The Burden of Unsafe Abortion Six Years before the COVID-19 Era in a Nigerian Tertiary Hospital: An Analytical Retrospective Study.

BACKGROUND: Unsafe abortion remains a leading cause of maternal mortality and morbidity, especially in developing countries with restrictive abortion laws. Disease containment measures during the COVID-19 pandemic have reduced access to contraception and safe abortion care, potentially increasing rates of unintended pregnancies and unsafe abortion. OBJECTIVE: To evaluate the morbidity and mortality burden of unsafe abortion before the COVID-19 pandemic. METHODS: A six-year analytical retrospective study of unsafe abortion at the Federal Medical Centre, Lokoja, Nigeria. All case records of unsafe abortion managed within the study period were retrieved, and relevant data extracted using a purpose-designed proforma. Data obtained was analysed using the IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Associations between categorical independent and outcome variables were assessed using the Chi square test at 95% confidence level. A p-value of <0.05 was considered statistically significant. RESULTS: The prevalence of unsafe abortion was 8.6 per 1,000 deliveries. More than one-half (37, 52.9%) were medical abortions using misoprostol tablets. The mean age of the women was 23.15+ 3.96 years, and most of them were single (49, 70%), with primary/ secondary education (42, 60%), and of low socioeconomic status (67, 95.7%). Nearly one-half (33, 47.1%) had either never used any modern contraceptive (9, 12.9%) or only used emergency contraception (24, 34.3%). The predominant complications of unsafe abortion included retained product of conception (69, 98.6%), haemorrhagic shock (22,31.4%), and sepsis (19, 27.1%). There were two maternal deaths, giving a case fatality rate of 2.9%. CONCLUSION: Unsafe abortion remains a significant cause of maternal mortality and morbidity in our setting. Improving access to effective modern contraceptives and liberalizing our abortion laws may reduce maternal morbidity and mortality from unsafe abortion.

CONTEXTE: L'avortement à risque reste l'une des principales causes de mortalité et de morbidité maternelles, en particulier dans les pays en développement où les lois sur l'avortement sont restrictives. Les mesures de confinement de la maladie pendant la pandémie de COVID-19 ont réduit l'accès à la contraception et aux soins d'avortement sûrs, augmentant potentiellement les taux de grossesses non désirées et d'avortements à risque. OBJECTIF: Évaluer le fardeau de morbidité et de mortalité de l'avortement à risque avant la pandémie de COVID-19. METHODES: Une étude rétrospective analytique de six ans sur l'avortement à risque au Fédéral Médical Center, Lokoja, Nigeria. Tous les dossiers de tous les cas d'avortement à risque pris en charge au cours de la période d'étude ont été récupérés et les données pertinentes extraites à l'aide d'un formulaire conçu à cet effet. Les données obtenues ont été analysées à l'aide d'IBM SPSS Statistiques pour Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Les associations entre les variables indépendantes catégorielles et les variables de résultat ont été évaluées à l'aide du test du chi carré à un niveau de confiance de 95 %. Une valeur de p <0,05 était considérée comme statistiquement significative. RESULTATS: L'prévalence des avortements à risque était de 8,6 pour 1000 accouchements. Plus de la moitié (37, 52,9%) étaient des avortements médicamenteux utilisant comprimés de misoprostol. L'âge moyen des femmes était de 23,15+ 3,96 ans, et la plupart d'entre elles étaient célibataires (49, 70%), avec une éducation primaire/secondaire (42, 60%) et de statut socio-économique bas (67, 95,7%). Près de la moitié (33, 47,1%) n'avaient jamais utilisé de contraceptif moderne (9,12,9%) ou n'avaient utilisé qu'une contraception d'urgence (24, 34,3%). Les complications prédominantes comprenaient la rétention du produit de conception (69, 98,6 %), le choc hémorragique (22, 31,4 %) et la septicémie (19, 27,1 %). Il y a eu deux décès maternels, soit un taux de létalité de 2,9 %. CONCLUSION: L'avortement à risque reste une cause importante de mortalité et de morbidité maternelles dans notre contexte. L'amélioration de l'accès à des contraceptifs modernes efficaces et la libéralisation de nos lois sur l'avortement réduiront la morbidité et la mortalité maternelles dues à l'avortement à risque. Mots-clés: Planification familiale, Avortement illégal/criminel, morbidité et mortalité maternelles, Produit de la conception retenu, Besoin non satisfait.

Experience with the bonanno catheter in the management of OHSS from IVF-ET Cycles.

OBJECTIVE: To document our experience with the use of the Bonanno catheter as a closed abdominal drain for OHSS Methods: A retrospective study of all IVF embryo transfer (ET) treatment cycles carried out between May 2006 and April 2009 at a dedicated IVF centre. Case notes of patients with OHSS were retrieved and the outcome of the continuous closed abdominal drain with Bonanno catheter documented. RESULT: Within the period under review, 234 patients had controlled ovarian stimulation with ultrasound guided egg retrieval. Two hundred and twenty eight (228) got to the stage of embryo transfer with 72 clinical pregnancies. The clinical pregnancy rate was 31.58%. Fourteen (6%) of those who were stimulated developed OHSS and had a closed abdominal drain of the ascitic fluid using the Bonanno catheter. The average number of days of the abdominal drainage was 7.5days and the average volume of ascitic fluid drained from a patient per day was 2454.9 + 748mls. Eight (8) patients who had OHSS achieved clinical pregnancy (six intrauterine, one ectopic and one heterotopic pregnancies), giving a clinical pregnancy rate of 57.14% in patients with OHSS. Four patients had blocked Bonanno catheters and three of them had the catheter changed while the fourth had the catheter successfully flushed. Four patients had the insertion site dressing changed due to soaking with ascitic fluid. There was no incidence of injury to intra abdominal organs or broken catheter. CONCLUSION: Bonanno Catheter is both effective and safe in draining ascitic fluid following OHSS.

IVF Pregnancy and Delivery following Ultrasound Scan Guided Aspiration of a Left Hydrosalpinx- A Case Report.

The presence of hydrosalpinges is known to significantly reduce the pregnancy and implantation rates following in vitro fertilization (IVF). Salpingectomy or laparoscopic tubal occlusion before IVF have been shown to significantly improve pregnancy rates. Aspiration of the hydrosalpinges at the time of oocyte retrieval for IVF had been proposed as a viable alternative. We present a 36- year old nullipara with unilateral hydrosalpinx who declined salpingectomy prior to IVF treatment and subsequently had two failed IVF cycles. She however became pregnant with the third IVF attempt, following transvaginal ultrasound scan guided aspiration of the hydrosalpinx fluid at the time of oocyte retrieval. Large randomized trials are needed to clearly identify the place of ultrasound scan guided aspiration of hydrosalpinges on IVF outcome.

Comparison of IVF/ICSI outcome in patients with polycystic ovarian syndrome or tubal factor infertility.

BACKGROUND: One of the recognized treatment options for patients with polycystic ovarian syndrome (PCOS) is in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Fears are however sometimes raised concerning the likely outcome of treatment in such patients compared with their counterparts with tubal factor infertility. OBJECTIVE: To compare the IVF/ICSI performance in women with PCOS and those with tubal factor infertility. MATERIALS AND METHODS: A retrospective analysis. Case notes of 30 patients, 35 years and below, with PCOS and who underwent 33 IVF/ICSI cycles and those of 42 age-controlled patients with tubal factor infertility and who had 43 cycles between December 2004 and April 2008 were retrieved. Data including duration of down-regulation, dose of human Menopausal Gonadotropin (hMG), number of cancelled treatments, endometrial thickness, number of oocytes retrieved and fertilization rate, in addition to the number of embryos transferred with resultant pregnancy outcome were compared between the two groups. The main outcome measures were response to gonadotropin stimulation, fertilization rate and clinical pregnancy rate. RESULTS: There was no significant difference between the PCOS group and the tubal factor infertility group in the hMG dose (2.7 vs. 3.4 vials, respectively), endometrial thickness (10.5 vs. 10.1 mm, respectively) and embryos transferred (3.1 vs. 2.9, respectively). The fertilization rate was significantly higher in the tubal factor infertility group, which was 81.48% as against 63.24% for the PCOS group ( P < 0.0001). While more cases of ovarian hyperstimulation syndrome (OHSS) occurred in the PCOS group ( P = 0.049), overall clinical pregnancy rate per embryo transfer was similar (45.45% vs. 42.85%; P = 1), with similar miscarriage rates. CONCLUSION: IVF/ICSI performance in patients with PCOS is probably similar to their counterparts with tubal factor infertility with, however, a reduced fertilization rate and higher incidence of OHSS.

Ectopic pregnancy following in vitro fertilisation and embryo transfer.

BACKGROUND: ectopic pregnancy is one of the recognised complications of in vitro fertilisation (IVF) and embryo transfer. OBJECTIVE: to review cases of ectopic pregnancy following IVF at a fertility unit, with the aim of raising awareness towards its increased incidence and pattern of presentation. METHODS: case records of patients who had ectopic pregnancy following IVF over a three-year-period (July 2005-June 2008) were retrieved from the medical records department. Data including age, parity, risk factors for ectopic pregnancy as well as management modality were extracted and analysed. RESULTS: There were 64 clinical pregnancies during the study period. Of these, five were ectopic pregnancies, given a frequency of 7.8%. The minimum number of embryos transferred was two and maximum four. All the five cases had easy embryo transfer. There was one case of heterotopic pregnancy. Two (40%) patients had previous ectopic pregnancies with one having a third ectopic pregnancy despite previous bilateral salpingectomies. Four (80%) of the five cases had laparotomy done. Three (60%) cases had ruptured ectopic pregnancies. One case was managed conservatively with methotrexate. CONCLUSION: ectopic pregnancy can present following IVF procedures. A high index of suspicion is necessary even in cases with previous bilateral salpingectomies or easy embryo transfer.

Patients' preference for number of embryos transferred during IVF/ICSI: a Nigerian experience.

BACKGROUND: The Human Fertilization and Embryology Authority is considering limiting the number of embryos that can be transferred to single embryo per cycle as has been done in several European countries, with the aim of reducing the rate of multiple pregnancies and its attendant complications following in vitro fertilization (IVF) / Intracytoplasmic sperm injection (ICSI). OBJECTIVE: To determine the number of embryos patients' attending a fertility clinic in Nigeria, would prefer transferred during IVF/ICSI. MATERIALS AND METHODS: Fifty four consecutive female patients who underwent IVF/ICSI procedures between May 2006 and April 2007 at the Port Harcourt Fertility Centre, Rivers State were interviewed using structured questionnaires. They were informed of all the obstetric and perinatal complications of multiple pregnancies and the advantages and trend towards single embryo transfer and then asked to choose the number of embryos (one, two or three) they would prefer transferred assuming similar implantation rates. Each respondent was allowed to give reason(s) for their choice. DESIGN: Prospective, descriptive study. RESULTS: Fifty one (94.4%) of the respondents preferred the transfer of multiple (2 or 3) embryos. Only three (5.6%) patients opted for single embryo transfer. Majority of the patients (31 or 60.8%) preferred multiple embryo transfer because of their desire for twins while twenty (39.2%) cited cost of IVF as their reason. Fifteen (29.4%) patients saw multiple pregnancies as a compensation for their long periods of infertility. CONCLUSION: With the desire for twins and high poverty level in Nigeria, a policy of single embryo transfer might be difficult to implement. Health economic studies would be required to determine if the accumulative cost of taking care of twins/triplets is less, equal or outweighs the cost of several single embryo transfers.

Patients' Preference for Number of Embryos Transferred During IVF/ICSI a Nigerian Experience

Background: The Human Fertilization and Embryology Authority is considering limiting the number of embryos that can be transferred to single embryo per cycle as has been done in several European countries; with the aim of reducing the rate of multiple pregnancies and its attendant complications following in vitro fertilization (IVF) / Intracytoplasmic sperm injection (ICSI). Objective: To determine the number of embryos patients' attending a fertility clinic in Nigeria; would prefer transferred during IVF/ICSI. Materials and Methods: Fifty four consecutive female patients who underwent IVF/ICSI procedures between May 2006 and April 2007 at the Port Harcourt Fertility Centre; Rivers State were interviewed using structured questionnaires. They were informed of all the obstetric and perinatal complications of multiple pregnancies and the advantages and trend towards single embryo transfer and then asked to choose the number of embryos (one; two or three) they would prefer transferred assuming similar implantation rates. Each respondent was allowed to give reason(s) for their choice. Design: Prospective; descriptive study. Results: Fifty one (94.4) of the respondents preferred the transfer of multiple (2 or 3) embryos. Only three (5.6) patients opted for single embryo transfer. Majority of the patients (31 or 60.8) preferred multiple embryo transfer because of their desire for twins while twenty (39.2) cited cost of IVF as their reason. Fifteen (29.4) patients saw multiple pregnancies as a compensation for their long periods of infertility. Conclusion: With the desire for twins and high poverty level in Nigeria; a policy of single embryo transfer might be difficult to implement. Health economic studies would be required to determine if the accumulative cost of taking care of twins/triplets is less; equal or outweighs the cost of several single embryo transfers

The effect of endometrial thickness on in vitro fertilization (IVF)-embryo transfer/intracytoplasmic sperm injection (ICSI) outcome.

The value of measuring the endometrial thickness and studying the endometrial receptivity in the context of assisted conception remains a contentious issue. A prospective analysis was carried out to determine the effect of endometrial thickness on IVF - embryo transfer/ICSI outcome in dedicated Assisted Reproductive Technology (ART) units in Abuja and Rivers State, Nigeria. Two hundred and fifty one patients who met the inclusion criteria were analysed. They were grouped on the basis of endometrial thickness into 3 groups; <7 mm, 7 - 14 mm and >14 mm. The main outcome measure was clinical pregnancy. There were significantly more pregnancies in the 7 - 14 mm endometrial thickness group compared to the <7 mm and >14 mm groups, p=0.004 and p<0.0001 respectively. The findings suggest that following IVF/ICSI, significantly more pregnancies occurred when the endometrial thickness was between 7 and 14 mm.

Placenta Praevia at the University of Port Harcourt Teaching Hospital: a Five Year Retrospective Study

Placenta praevia is a major cause of obstetric haemorrhage commonly encountered in clinical practice in our environment. It is a life threatening condition both to the mother and her baby.To report the incidence of placenta praevia and describe its clinical presentation; associated risk factors and maternal and perinatal outcomes over a five year period at the University of Port Harcourt Teaching Hospital; Port Harcourt. A cross-sectional study design was employed in the review of hospital records of all women who had placenta praevia and had labour/delivery services at the University of Port Harcourt Teaching Hospital between January 2002 and December 2006. Simple frequencies; cross tabulations and summary statistics were computed and analysed using SPSS version 11 soft ware. Chi-square test of significance was used to compare proportions at P-value- 0.05.One hundred and forty cases of placenta praevia were observed over five years; giving a yearly rate of 28 cases; and an incidence rate of 1.0out of 13;870. One hundred and eighteen women (93.6) had vaginal bleeding out of which 96 (76.1) were painless vaginal bleeding. The mean time from onset of vaginal bleeding to presentation in hospital was 10.98(+ 13.08) hours. The commonly identified known risk factors were induced abortion (50) and previous caesarean section (25). The average time of hospitalization was 13.83 (+ 9.76) days. One hundred and fourteen cases (90.5) had diagnosis confirmed by ultrasound scan while twelve cases (9.5) had Examination Under Anaesthesia (EUA). The mean gestational age at delivery was 37.1 weeks. Caesarean delivery was performed for 101 (80) cases; while 25 (20) had vaginal delivery. There was one maternal death. Thirty two (25.3) babies had birth asphyxia. The perinatal mortality rate was 61.5/1;000 total births. Placenta praevia is still an important obstetric problem in our environment. Despite the fact that most of our women present late; the availability of blood transfusion services; adequate manpower; ultrasound scan and neonatal intensive care facilities have contributed immensely to improve maternal and fetal outcome of this condition in our centre