Fertility Following Myomectomy at Aba; Southeastern Nigeria

Background: While hysterectomy remains the gold standard treatment for fibroids; it is an unacceptable treatment option for women who wish to conserve their fertility. The actual effects of myomectomy on fertility remain uncertain though. Objective: The objective was to ascertain pregnancy and live birth rates among a small group of women undergoing abdominal myomectomy. Methods: The study population consisted of women of reproductive age intending to conceive soon after undergoing abdominal myomectomy. A total of 40 women who met the inclusion criteria were recruited for the study and followed-up for 4 years. Women who achieved pregnancy within the study period were analyzed in terms of their demographics and intra-operative findings. Results: The mean age of the women was 28 years (range 24-35) married for about 3 years. Majority of the women (50%) had more than 11 fibroid nodules; and the largest nodule was bigger than 5 cm in 35 women (87.5%). Cumulative pregnancy rate was 60% (24/40) while live birth rate was 22/40 (55%) following myomectomy and majority 19/22 achieved this within 2 years of myomectomy. Conclusion: Myomectomy for fibroid-associated infertility increase pregnancy rates such that approximately 60% of women undergoing the procedure subsequently conceive

Antenatal determinants of oro-facial clefts in Southern Nigeria.

OBJECTIVES: Cleft lip with or without cleft palate, is the most common serious congenital anomaly that affects the orofacial regions. The management and care of the cleft patient constitutes a substantial proportion of the workload of the Nigerian maxillofacial surgeon and allied specialties. Yet, there are no specific programmes targeted at this group. We believe that the findings of this study is capable of identifying useful interventions for designing programs that will lead to a reduction in the burden of orofacial cleft in Nigeria. METHODS: It was a transverse cross-sectional study that was undertaken at the Maxillofacial Units of the University of Benin Teaching Hospital and the Central Hospital, Benin City respectively. The prevalence and antenatal determinants of cleft lip and palate were determined. RESULTS: Cleft lip and palate were often encountered in clinical practice in Benin City with a prevalence of 1.35%. The results showed that orofacial clefts were commoner in females and that the combined unilateral cleft lip and palate was the commonest entity encountered amongst the cases. The following risk factors were associated with the risk of development of cleft lip and palate: Paternal age >40 years, maternal age >35 years, genetic/family history, low socio-economic status, alcohol consumption and indulgence in the intake of herbal medications in pregnancy. CONCLUSION: Public health education programmes and advocacy activities geared towards raising awareness of the identified risk factors for the development of cleft lip and or cleft palate would go a long way to obviate the occurrence and reduce the burden.

Contraceptive choices of women in rural Southeastern Nigeria.

OBJECTIVE: To evaluate the contraceptive choices and usage of women in rural Aba, Southeastern Nigeria, and identify factors influencing their choice and usage of modern contraceptive methods. METHODS: The records of new and old acceptors of family planning methods between 1 November 2005 and 31 October 2007 at the reproductive health clinic of a primary health care center in Osisioma Ngwa local government area in the suburb ofAba, were reviewed and analyzed. Qualitative data was collected by in-depth interviews (IDIs) of 88 out of 188 clients whose records were analyzed. RESULTS: Majority of the clients (71.8%) accepted injectable hormonal contraceptives followed by the intrauterine contraceptive devices (IUDs) (14.4%). Sub-dermal contraceptive implants were accepted by 6.9% of the women and female sterilization by 3.2%. The oral contraceptive pills and the male condom were the least accepted by the clients. Only 2.1% of the contraceptive acceptors were adolescents. The modal age of the acceptors was 30 years and the average age 33.4 years while the age range was 18-51 years. The average parity was 4.7 while the modal parity was 5. The indication for contraception was child spacing in 30% of the clients and permanent limitation of the family size in 70% of the clients. Attitude of the women to the various methods of contraception was an important factor influencing contraceptive choices of the women interviewed. CONCLUSION: The study has shown that the most commonly used contraceptive method in rural Southeastern Nigeria is the injectable hormonal contraceptives. Strategies to increase contraceptive use in rural Nigeria must include improving delivery of correct and adequate information about the available contraceptive methods.

The story of abortion: issues, controversies and a case for the review of the Nigerian national abortion laws.

Abortion continues to be a major public health issue that evokes social, political, legal, cultural and religious sentiments and debates in all societies. This is particularly so in countries with restrictive abortion laws. It is one of the leading causes of maternal mortality and morbidity. Despite variations in the legal status of abortions in favor of restrictiveness in developing countries compared with developed countries, overall rates are quite higher in the developing countries. This review article therefore, examines the historical perspectives of induced abortion as well as the issues and controversies associated with induced abortion. Also, a review of the Nigeria national abortion law is made. We believe that this is capable of identifying useful interventions for designing programs that will lead to a reduction in the burden of unsafe abortion in developing countries.

Placenta accreta and the developing world--a review.

BACKGROUND: The rising Caesarean section rate in the developing world implies that the incidence of placenta accreta might be on the increase and this might worsen the maternal mortality burden. OBJECTIVE: To draw the attention of Obstetricians and other relevant professionals to this emerging but challenging trend. DATA SOURCES: Original research findings and reviews published in the English literature. Additional information was obtained from texts and electronic books such as CD ROMS. DATA EXTRACTION: Online searches of electronic database (Medline, Pubmed and Embase), requests for reprints from corresponding authors and institutional/private subscriptions. DATA SYNTHESIS: Information obtained was categorised accordingly. CONCLUSION: Optimal treatment of women with placenta accreta requires recognition of the clinical risk factors, accurate pre-operative diagnosis and meticulous planning to ensure safety at the time of delivery. In view of the rising incidence of this condition, and the absence of a highly reliable antenatal diagnostic method especially in developing countries, a high index of suspicion and advanced preparation is required to reduce its associated maternal morbidity and mortality.

Coitally Related Traumatic Injury of the Female Genital Tract in a Nigerian Urban Setting: A-5 year review.

BACKGROUND: Available evidence suggests that most female lower genital tract injuries are primarily of coital origin and may result in death where prompt diagnosis and treatment is not obtained. Yet there is paucity of recent reports on this clinical entity from our setting. METHODS: This was a retrospective study of the service delivery records of patients with coital trauma seen at the University of Benin Teaching Hospital over 5 years. RESULTS: The incidence of coital trauma was 0.7% of the total gynaecological patients (3,300) seen within the study period. Majority (52.2%) of the patients were nulliparous. A significant proportion (73.9%) of the patients were single and 82.2% had primary or no formal education. Coital laceration occurred in sexual intercourse with boyfriends in 39.1% of patients and casual sex partners in 30.4% of cases. Non-consensual sex was reported in 47.8% of the patients and 39.1% had consensual sex. Sex was pre-marital in 65.2% of the cases. Inadequate or lack of foreplay was a significant predisposing circumstance to coital trauma (56.5%). Pain was a presenting symptom in 60.9% of cases, and same proportion of patients had laceration > 4cm. CONCLUSION: The incidence of coitally associated trauma was low. Nulliparity, low levels of education, non-consensual and premarital sex with little or no foreplay were strongly correlated with the risk of coital trauma. Severe forms of intra-peritoneal complications were not documented in this series. Management strategies were quite adequate.

Factors associated with the knowledge, practice and perceptions of contraception in rural southern Nigeria.

BACKGROUND: Significant proportion of maternal deaths in Nigeria is due to complications of unsafe abortions, and these abortions are responses to unwanted pregnancies that could have been prevented by effective contraceptive programming. Despite intense programmatic efforts by the Nigerian government and various non-governmental agencies to reverse the trend, there has been little evidence to suggest a systematic improvement in these indicators. METHODOLOGY: A household random survey of 1,528 women aged between 15-49 years was undertaken at Amukpe community in Nigeria, to determine their knowledge, practice and perceptions of contraception. RESULTS: The results showed that 86.2% of the respondents had secondary or less level of education and 19.2% of the respondents were single parents. The level of contraceptive awareness was high (92.3%) and 88% of the respondents became aware of contraception in the last 14 years. Friends/relatives (40.6%), followed by nurses (31.7%) and then doctors (17.3%) were the common sources of contraceptive awareness. The most widely known contraceptive methods were injectables, condoms, POP and OCP. The specific knowledge of emergency contraception was poor. The factors associated with low contraceptive usage were poor level of training and ineffective conveyance of relevant information to clients by health personnel, low literacy levels, extremes of reproductive age and extremes of parity. Others were fear of side effects, lack of knowledge, and lack of spousal consent. CONCLUSION: Contraceptive usage remain poor despite high level of awareness. Effective educational and counseling interventions are likely to improve providers' and consumers' knowledge and subsequent uptake of contraceptive usage.

Lessons learned from the outcome of bloodless emergency laparotomies on Jehovah's Witness women presenting in the extremis with ruptured uterus.

OBJECTIVE: We compared the outcomes of bloodless emergency laparotomies for uterine rupture in twenty Jehovah's Witness (JW) women who were in a state of haemorrhagic shock with 45 other women who received blood transfusion. METHODS: The case records of twenty Jehovah's Witness patients, who underwent bloodless emergency laparotomies for ruptured uterus complicated by haemorrhagic shock between 1 January 2000 and 31 December 2006 were reviewed. We also reviewed the case records of 45 other patients who underwent similar surgical procedures for similar indications and in whom blood was transfused. The outcome variables compared were maternal deaths, infectious morbidity, acute respiratory distress syndrome, disseminated intravascular coagulation, length of post laparotomy ventilatory support, and length of postpartum hospitalization. RESULTS: Demographic and obstetric characteristics were similar in both groups. Seventeen out of the twenty Jehovah's Witness patients who refused blood transfusion survived the laparotomies and were discharged home in good condition. Three died of peritonitis. Six out of the 45 patients who received blood transfusion also died of peritonitis and one died of disseminated intravascular coagulopathy. The average duration of post partum hospitalization was 8 days in the group of patients transfused and 7 days in the group not transfused. Disseminated intravascular coagulation occurred post partum in two of the patients transfused. No case of acute respiratory distress syndrome or amniotic fluid embolism was identified in either group. CONCLUSION: Patients who are in haemorrhagic shock from ruptured uterus and refuse blood transfusion can still be salvaged in a low resource setting. The study adds evidence that major operative procedures can be carried out on Jehovah's Witness patients without blood transfusions or blood products.

Perceptions and attitudes of a rural community to abortion in the Niger-delta region of Nigeria.

OBJECTIVE: To determine the perceptions and beliefs relating to unwanted pregnancy, family planning and abortion, and identify issues that can be leveraged to initiate positive attitudes towards family planning and abortion in the area. MATERIALS AND METHODS: Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted in Amukpe, Delta State, Nigeria. A highly motivated and well-trained team versed in the local language and culture conducted the FGDs and IDIs. RESULTS: There was unanimity that unwanted pregnancies was quite common amongst women of reproductive age group and constitute a significant problem in the community. Abortion, particularly in the hands of quacks was a major option to handling an unwanted pregnancy. Almost all agreed that their culture and religion abhors abortion, yet widely practiced because of the odium associated with an unwanted pregnancy in the community. The knowledge of the Nigeria National abortion law even amongst the health workers and teachers was generally poor. The participants agreed that there were problems and complications (often severe) including death associated with abortion in the community. It was largely agreed that contraceptive knowledge and usage was poor. The reasons adduced for this include lack of knowledge, lack of spousal consent, socio-cultural taboos and misconceptions, as well as economic reasons. It was suggested that imbibing positive family values by parents in their wards and government leveraging the socio-economic status of the community will go a long way to stemming the tide. CONCLUSION: Unwanted pregnancy, unsafe abortion and abortion complications are reported to be common amongst women of reproductive age group in Amukpe community, whilst contraceptive awareness and usage is poor.

Salvage autotransfusion versus homologous blood transfusion for ruptured ectopic pregnancy.

OBJECTIVE: To compare the clinical outcomes of simple salvage autotransfusion and homologous blood transfusion in the management of ruptured ectopic pregnancies. METHODS: Standard statistical analysis was done and relative risk (RR) and 95% confidence interval (CI) were calculated for 112 women randomized to salvage autotransfusion or donor blood transfusion following ruptured ectopic pregnancy. RESULTS: More women in the autologous group received more than 1000 mL of blood (RR, 6.41; 95% CI, 2.75-15.24) and had a hematocrit greater than 0.27 at discharge (RR, 3.62; 95% CI, 1.41-6.67). There were no significant differences in the incidence of postoperative fever (RR, 0.95; 95% CI, 0.43-2.01), postoperative wound infection (RR, 0.73; 95% CI, 0.17-3.19) or duration of hospital stay longer than 7 days (RR, 1.3; 95% CI, 0.44-4.31). CONCLUSION: In resource-poor countries, women with a ruptured ectopic pregnancy receive more blood with salvage autotransfusion.

Infertility among Nigerian Couples as seen in Calabar

Objective: This study was conducted to determine the infertility pattern among Nigerian couples in Calabar and to examine the outcome of our management strategies.Methods: A retrospective descriptive design study based on findings from the clinical files of infertile couples presenting at the gynaecology and the male fertility clinics of University of Calabar Teaching Hospital over a five-year period (2001-2005). Data were collected from all the documented clinical and laboratory findings.Results: The obvious causes of infertility constituted 58in females; 30in males and 12in both partners. Primary infertility was found in 69.7of males and 34.5of females and secondary infertility in 30.3of males and 65.5of females. Infection appears to be a strong predisposing factor to infertility in both male and female patients in our study population. Pregnancy was achieved in 24of our female patients who had tubal surgery; while 69of our males who had varicocelectomy had improvement in seminal fluid parameters.Conclusion: Prevention and prompt treatment of infection; particularly the sexually transmitted infections could be beneficial in the reduction of infertility among couples

External cephalic version (ECV): experience in a sub-Saharan African hospital.

External cephalic version (ECV) is not a popular procedure in developing countries such as Nigeria. Over a 3-year period, we prospectively studied women who had ECV in a Nigerian University Teaching hospital. Comparative analysis was made between the successful ECV and the unsuccessful ECV groups. Following adequate counselling, Nigerian women were willing to accept an ECV for the singleton term breech. The ECV success rate was 67%. Favourable factors for success were multiparity (Relative Risk, RR 3.8; 95% confidence interval, CI 1.14 - 12.1), flexed breech (RR 2.4; 95% CI 1.02 - 5.7), unengaged breech (RR 4.8; 95% CI 1.3 - 17.2), normal liquor volume (RR 4.8; 95% CI 1.3 - 17.1) and a posterior placenta (RR 6.8; 95% CI 2.8 - 16). Once turned, 97% of the babies remained cephalic until delivery. The caesarean section rate in each group was higher than the unit rate of 12.7%. There was one fetal death from cord prolapse in the vaginal breech delivery group.

Management of cervical incompetence in Aba, south-eastern Nigeria.

BACKGROUND: There have been relatively few reports on the outcome of cervical cerclage performed in non-tertiary centres. The aim of this study was to determine the pregnancy complications and outcome in patients following cervical cerclage. METHODS: Seventy-one patients who had 103 pregnancies and underwent cervical cerclage at Women's Hospital, Aba over a ten-year period were reviewed. The diagnosis of cervical incompetence was made from the history in 90.6% of cases and also in some cases by hysterosalpingography and ultrasonography. RESULTS: The Shirodkar (65%) and McDonald (35%) techniques were employed and 10.7% of cases were done as emergency procedures. The more common post-insertion complications were urinary tract infection (50.4%), preterm rupture of membranes (20.4%) and vulvovaginitis (14.6%). Common labour associated complications were antepartum haemorrhage, perineal/cervical tears and malpresentations. The preterm birth rate was 32%. Term births accounted for 68% of the deliveries. The overall fetal salvage rate was 92.2%. Antepartum haemorrhge was a significant indication for caesarean section delivery. The perinatal mortality was 63.2 per 1000 and there was no maternal death. CONCLUSION: The high fetal salvage rate of 92.2% justifies the procedure of cervical cerclage.

Case Report - Heterotopic Pregnancy with Spontaneous Vaginal Delivery at 36 Weeks and Laparotomy at Term - A Case Report

Heterotopic pregnancy; although rare; is occurring more frequently because of an increase in genital infection and the escalating use of new reproductive technologies in infertility patients. The case of a 30-year-old para 2+1 prophetess is presented. She had a spontaneous vaginal delivery at term. Persistent abdominal pain and distension led to suspicion of heterotopic pregnancy. This was confirmed by ultrasonography. Laparotomy revealed a macerated fetus in the peritoneal cavity. The purpose of this report is to sensitise practitioners about the reality and existence of the condition

An audit of five years' experience of pregnancy in spinal cord damaged women. A regional unit's experience and a review of the literature.

In a retrospective review of pregnancy and delivery in 8 spinal cord damaged women managed at Hexham General Hospital Spinal and Maternity Units between 1986 and 1991, antenatal complications included urinary tract infection, anaemia, constipation, suspected deep venous thrombosis and pressure sores. Five of the 8 patients had adductor spasms. Autonomic hyperreflexia occurred in 2 patients in the antenatal period, and in one patient in the postpartum period. Four patients were delivered by caesarean section, and 4 of the 8 patients had breech presentation of the foetus at delivery. The perinatal outcome was good.

Outcome of cesarean section in twin pregnancy.

In an 8-year period (January 1978 to December, 1985), the 17,379 deliveries at the University of Benin Teaching Hospital (UBTH) consisted of 2089 cesarean sections (12.0%), 56 of which were associated with twin pregnancy. The main indications for cesarean section on the twin pregnancies were antepartum hemorrhage (placenta previa), malpresentation, cervical dystocia and previous cesarean section. The maternal mortality rate was 2% for all twin mothers delivered by cesarean section. There was no statistical difference in perinatal mortality rates (PMR) for all twin deliveries, vaginal twin deliveries and deliveries by cesareans section which were 111,113 and 100 per 1000 births, respectively. In the case of a retained second twin, however, recorded PMR was significantly higher (133 per 1000 births). Consideration of more liberal recourse to cesarean section in all cases of twins may reduce these unacceptably high perinatal death rates in twin pregnancy.