-to-pubes, tended to be average or tall in height, aged 20-29, having their 2nd, 3rd or 4th child. There were 25 in the study group with genital tract or wound infection, compared to 6 in the controls. 2 women from the study group died from complications of anesthesia of sepsis. This study suggests that African women with occipito-posterior presentation have poorer outcomes, because of pelvic disproportion, than either European of African women with normal presentation.^ieng

Brenner tumor as encountered in a southern Nigerian Hospital.

Brenner tumor is an uncommon ovarian tumor whose etiology and hormonal activity have aroused controversies. The salient features of three cases of this tumor seen at the University of Port Harcourt Teaching Hospital, Nigeria, between March 1981 and March 1987 are discussed. In one case, the tumor was bilateral and was associated with secondary polycythemia. Another case was associated with a full term pregnancy and here the tumor contained luteinized stromal cells. Although such cells are usually associated with estrogenic activity, the full term pregnancy in this case will suggest at best a low level of hormonal activity. The last case was an incidental microscopic lesion in a postmenopausal woman.

Maternal death in the booked and unbooked patients: University of Port Harcourt Teaching Hospital experience.

PIP: Between September 1983 and August 1986, there were 10,665 deliveries and 103 maternal deaths at the University of Port Harcourt Teaching Hospital. 12 of these deaths were from abortions and 4 from ectopic pregnancies giving an overall maternal mortality rate of 9.7/1000 deliveries. 24 of the mothers that died were booked (mortality rate 3.5/1000) and 63 were unbooked (mortality rate 17.8/10000. The principal clinical causes of death were the same in both booked and unbooked patients and included ruptured uterus booked 42%, unbooked 21%), bacterial infection booked 33%, unbooked 35%), and eclampsia (booked 13%, unbooked 14%). For the booked patients, other causes of maternal death include postpartum hemorrhage (17%), medical complications (8%), and anesthetic death (4%). Additional causes of death for the unbooked patients are postpartum hemorrhage (8%), antepartum hemorrhage (3%), severe anemia (6%), medical complications (13%), surgical complications (2%), and uncertain causes (3%). It was also observed that those who died undelivered mainly had ruptured uterus; 7 booked patients who died after spontaneous vertex deliveries died of postpartum hemorrhage, eclampsia, bacterial infection, and acute renal failure; and 13 patients were puerperal admissions. 17% of the deaths in the unbooked patients were from teenage pregnancies while none were from the booked patients. The age group 20-29 contributed 54% of deaths in the booked and 39% of deaths in the unbooked. Fetal outcome was very poor as 17% of the booked patients and 66% of the unbooked patients arrived at the hospital when their babies had already died in utero. Avoidable factors include the failure to have antenatal care which could prevent deaths from anemia, antepartum hemorrhage, and medical complications but not prevent deaths from rupture uterus; difficulties with means of transportation from patients' home to the hospital; harmful cultural practices; and operation difficulties within the hospital. The dominant adverse factors were illiteracy in the unbooked women (84%) and the effects of serious defects in the existing health services in the booked women such as problems with blood transfusions, availability of medical staff, and shortages of intravenous fluids, blood, and essential drugs and equipment. Formal education, antenatal care, and improved health services still remain the key to a large-scale reduction in maternal mortality.^ieng

The prevention of anaemia in pregnancy in primigravidae in the guinea savanna of Nigeria.

Two hundred Hausa primigravidae at Zaria were divided into five groups in a randomized double-blind trial of antenatal oral antimalarial prophylaxis, and haematinic supplements. Group 1 received no active treatment. Groups 2 to 5 were given chloroquine 600 mg base once, followed by proguanil 100 mg per day. In addition, group 3 received iron 60 mg daily, group 4 folic acid 1 mg daily, and group 5 iron plus folic acid. Forty-five percent were anaemic (haemoglobin (Hb) less than 11.0 g dl-1) at first attendance before 24 weeks of gestation, and malaria parasitaemia (predominantly Plasmodium falciparum) was seen in 27%, of whom 60% were anaemic. The mean Hb fell during pregnancy in group 1, and seven patients in this group had to be removed from the trial and treated for severe anaemia (packed cell volume (PCV) less than 0.26). Only five patients in the other groups developed severe anaemia (P = 0.006), two of whom had malaria following failure to take treatment. Patients in group 1 had the lowest mean Hb at 28 and 36 weeks of gestation, and patients receiving antimalarials and iron (groups 3 and 5) had the highest Hb at 28 weeks, but differences were not significant, possibly due to removal from the trial of patients with severe anaemia. Anaemia (Hb less than 12.0 g dl-1) at six weeks after delivery was observed in 61% of those not receiving active treatment (group 1), in 39% of those protected against malaria but not receiving iron supplements (groups 2 and 4) and in only 18% of patients receiving both antimalarials and iron (groups 3 and 5). Folic acid had no significant effect on mean Hb. Proguanil was confirmed to be a highly effective causal prophylaxis. Prevention of malaria, without folic acid supplements, reduced the frequency of megaloblastic erythropoiesis from 56% to 25%. Folic acid supplements abolished megaloblastosis, except in three patients who were apparently not taking the treatment prescribed. Red cell folate (RCF) concentrations were higher in subjects with malaria, probably due to intracellular synthesis by plasmodia. Infants of mothers not receiving antimalarials appeared to have an erythroid hyperplasia. Maternal folate supplements raised infants' serum folate and RCF. Fourteen per cent had low birth weight (less than 2500 g), and the perinatal death rate was 11%; the greatest number were in group 1, but not significantly. A regime is proposed for the prevention of malaria, iron deficiency, folate deficiency and anaemia in pregnancy in the guinea savanna of Nigeria.

Anaemia in young primigravidae in the guinea savanna of Nigeria: sickle-cell trait gives partial protection against malaria.

Haematological indices, malarial parasitaemia, serum and red cell folate (SFA, RCF), serum vitamin B12 and haemoglobin (Hb) electrophoretic patterns were studied in 228 non-elite young Hausa primigravidae at less than 24 weeks of gestation. The study was conducted in the guinea savanna of Nigeria, where malaria is hyperendemic. Ninety-nine (43%) were anaemic (Hb less than 11.0 g dl-1). The commonest cause of anaemia was malaria, in 28% of all and 40% of anaemic subjects. Plasmodium falciparum was predominant; P. malariae was seen in 1.3% and P. ovale was not recorded. Parasitaemia was more frequent and more dense in the wet than the dry season. Iron deficiency was diagnosed in 18% of all and 25% of anaemic women; 14% of all patients were folate-deficient; high MCV and MCH correlated with anaemia, and low SFA was associated weakly with anaemia and malaria. Serum vitamin B12 was normal or high in all 145 in whom it was measured; 3% had congenital elliptocytosis, but this did not contribute to the anaemia. Sickle-cell trait was present in 26% and Hb-AC in less than 1%. Hb-AS was associated with significantly lower frequency and density of P. falciparum; this has not been demonstrated in pregnancy in Africa previously. However, the parasitological advantage was not reflected in any haematological advantage. The roles of malaria, folate-deficiency and iron-deficiency in the causation of anaemia in Hausa primigravidae will be defined further by a double-blind trial of antimalarial prophylactics, iron supplements and folic acid supplements.

Engagement of the fetal head in the negro primigravida.

A prospective study into causes of non-engagement of the fetal head at term in the negroid primigravida showed no correlation with fetal birth weight nor with the pelvic brim inclination. However, there was a significant difference (p less than 0.05) between the mean head circumference of babies with heads which had not engaged (34.1 cm) and with those which had (33.1 cm). Labour was generally prolonged with a high head at term, but there was no increase in the incidence of fetal or maternal mortality and morbidity nor was it associated with an increase in the rate of operative interference. In addition, retrospective studies on pelvic brim inclination between 31 Nigerian primiparae and matched Caucasians at the Queen Charlotte's Maternity Hospital showed no statistically significant differences. It is suggested that an unengaged fetal head in early labour should not by itself be an indication for early delivery by caesarean section.