Management of covid-19: a practical guideline for maternal and newborn health care providers in Sub-Saharan Africa.

COVID-19 is a pandemic that is currently ravaging the world. Infection rate is steadily increasing in Sub-Saharan Africa. Pregnant women and their infants may suffer severe illnesses due to their lower immunity. This guideline prepares and equips clinicians working in the maternal and newborn sections in the sub-region to manage COVID-19 during pregnancy and childbirth.

Retinopathy of prematurity and associated factors in Lagos, Nigeria.

BACKGROUND: Screening and early treatment of retinopathy of prematurity (ROP) is important to reduce visual impairment in at risk infants. AIM: To determine the frequency and risk factors associated with ROP in preterm infants in Lagos University Teaching Hospital. METHODS: This was a prospective cohort study of preterm infants with gestational age (GA) less than 32 weeks and birthweight 1500 g or less conducted from November 2011 to May 2014. The infants' eyes were examined using an indirect ophthalmoscope at 4-6 weeks of life or at 34 weeks post-conceptual age. Examinations were repeated weekly until regression or progression to a high risk pre-threshold disease. Staging was according to the revised International Classification for ROP and treatment criteria were as defined by the Early Treatment for ROP study. The GA, birth weight (BW), use of oxygen, presence of respiratory distress syndrome and other risk factors were recorded and tested for significance. RESULTS: Twelve (15%) of the 80 infants examined had any ROP and six (7.5%) had treatable ROP. The mean (SD) GA and BW for infants with ROP were both lower than for those without ROP; 28.2 (1.7) weeks vs 29.1 (1.6) weeks and 1124 (212) g vs 1251 (274) g for GA and BW, respectively. Risk factors such as supplemental oxygen, sepsis, respiratory distress and anaemia were not significantly associated with ROP. CONCLUSION: The frequency of ROP and treatable ROP was high; it is therefore recommended that routine care of preterm infants should include screening for ROP and that affordable treatment facilities should be provided in public hospitals.

National neonatal resuscitation training program in Nigeria (2008-2012): a preliminary report.

BACKGROUND: Routine institutional training of doctors and nurses on newborn resuscitation have commenced, to improve the quality of resuscitation available to high-risk babies, in Nigeria, as a means of reducing newborn deaths in the country. Perinatal asphyxia contributes to 26% of newborn deaths in Nigeria. Perinatal asphyxia results when babies have difficulty establishing spontaneous respiration after birth. MATERIALS AND METHODS: Between 2008 and 2012, doctors and nurses drawn from all the geo-political zones were trained using the Neonatal Resuscitation Training (NRT) manual of the American Heart Association and the American Academy of Pediatrics. Questionnaire-based, cross-sectional surveys of doctor and nurse trainees from the six geo-political zones in Nigeria were conducted eight months after the primary training, to evaluate the post-training neonatal resuscitation activities. RESULTS: Over the period of study, 357 doctors and 370 nurse/midwives were primarily trained in NRT. The overall ratio of step down training was 1:22 with 1:18 for doctors and 1:26 for nurses. In 2008, the delivery attendance rates were 11 per doctor and 9 per nurse/midwife. These rates increased to 30 per doctor and 47 per nurse in 2012. Between 88 and 94% of the doctors and between 72 and 93% of the nurses successfully used bag and mask to help babies breathe in the post-training period. The nurses used bag and mask for infant resuscitation more frequently, compared to doctors, with the rate fluctuating between two-to-one and four-to-one. Over the years, 87 to 94% of the doctors and 92 to 97% of the nurses/midwives trained other birth attendants. CONCLUSION: The NRT in Nigeria is well-subscribed and the frequency of secondary training is good.

Prevalence and outcome of higher order multiple pregnancies in Lagos, Nigeria.

OBJECTIVE: To determine the prevalence and outcome of higher order multiple (HOM) pregnancies in Lagos, Nigeria. METHODS: The mode of delivery, gestational age, pregnancy and neonatal outcome of babies delivered from HOM pregnancies were reviewed retrospectively from the labor ward and theater registers, neonatal unit admission records and medical notes in a tertiary referral centre from April 2009 to March 2012. RESULTS: Twenty-two (15, 6 and 1 set of triplets, quadruplets and quintuplet, respectively) of 6521 pregnancies delivered during the period were HOM pregnancies giving a prevalence of 3.37/1000. All the 74 babies except 12 were delivered by cesarean section. There were 18 perinatal deaths giving a perinatal mortality rate of 243 per 1000. Overall mortality was significantly associated with no antenatal booking (21 versus 5, OR: 21.0, 95% CI: 2.1-72.3, p = 0.000), gestational age ≤30 weeks (21 versus 5, OR: 46.2, 95% CI: 11.2-189.9, p = 0.000) and birth weight <1000 g for live births (p = 0.000). Mode of delivery and number of fetuses >3 were however not significantly associated with mortality. CONCLUSION: Reduction of early preterm births by proper antenatal care and close feto-maternal monitoring of HOM pregnancies will significantly reduce the resultant immediate poor outcomes for these pregnancies and their newborns.

Prospective audit of perinatal mortality among inborn babies in a tertiary health center in Lagos, Nigeria.

BACKGROUND: The perinatal mortality rate remains an important indicator of maternal care and maternal health and nutrition, and also reflects the quality of obstetric and pediatric care available. The causes of most of the perinatal deaths are preventable, thus making it important to identify the risk factors in each health environment. OBJECTIVE: The aim was to prospectively audit the perinatal mortality and associated risk factors in a tertiary health facility in a developing country. MATERIALS AND METHODS: Data for all consecutive deliveries in the labor ward complex of Lagos University Teaching Hospital (LUTH) between June 2002 and November 2002 were obtained from the patients' record and by interviewing the mothers using a questionnaire. The babies were followed up for 7 days post delivery. RESULTS: There were 51 (8.5%) perinatal deaths made up of 43 (7.1%) stillbirths (15 fresh and 28 macerated) and 8 (6.1%) early neonatal deaths giving a perinatal mortality rate of 84.6/1000. Maternal factors that significantly affected perinatal deaths were maternal age, parity, antenatal care booking and the hospital where the mother was booked for antenatal care, number of previous child deaths, and complications of pregnancy. Mode of delivery and complications of labor were the significant intrapartum factors. Fetal factors that influenced perinatal deaths were fetal presentation, birth weight, and Apgar scores at 1 and 5 min. When multiple logistic regression (multivariable analysis) of perinatal mortality on possible risk factors was done, only the Apgar score at 5 min, birth weight, and parity were significant risk factors. CONCLUSION: The study shows a high perinatal mortality rate with majority of perinatal deaths occurring before the delivery. Significant risk factors are a low Apgar score at 5 min, low birth weight, and high parity.

Prospective Audit of Perinatal Mortality among Inborn Babies in a Tertiary Health Center in Lagos; Nigeria

Background: The perinatal mortality rate remains an important indicator of maternal care and maternal health and nutrition; and also reflects the quality of obstetric and pediatric care available. The causes of most of the perinatal deaths are preventable; thus making it important to identify the risk factors in each health environment. Objective: The aim was to prospectively audit the perinatal mortality and associated risk factors in a tertiary health facility in a developing country. Materials and Methods: Data for all consecutive deliveries in the labor ward complex of Lagos University Teaching Hospital (LUTH) between June 2002 and November 2002 were obtained from the patients' record and by interviewing the mothers using a questionnaire. The babies were followed up for 7 days postdelivery. Results: There were 51 (8.5) perinatal deaths made up of 43 (7.1) stillbirths (15 fresh and 28 macerated) and 8 (6.1) early neonatal deaths giving a perinatal mortality rate of 84.6/1000. Maternal factors that significantly affected perinatal deaths were maternal age; parity; antenatal care booking and the hospital where the mother was booked for antenatal care; number of previous child deaths; and complications of pregnancy. Mode of delivery and complications of labor were the significant intrapartum factors. Fetal factors that influenced perinatal deaths were fetal presentation; birth weight; and Apgar scores at 1 and 5 min. When multiple logistic regression (multivariable analysis) of perinatal mortality on possible risk factors was done; only the Apgar score at 5 min; birth weight; and parity were significant risk factors. Conclusion: The study shows a high perinatal mortality rate with majority of perinatal deaths occurring before the delivery. Significant risk factors are a low Apgar score at 5 min; low birth weight; and high parity

Congenital heart diseases associated with identified syndromes and other extra-cardiac congenital malformations in children in Lagos.

BACKGROUND: Congenital heart diseases are commonly associated with other extra cardiac congenital malformations. OBJECTIVE: To identify congenital heart diseases associated with identified syndromes and other extra cardiac congenital malformations in children in our hospital. METHODS: A prospective descriptive study done on children with congenital malformations referred to the Lagos University Teaching Hospital, Nigeria (LUTH) for echocardiographic evaluation. A thorough 2D assessment of the chambers, septa, heart vessels and concordance of the atrium and ventricle and the great vessels was made. Echo-cardiographic data obtained included M mode direct measurements of dimensions of left atrium, aortic root, right ventricular outflow tract, left ventricle in diastole/systole, wall thicknesses--right ventricular wall, interventricular septum, left ventricular posterior wall. Fractional shortening was derived from M mode data. Final diagnosis of the congenital heart disease was recorded. RESULTS: A total of 101 children with congenital malformations had echocardiography studies done as part of their clinical evaluation, 15 (14.9%) were neonates, 53 (52.5%) infants 25 (24.8%) were aged one to five years and 8 (7.9%) were above five years of age. Recognised syndromes were seen in 69 (68%) cases. Down syndrome with 54 children contributed 78.3% of those with known syndromes. Other identified syndromes and associations were Marfan's, Noonan's, Edwards, Prune Belly, Apert, Ellis-van Creveld syndrome and congenital rubella syndrome. Congenital heart diseases were detected in 73 (72.3%) patients while 28 (27.7%) had no heart defect. The commonest identified congenital heart disease was ventricular septal defect affecting 30 (29.7%) patients. CONCLUSION: Congenital heart diseases are common in children with congenital malformations. Down syndrome was the most common malformation and the congenital heart disease most associated with the congenital malformations was ventricular septal defect. This study emphasizes the need for cardiac assessment of children with congenital malformations.

Anthropometric indices of infants born to HIV-1-infected mothers: a prospective cohort study in Lagos, Nigeria.

Numerous studies have reported that HIV-infected pregnant women are at increased risk of delivery of low birth weight (LBW) infants, of preterm deliveries and of intrauterine growth restriction. The objective of the study was to determine the effect of maternal HIV infection on the anthropometric characteristics of the babies at birth. A prospective study was carried out at the Lagos University Teaching Hospital, Nigeria. There were three times more LBW babies in the HIV-positive group than in the uninfected mothers (odds ratio = 3.47, 95% confidence interval = 1.69, 7.27; chi(2) = 12.99, P = 0.0003).The maternal weight (t = 15.85; P = 0.0001), maternal body mass index (BMI) (t = 15.07; P = 0.0003), birth weight of infants (t = 27.17; P = 0.0001) and birth length (t = 31.20; P = 0.001) were significantly less in HIV-positive mothers than in controls. In conclusion, poor maternal bodyweight and low BMI are significant contributors to LBW in HIV-infected women. Nutritional counselling, dietary intake and weight monitoring during pregnancy should be emphasized to improve pregnancy outcome in HIV-infected women.

Effect of antiretroviral therapy on asymptomatic malaria parasitaemia in HIV-1 infected children.

OBJECTIVE: To investigate the effect of antiretroviral ARV) therapy on the level of asymptomatic malaria parasitaemia in HIV-1 infected children. METHODS: Sixty-six HIV infected children had blood films prepared for malaria parasite identification and count. Mean parasite densities were compared across clinical stages and immunologic categories of disease and antiretroviral treatment status. RESULTS: Forty-five (68%) were less than 6 years old and 50 (75.7%) had advanced HIV disease. Twenty seven (41%) were on antiretroviral therapy. The prevalence of ASMP in the treated and untreated group was 44.4% and 15.4% respectively (p<0.01). The mean parasite density in the ARV treatment group was also significantly higher than in the untreated group (p=0.0071). CONCLUSIONS: ARV therapy seems to be associated with higher rates of ASMP and higher mean parasite counts.

Effect of antiretroviral therapy on asymptomatic malaria parasitaemia in HIV-1 infected children.

OBJECTIVE: To investigate the effect of antiretroviral (ARV) therapy on the level of asymptomatic malaria parasitaemia in HIV-1 infected children. METHODS: Sixty-six HIV infected children had blood films prepared for malaria parasite identification and count. Mean parasite densities were compared across clinical stages and immunologic categories of disease and antiretroviral treatment status. RESULTS: Forty-five (68%) were less than 6 years old and 50 (75.7%) had advanced HIV disease. Twenty seven (41%) were on antiretroviral therapy. The prevalence of ASMP in the treated and untreated group was 44.4% and 15.4% respectively (p<0.01). The mean parasite density in the ARV treatment group was also significantly higher than in the untreated group (p=0.0071). CONCLUSIONS: ARV therapy seems to be associated with higher rates of ASMP and higher mean parasite counts.

Maternal HIV infection and intrauterine growth: a prospective study in Lagos, Nigeria.

BACKGROUND: Low birth weight (LBW) is the most important cause of perinatal mortality and morbidity worldwide and particularly so in developing countries. Maternal HIV (Human Immunodeficiency Virus) infection has been identified as one of the risk factors to the development of low birth weight babies. OBJECTIVE: To evaluate the effect of maternal HIV infection on the birth weight of the newborn at tertiary hospital in West Africa. METHODS: The anthropometry of all HIV seropositive women who delivered in LUTH as well as that of their babies was determined using standard methods. Controls consisted of HIV seronegative women and their babies matched for age and parity with the above subjects. RESULTS: There were a total of 262 subjects of whom 132 (50.4%) were HIV seropositive and 130 (49.6%) were HIV seronegative controls. There were five times more low birth weight (LBW) infants in the HIV seropositive group than in the controls (OR 5.77, CI=2.19-16.80; p=0.000075). The mean maternal body mass index, BMI (p=0.0003), mean maternal weight (p=0.0004) and mean birth weight of newborns (p=0.0002) were significantly lower in the HIV seropositive group than in the controls. Maternal weight and gestational age were significantly associated with low birth weight (OR 15.3, CI=2.6-316.0; p=0.002) and (OR 3.78, CI=1.37-10.9; p=0.007) respectively. CONCLUSION: Maternal HIV infection is strongly associated with low maternal BMI and low birth weight in their offspring.

Plasma magnesium and calcium levels in children with epilepsy in lagos.

BACKGROUND: Magnesium and calcium have been found to have increasing roles in the patho-physiology of epilepsy. Hypomagnesaemia and hypocalcaemia cause hyper-exitability of neurons and have been associated strongly with seizures in adults and children. OBJECTIVES: To determine if hypomagnesaemia or hypocalcaemia is present in Nigerian children with epilepsy and to determine the relationship between serum magnesium and calcium levels and frequency and control of epilepsy. DESIGN: A prospective case control study at the Lagos University Teaching Hospital. PATIENTS AND METHODS: 45 children with epilepsy and 45 controls were recruited from the paediatric neurology unit of the Lagos University Teaching Hospital. Serum magnesium and calcium were measured by spectrophotometric methods. RESULTS: Serum magnesium and calcium was significantly lower in the patients compared to the controls; Magnesium - 0.98 (0.0005) Vs 1.2 (0.04) mmol/L, p< 0.0001 and Calcium - 2.29 (0.04) Vs 2.3 (0.02) mmol/L, p<0.05 respectively. No significant differences were noted in the plasma phosphorus and albumin concentrations. CONCLUSION: Magnesium and calcium levels are lower in the epileptic children compared to the controls during the seizure-free periods. More studies are needed to evaluate these electrolytes during seizures and the effect of the different anticonvulsant drugs on these electrolytes.

Haematological abnormalities associated with paediatric HIV/AIDS in Lagos.

INTRODUCTION: In HIV-1-infected children, haematological disturbances include bone marrow abnormalities and peripheral cytopenias. All three major cell lineages can be depressed. METHODS: A cross-sectional study of baseline haematological parameters was undertaken in 68 children with confirmed HIV infection. In all cases, a complete blood count was done and some had CD4+ counts and HIV RNA PCR. The CD4+ count was analysed by the Coulter manual latex particle monoclonal antibody method and HIV RNA PCR by Roche Amplicor Monitor, version 1.5. RESULTS: Anaemia (< 100 g/L) was present in 77.9%, severe (< 60 g/L) in 5.9%, moderate (60-70 g/L) in 32.3% and mild (80-99 g/L) in 39.7%. The mean haemoglobin concentration decreased as disease progressed (p < 0.05); 6% had leucopenia, 17.5% had neutropenia and 2.5% (one case) had thrombocytopenia; also, the four (6%) subjects with leucopenia were in clinical stages B and C. Neutropenia, lymphocytopenia and thrombocytopenia were seen more in clinical stages B and C, though this relationship was not statistically significant. CONCLUSION: Both the erythroid and other cells lines are affected by HIV/AIDS and other associated factors. Anaemia is the most common haematological abnormality. The severity of peripheral cytopenias is related to the disease burden.

Estimation of the rate of mother to child transmission of HIV in Nigeria.

Definitive diagnosis of HIV infection in infants < 18 months of age who were born to HIV-infected mothers is still posing some difficulty in Nigeria and other developing countries. Within this age definitive diagnosis can only be carried out by antigen based techniques which are indeed not available in these developing countries. This has resulted in the absence of authoritative data on the rate of mother-to-child transmission in these countries. Nigeria inclusive. The present pilot study was therefore carried out to generate some information on the rate of mother to child transmission in Nigeria using the PCR technique. Plasma samples were obtained from 68 children of both sexes less than 18 months of age and who were born to HIV infected mothers. The samples were collected from two pediatric departments. in Lagos and in Benin. The presence of HIV 1 RNA in each of the samples. was determined using the Amplicor Monitor V 1.5 technique (Roche Diagnostics). Data showed that HIV-1 RNA was detected in 15 of the 68 samples tested. This gave an HIV-1 RNA detection rate of 22%. Among women who had some intervention, the rate of transmission of infection was 11% while the rate among those without intervention was 30%. The 22% transmission rate recorded in this study is close to the range of 25 to 35% that has been reported in several developed and a few developing countries. A multicenter nationwide study will still be needed to determine the national mother to child transmission rate in Nigeria.

Serum magnesium, phosphate and calcium in Nigerian children with sickle cell disease.

BACKGROUND: Biochemical abnormalities have been associated with sickle cell disease. Studies on phosphorus and magnesium in sickle cell disease have been conflicting. There is paucity of information on the role of these ions in the pathogenesis and management of sickle cell disease. This study was set out to determine the serum levels of magnesium, phosphorus and calcium in Nigerian children with sickle cell disease. STUDY DESIGN: A case-control study carried out on children with HbSS genotype (cases) and age-matched controls with HbAA. Serum magnesium, calcium, phosphorus and albumin were measured using colorimetric methods. RESULTS: Eighty-six subjects and forty-five controls were studied. The mean serum magnesium was 0.99mmol/L (0.02) and 0.98mmol/L (0.02) in the cases and controls respectively. The difference was not significant. Mean serum calcium was significantly lower in the cases [2.1mmol/L (0.3)] compared with the controls [2.3mmol/ L (0.15)]; p<0.01. Serum phosphorus was significantly higher in the cases than in the controls [2.2mmol/L (0.7) versus (1.5mmol/L (0.6); p<0.001]. There was no statistical difference in the albumin binding of calcium in both groups. A positive correlation existed between serum phosphorus and magnesium and also between serum calcium and magnesium in the cases group but no correlation between these parameters and age was found. CONCLUSION: Children with sickle cell anaemia in this study had normo-magnesaemia, hyperphosphataemia and hypocalcaemia. Further studies on changes in intracellular concentrations of these ions in children with sickle cell disease are required. Such findings could be useful in designing better management in individuals with this abnormality.

Outcome of low birth weight neonates in a tertiary health care centre in Lagos, Nigeria.

The records of all low birth weight (LBW) neonates admitted into the Neonatal Unit of the Lagos University Teaching Hospital (LUTH) from January 1997 to December 2001 were retrospectively analysed in order to determine the outcome and risk factors associated with mortality. There were 535 LBW admissions of which 411(76.8%) survived while 124(23.2%) died. The birth weight specific mortality rate for the < 1000g neonates was 818 per 1000, 451 per 1000 for the 1000-1499g, 216 per 1000 for the 1500-1999g, and 67 per 1000 for the 2000-2499g neonates (X2 = 127.70, p = 0.0001). Primary indications for admission were neonatal sepsis (25.2%), perinatal asphyxia (23.0%) and neonatal jaundice (19.6%) with case fatality rates of 20.0%, 34.1% and 10.5% respectively (X2 = 34.24, p = 0.00001). Death occurred within 48 hours of admission in 45.2% of subjects and by the 7th day, 72.6% had died (X2 = 70.07, p = 0.0001). Significant risk factors associated with mortality were birth weight [OR 4.24, 95% CI = 3.14-5.72] and category of LBW [OR 2.79, 95% CI = 1.65-4.69]. Sex, twinning, booking status and mode of delivery had no significant influence on mortality. Since the provision of adequate intensive care for these vulnerable infants remains a major challenge in countries with poor resources, efforts should be intensified to implement effective strategies for the reduction of low birth weight deliveries.

Anthropometric measurements in the detection of low birth weight infants in Lagos.

The present study was undertaken to determine the anthropometric risk indicators in the detection of infants with low birth weight. A total of 788 consecutive, singleton, live born infants had anthropometric measurements determined within 24 hours of life using standard methods. There were 389 (49.37%) males and 399 (50.63%) females; 136 (17.56%) of the infants were of low birth weight (LBW). Birthweight was significantly correlated with occipitofrontal circumference (OFC; r = 0.66), length (r = 0.86), mid-arm circumference (MAC; r = 0.88) and maximum thigh circumference (MTC; r = 0.95) (p < 0.001). Furthermore, OFC of 33.6 cm and 32.3 cm, length of 47.7 cm and 45.5 cm, MAC of 9.6 cm and 9.1 cm, and MTC values of 15.5 cm and 14.9 cm were the corresponding cut-off values with the best combination of sensitivity, specificity and predictive values (p < 0.001) for identifying infants with birth weights of < 2500 g and < 2000 g respectively. The use of these risk indicators would help to identify newborns for close supervision and care, as well as prevent mortality and postnatal developmental retardation.

Physical health status of pupils in a school for the mentally disabled in Lagos.

The study set out to assess the health status of pupils of a school for children with mental disability. The school is Modupe Cole Memorial Child Care and Treatment Home School, Akoka, Lagos. The records of 211 pupils were reviewed and the pupils were clinically examined by the author. Seventy-four (35.1%) of the subjects had complete immunization, 48(22.7%) had incomplete immunization while 44(20.9%) received no immunization. The probable aetiology of mental disability in the subjects was due to postnatal causes (96; 45.5%), natal causes (44; 20.8%), prenatal causes (12; 5.7%) and unknown (59; 28.0%). The most abnormal findings on physical examination were in the central nervous system (199; 94.3%), the musculoskeletal system (137; 64.9%), the mouth/teeth (125; 59.2%) and the skin (98; 46.4%). These findings were worse amongst the residential students than in the non-residential students (p < 0.001). The information obtained from this study will help to serve as a reference for purposes of health planning and policy formulation for children with mental disability.