Effectiveness of Combined Preoperative Sublingual Misoprostol and Intravenous Tranexamic Acid on Intraoperative Blood Loss During Elective Caesarean Section: A Randomised, Blinded, Placebo-Controlled Trial.

INTRODUCTION: The objective of this study was to evaluate the effect of preoperative administration of sublingual misoprostol and intravenous tranexamic acid (TXA) on intraoperative blood loss during elective caesarean sections. METHODS: This was a double-blinded, randomised, placebo-controlled study involving 116 women scheduled for elective caesarean sections. The treatment arm, group 1 (n=58), received 1000 mg of intravenous tranexamic acid 10-15 minutes before skin incision and 600 mcg of sublingual misoprostol after sub-arachnoid anaesthesia and before skin incision. Group 2 (n=58) received placebos; both groups had oxytocin injections at the delivery of the placenta. The data were analyzed using IBM® Statistical Package for the Social Sciences (SPSS) version 24 (IBM Corp., Armonk, NY). RESULTS: The primary outcome was the intraoperative blood loss and the difference between preoperative and postoperative hematocrit values in both groups. The mean intraoperative blood loss was significantly lower in the study group than in the control group (308.552 ± 42.991 mL versus 736.414 ± 171.889 mL, p<0.001). The differences between the preoperative and post-operative hematocrit values were also significantly lower in the study group than in the control group (2.212% ± 0.805% versus 5.660% ± 2.496%, p<0.001). CONCLUSION: Preoperative administration of 1000 mg of intravenous tranexamic acid and 600 mcg of sublingual misoprostol significantly reduced blood loss related to elective caesarean delivery.

Trend and Causes of Maternal Mortality in a Nigerian Tertiary Hospital: A 5-year Retrospective Study (2010-2014) at the University of Calabar Teaching Hospital, Calabar, Nigeria.

BACKGROUND: Maternal mortality ratios (MMR) are still unacceptably high in many low-income countries especially in sub-Saharan Africa. MMR had been reported to have improved from an initial 3,026 per 100,000 live births in 1999 to 941 in 2009, at the University of Calabar Teaching Hospital (UCTH), Calabar, a tertiary health facility in Nigeria. Post-partum haemorrhage and hypertensive diseases of pregnancy have been the common causes of maternal deaths in the facility. AIM: This study was aimed at determining the trend in maternal mortality in the same facility, following institution of some facility-based intervention measures. METHODOLOGY: A retrospective study design was utilised with extraction and review of medical records of pregnancy-related deaths in UCTH, Calabar, from January 2010 to December 2014. The beginning of the review period coincided with the period the "Woman Intervention Trial" was set up to reduce maternal mortality in the facility. This trial consists of the use of Tranexamic acid for prevention of post-partum haemorrhage, as well as more proactive attendance to parturition. RESULTS: There were 13,605 live births and sixty-one (61) pregnancy-related deaths in UCTH during the study period. This yielded a facility Maternal Mortality Ratio of 448 per 100,000 live births. In the previous 11-year period of review, there was sustained the decline in MMR by 72.9% in the initial four years (from 793 in 2010 to 215 in 2013), with the onset of resurgence to 366 in the last year (2014). Mean age at maternal death was 27 ± 6.5 years, with most subjects (45, 73.8%) being within 20-34 years age group. Forty-eight (78.7%) were married, 26 (42.6%) were unemployed, and 33 (55.7%) had at least secondary level of education. Septic abortion (13, 21.3%) and hypertensive diseases of pregnancy (10, 16.4%) were the leading causes of death. Over three quarters (47, 77.0%) had not received care from any health facility. Most deaths (46, 75.5%) occurred between 24 and 97 hours of admission. CONCLUSION: Compared with previous trends, there has been a significant improvement in maternal mortality ratio in the study setting. There is also a significant change in the leading cause of maternal deaths, with septic abortion and hypertensive disease of pregnancy now replacing post-partum haemorrhage and puerperal sepsis that was previously reported. This success may be attributable to the institution of the Woman trial intervention which is still ongoing in other parts of the world. There is, however, need to sustain effort at a further reduction in MMR towards the attainment of set sustainable development goals (SDGs), through improvement in the provision of maternal health services in low-income countries.

Parturients' Awareness and Perception of Benefits of Breast Feeding in the Prevention of Infant and Childhood Oral and Dental Diseases.

BACKGROUND: Breastfed babies have a better chance of improved oral and dental health than their counterparts that were artificially-fed. OBJECTIVE: To assess the knowledge and attitude of postnatal mothers on the benefits of breastfeeding in prevention of oral and dental diseases. MATERIALS AND METHODS: A cross - sectional descriptive survey of 206 mothers attending the postnatal clinic of the University of Calabar Teaching Hospital, Calabar on the knowledge and attitude of breastfeeding in prevention of oral diseases in infants. RESULTS: Initiation of breastfeeding was early within 3 days of childbirth in 90.3% of mothers. The lack of awareness or knowledge of specific childhood dental/oral disorders prevented by breastfeeding by majority (89.3%) of the respondents was statistically significant. Actual willingness to breastfeed baby for longer periods after instruction on specific oral health benefits of breastfeeding was elicited in 180 (87.4%) mothers. CONCLUSION: There is a need to improve the knowledge of specific benefits of breastfeeding in prevention of dental diseases. This calls for education of the health professionals beside the dental practitioners who handle the mothers for themselves to be aware. FUNDING: The study was funded by the authors.

Postpartum Vaginal Blood Loss following Two Different Methods of Cervical Ripening.

Eighty women undergoing induction of labor at the University of Calabar Teaching Hospital were recruited and randomly allocated into two treatment groups (40 each), to receive either serial 50 µg doses of misoprostol or intracervical Foley catheter. Vaginal blood loss was collected and measured using an under buttocks plastic collection bag and by perineal pad weighing up to 6 hours postpartum. There were no significant differences between the two groups with respect to sociodemographic and obstetric characteristics. Comparison of blood loss in vaginal deliveries between the two groups revealed that subjects in the misoprostol group had significantly higher blood loss than subjects in the Foley catheter group (488 ± 222 versus 326 ± 106, p<0.05). In both groups, there was strong and statistically significant positive correlation between postpartum blood loss and induction delivery interval (r=0.75, p<0.0001; r=0.77, p<0.0001). There were no significant differences in maternal outcomes. In view of this, further study is required to ascertain if lower doses of misoprostol for induction of labor may result in lesser blood loss. This trial is registered with ISRCTN14479515.

Determination of Accuracy of Fetal Weight Using Ultrasound and Clinical Fetal Weight Estimations in Calabar South, South Nigeria.

Information on fetal weight is of importance to obstetricians in the management of pregnancy and delivery. The objective of this study is to compare the accuracy of clinical and sonographic methods of predicting fetal weights at term. This prospective comparative study of 200 parturients was conducted at the University of Calabar Teaching Hospital, Calabar. The study participants were mothers with singleton term pregnancy admitted for delivery. The mean absolute percentage errors of both clinical and ultrasound methods were 11.16% ± 9.48 and 9.036% ± 7.61, respectively, and the difference was not statistically significant (P = 0.205). The accuracy within 10% of actual birth weights was 69.5% and 72% for both clinical estimation of fetal weight and ultrasound, respectively, and the difference was not statistically significant (P = 0.755). The accuracy of fetal weight estimation using Dare's formula is comparable to ultrasound estimates for predicting birth weight at term.

Obstructed labour in resource-poor settings: the need for revival of symphysiotomy in Nigeria.

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions thereby facilitating vaginal delivery of the foetus in the presence of mild to moderate cephalopelvic disproportion. It is performed with local anaesthesia, does not require an operating theatre or advanced surgical skills. It can be a lifesaving procedure for both mother and baby in obstructed labour, especially in rural areas and resource-poor settings of developing countries, where a 24 hours availability of a caesarean section cannot be guaranteed. It is a simple underused technology that can be performed by a graduate doctor or midwife in rural health facilities and hospitals where most of the times, in Nigeria, there are no practicing specialist obstetricians. In rural hospital and in communities where sympysiotomy is still being performed, it is evident that it is preferred to caesarean section because of the socio-cultural desire to achieve a vaginal delivery. This paper highlights our experiences with symphysiotomy in a rural Roman Catholic hospital providing evidence on the safety of symphysiotomy and the need for its revival and reinstatement in the obstetric arsenal in Nigeria and similar countries in sub-Saharan Africa where maternal mortality as a result of prolonged and neglected obstructed labour still occur.

Obstetric outcomes of booked teenage pregnancies at University of Calabar Teaching Hospital, Nigeria.

BACKGROUND: Teenage pregnancy is high-risk and associated with complications due to adverse physiological, anatomical, and socioeconomic factors. The purpose of this study was to determine the patterns and obstetric outcomes of booked teenage pregnancies at the University of Calabar Teaching Hospital (UCTH) in Nigeria. METHODS: A retrospective comparative analysis of teenage pregnancies and mature mothers at UCTH was carried out from January 2011 to December 2011. A total of 82 teenage pregnancies and 72 mature pregnancies were compared. RESULTS: There were 145 teenage deliveries from a total of 2313 deliveries, ie, 6.3% of total deliveries. There was no statistically significant difference in the mode of delivery (cesarean section, spontaneous vaginal delivery, instrumental delivery) between the groups of mothers. There was also no difference in risk of complications, including obstructed labor, retained placenta, uterine atony, pre-eclampsia/eclampsia, and antepartum hemorrhage. However, teenage mothers had more perineal lacerations (P = 0.02) and more preterm labor (P = 0.05), and delivered more low-birth-weight babies (P = 0.02). CONCLUSION: Supervised teenage pregnancy may not be as hazardous as previously thought.

Awareness of birth preparedness and complication readiness in southeastern Nigeria.

The aims of this study are to assess the awareness and intention to use maternity services. This was a multicentric study involving 800 women. Educational status was the best predictor of awareness of birth preparedness (P = 0.0029), but not a good predictor of intention to attend four antenatal clinic sessions (P = 0.449). Parity was a better predictor of knowledge of severe vaginal bleeding as a key danger sign during pregnancy than educational level (P = 0.0009 and P = 0.3849, resp.). Plan to identify a means of transport to the place of childbirth was related to greater awareness of birth preparedness (χ(2) = 0.3255; P = 0.5683). Parity was a highly significant predictor (P = 0.0089) of planning to save money. Planning to save money for childbirth was associated with greater awareness of community financial support system (χ(2) = 0.8602; P = 0.3536). Access to skilled birth attendance should be promoted.

Proposed framework for making focused antenatal care services accessible: a review of the nigerian setting.

The aim of this paper is to propose a framework for making antenatal care an effective strategy in reducing the high maternal mortality ratio in Nigeria. On-site visits to five teaching hospitals were carried out between 2006 and 2008 to assess the practice of antenatal care. Group discussions with 200 parturients on their awareness of birth preparedness/complication readiness were conducted, in October, 2008. The findings of this study are discussed in line with the proposed practice of focused antenatal care. The practice of antenatal care in all the hospitals visited was the traditional approach based on earlier European models. Awareness of birth preparedness/complication readiness, by parturients, as a goal-directed intervention during antenatal care was low (21.5%). To reduce maternal deaths through antenatal care, it is critical to link care with detecting and treating causes of maternal mortality by a skilled attendant.