INITIAL EXPERIENCE WITH 3D-ULTRASOUND AS AN ADJUNCT TO 2DULTRASOUND IN FETAL ANOMALY DIAGNOSIS IN A NIGERIAN DIAGNOSTIC FACILITY.

INTRODUCTION: Two-Dimensional ultrasound (2DUS) has been the preferred screening method for fetal abnormalities for several decades. Three-dimensional ultrasound (3DUS) is a technique that converts standard 2D grayscale ultrasound images into a volumetric dataset which allows visualization of the fetus in all three dimensions at the same time. It provides an improved overview and a more clearly defined demonstration of adjusted anatomical planes. The use of 3D imaging is however limited to being an adjunct to 2DUS in the visualization of fetal anomalies. The objective of this study is to highlight the importance of adding three-dimensional ultrasound (3DUS) to two-dimensional ultrasound (2DUS) during fetal anomaly screening. METHODOLOGY: This is a descriptive study conducted at a private fetal diagnostic center, in Nigeria between January 2014 and December 2016. The diagnosis of fetal anomalies was first made with 2DUS after which they were evaluated with 3D ultrasound images displayed on the monitor. RESULTS: Nine fetuses with various fetal anomalies diagnosed on 2DUS were selected for further evaluation with 3DUS. These anomalies include a neck mass, lumbar spinal abnormality, bilateral cleft lip, thanatophoric dysplasia, anencephaly, omphalocele, posterior urethral valve with anhydramnios and ambiguous genitalia diagnosed. These anomalies were better demonstrated on 3DUS. CONCLUSION: 2DUS remains the mainstay imaging modality in screening for fetal anomalies. However, 3DUS may complement 2DUS by allowing better delineation of anomalies and gives the parents a better visualization and understanding of identified anomalies, thereby assisting in informed decision making.

Accuracy of intra-partum prediction of birth weight using maternal anthropometric parameters.

AIMS AND OBJECTIVES: This study aimed at predicting foetal birth weight using various clinical methods and to determine which of the methods is the most accurate in this population. SUBJECTS AND METHODS: Parturients of all parities admitted into the labour ward of OAUTHC, Ile-Ife at term for delivery were recruited for this study. They had their symphysiofundal height, abdominal circumference at the umbilical level, height and weight measured. The body mass index was then calculated. The birth weight was calculated from these measurements using four clinical formulae. The weights of the babies were measured after delivery and compared with the individual estimated birth weights. RESULTS: There were 400 women who met the inclusion criteria during the time of this study. Three of the methods [Johnson's Rule, Ojwang's Rule and 5% maternal weight] overestimated the birth weight while 10% BMI underestimated the birth weight significantly. CONCLUSION: There is a strong correlation between the birth weights predicted by the various clinical methods and the actual birth weight. The accuracy of the methods can be improved by using the derived modified formulae.

Cardiovascular and electrocardiographic changes in Nigerians with a normal pregnancy.

INTRODUCTION: Pregnancy is associated with major haemodynamic and cardiac changes, which can mimic or precipitate cardiac diseases. There is a paucity of this kind of data among pregnant Nigerian women. This study was aimed at describing the cardiovascular and electrocardiographic changes found among healthy pregnant Nigerian women. METHODS: This was an age-matched control study of 69 consecutive normal pregnant and 70 healthy non-pregnant controls. The study protocol included history, physical examination and 12-lead electrocardiography. RESULTS: Diastolic blood pressure < 60 mmHg was significantly commoner among pregnant subjects than controls (64.7 vs 24.3%, respectively, p < 0.005). Mean heart rate was higher among pregnant women (88.34 ± 11.46 bpm) than the controls (75.16 ± 12.22 bpm, p = 0.020). Pregnant subjects also had a higher proportion of left ventricular hypertrophy (LVH) (10.2 vs 0%, p < 0.05) than non-pregnant controls. Abnormal cardiac findings included a loud second heart sound (P(2)), missed beats and systolic murmurs (41.2% in pregnant subjects vs 12.9% in non-pregnant controls, p < 0.05). Negroid-pattern ST-segment elevation was commoner among controls (24.3%) than pregnant subjects (2.9%, p < 0.005). Arrhythmias were rare among the study participants. CONCLUSION: Significant findings on examination were low diastolic blood pressure and a systolic ejection murmur. However, ECG changes showed a normal frontal-plane QRS axis, normal PR interval, significantly rare normal Negroidpattern ST elevation, significant LVH based on Araoye RI > 12 mm and a rarity of all forms of arrhythmias. These data may help resolve some cardiac diagnostic difficulties during pregnancy.

Influence of maternal height on mode of delivery in Nigerian women.

AIMS AND OBJECTIVES: To determine the influence of maternal height on the mode of delivery even when matched for maternal characteristics. The study is a prospective cohort study comparing the mode of delivery in 57 short stature women (d"150 cm) with age and parity-matched, taller control women (n = 57). MATERIALS AND METHODS: A total of 114 parturients were studied, 57 of whom had a height of 150 cm or lower and constituted the study group, while the other 57 taller women were matched with respect to parity (i.e. belonging to same parity group of either nulliparity, para 1-3, para 4+) and maternal age group (i.e. <20, 20-34, 35+ years) to the shorter women and constituted the control group. Patients were also matched by gestational age (28-37 weeks, 38-42 weeks, 42+ weeks) and birth weight (<2500g, 2500-3999g, 4000+) groupings. RESULTS: Caesarean section rate in the short women was higher (42.1%) than in taller women (21.1%), P= 0.016, as was the incidence of cephalopelvic disproportion (35.5% versus 10.3% respectively, P = 0.010). Nevertheless, neonatal outcome remains good; the 5-min Apgar score <7 was 21.1% versus 15.8% respectively, P =0.469, while the stillbirth rate was 10.5% versus 7.0), P = 0.508. CONCLUSION: Short stature is independently associated with an increased risk of intrapartum caesarean section in Nigerian women and advocate early recourse to caesarean section to avoid undue delay.

Ovarian Non-Hodgkin's Lymphoma presenting as obstructive jaundice - a case report.

OBJECTIVE: To highlight the importance of considering abdominal Lymphoma as a differential diagnosis in the management of obstructive jaundice. PATIENT: A 51 year old female who presented with abdominal swelling associated with features of obstructive jaundice. Significant findings included jaundice on examination, with abdominal ascites. Laparotomy revealed three litres of icteric fluid. There was a huge left ovarian tumour measuring 14cm x 12cm. Massive peritoneal seedling involved the whole abdomen and pelvis was noted. Following surgery allowing for adequate wound healing, the patient was placed on appropriate chemotherapy. INVESTIGATION/DIAGNOSIS: Histology of excision biopsy revealed high grade Non-Hodgkins's Lymphoma. Screening for human deficiency virus (HIV) was negative. However the erythrocyte sedimentation rate (ESR) was raised at 92 mm Westergren in the first hour. The liver function tests were deranged with total bilirubin of 274 mmol/l and conjugated bilirubin of 204 mmol. serum Ast and Alt were also significantly raised. Total proteins, urea and electrolytes remained essentially within normal limits. The patient was placed on CHOP combination therapy. She attained remission after four cycles of chemotherapy and was discharged home. CONCLUSION: Abdominal Non-Hodgkin's Lymphoma should be a strong consideration in the management of obstructive jaundice.

Ovarian non-Hodgkin's lymphoma presenting as obstructive jaundice - a case report.

OBJECTIVE: To highlight the importance of considering abdominal Lymphoma as a differential diagnosis in the management of obstructive jaundice. PATIENT: A 51 year old female who presented with abdominal swelling associated with features of obstructive jaundice. Significant findings included jaundice on examination, with abdominal ascites. Laparotomy revealed three litres of icteric fluid. There was a huge left ovarian tumour measuring 14 cm x 12 cm. Massive peritoneal seedling involved the whole abdomen and pelvis was noted. Following surgery allowing for adequate wound healing, the patient was placed on appropriate chemotherapy. INVESTIGATION/DIAGNOSIS: Histology of excision biopsy revealed high grade Non-Hodgkins's Lymphoma. Screening for human deficiency virus (HIV) was negative. However the erythrocyte sedimentation rate (ESR) was raised at 92 mm Westergren in the first hour. The liver function tests were deranged with total bilirubin of 274 micromol/l and conjugated bilirubin of 204 micromol. serum Ast and Alt were also significantly raised. Total proteins, urea and electrolytes remained essentially within normal limits. The patient was placed on CHOP combination therapy. She attained remission after four cycles of chemotherapy and was discharged home. CONCLUSION: Abdominal Non-Hodgkin's Lymphoma should be a strong consideration in the management of obstructive jaundice.

Factors predicting failure of labour induction.

Our objective was to identify risk factors for failed labour induction. From January 2001 to December 2005, we conducted a retrospective case-control study in a Nigerian University Hospital. Cases were women who failed to deliver vaginally after labour induction, and therefore had caesarean section. Controls were patients who were similarly induced and achieved vaginal delivery. Univariate followed by Logistic regression analysis were performed. Failed induction occurred in 37.6%. Variables significantly and independently associated with failed induction were cervical effacement < 70% (adjusted odds ratio [OR] 5.12; 95% confidence interval [CI] 2.65-9.90), Bishop's score < 6 (OR 3.47; CI 1.75 - 6.85), nulliparity (OR 3.91; CI 1.92 - 7.99). Prolonged pregnancy independently reduced failure rate (OR 0.44: CI 0.24 - 0.81). These variables can help determine patients that will require early recourse to caesarean delivery in order to avoid prolonged induction-delivery interval.

Pre-term pre-labour rupture of membranes: effect of chorioamnionitis on overall neonatal outcome.

Our objective was to evaluate the association between clinical chorioamnionitis following preterm pre-labour rupture of membranes (PPROM) and adverse neonatal outcome. We compared retrospectively, adverse neonatal outcome of singleton pregnancies with documented PPROM who developed chorioamnionitis (cases) with those who did not (controls). Our result showed that poor neonatal outcome was significantly associated with chorioamnionitis (34% vs 13%; p = 0.008). This association was found on multiple logistic regression analysis to be independent (p < 0.05) of other risk factors for poor neonatal outcome, viz: latency period (p = 0.002) and gestational age at delivery (p < 0.001). We conclude that chorioamnionitis complicating PPROM worsen neonatal outcome. The implication of this on expectant management of PPROM is discussed.

Pattern and outcome of emergency surgery in a new Nigerian Teaching Hospital--The LAUTECH Osogbo experience.

AIMS AND OBJECTIVES: To present a 5 years experience on the pattern and outcome of emergency operations in a new teaching hospital. MATERIALS AND METHODS: A retrospective study carried out between April 1998 and March 2003 with appropriate data extracted from the available case notes. RESULTS: Two thousand and seventy operations were performed within the period of study. Seven hundred and twenty six of them were done as emergency. Obstetrics' and Gynaecology cases were 66.6% while 33.4% (including six cases of perforated uterus and gangrenous bowel from unsafe abortion) belong to the general surgery and specialty emergencies. Waiting time, mean of which was 39.5+/-2.7 hours, was unduly prolonged. Mortality was 10.3%. CONCLUSION: The high morbidity and mortality as reflected in this study could be reduced through prompt surgical interventions, education on contraceptive awareness and legistilation against unsafe abortion.

Pregnancy outcome in nulliparous women aged 35 or older.

Our objective was to examine pregnancy outcome in women age 35 and over. We compared pregnancy delivery complications in 207 women aged 35 years and older with 219 control women aged 25 - 29 years. Data was collected retrospectively and stratified by parity. Results of statistical analysis showed that the older women differed significantly in (1) antepartum factors (previous pregnancy experience, chronic and pregnancy-induced hypertension, maternal and gestational diabetes, placenta previa) (2) intrapartum factors (malpresentations, fetal disproportions, abnormal labour, caesarean and operative vaginal delivery) (3) neonatal outcomes (birth asphyxia, prematurity, low birth weight, neonatal intensive care unit admissions). However, birth trauma and perinatal mortality did not differ between the two groups. We concluded that pregnancies in older women are prone to complications, but when managed accordingly the overall perinatal outcomes were good.

Fetal station at the time of labour arrest and risk of caesarean delivery.

This study aimed to determine whether an unengaged vertex in nulliparous women experiencing active phase labour-arrest increased the caesarean delivery risk. We selected a retrospective cohort of 393 patients. Of these, the presenting part was unengaged in 307, and engaged in 86. Compared with the engaged vertex, unengaged vertex significantly increased the risk of caesarean delivery (27% vrs 7%, P < 0.001, with the risk increased 5 fold [Odds ratio 4.94, confidence intervals 2.08, 11.76]. The risk remains significant after adjusting for confounding variables on multiple logistic regression [adjusted OR 4.71, CI 1.99, 11.01]. However, the degree of unengagement did not significantly affect caesarean rate. (39% at -3 station, 39% at -2 station, and 33% at -1 station; P = 0.577). While an unengaged vertex significantly increased the caesarean delivery rate, the degree of unengagement did not, and the eventual vaginal delivery rate (73%) is high and should prevent hasty recourse to caesarean delivery.

Female genital mutilation: an analysis of 522 cases in South-Western Nigeria.

This study was conducted at three teaching hospitals in South-Western Nigeria. Paturients were examined to find out if they had had female genital mutilation. Those who did were given a self-administered questionnaire. Results show that all the patients had either Type I (69%) or Type II (31%) mutilation (using WHO classification). The average age at which the procedure was performed was 6.9+/-2.9 years, with 4% of women having the procedure performed in pregnancy. The majority of the procedures were performed by medically untrained personnel (89%). Up to 67% of the women reported complications following the procedure. Severe pain and bleeding were the most common (69%) of the complications reported. The most common reason given for the procedure is cultural/traditional (63%). About a fifth of the women want their female child to undergo female genital mutilation. This study highlights the need for further interventions aimed at discouraging the practice of female genital mutilation.

Pregnancy outcomes among nulliparous teenagers in suburban Nigeria.

Our objective was to study the pregnancy outcomes among teenagers in a rural Nigerian setting. Single births to 1394 nulliparous mothers aged

Risk factors of placenta accreta in Ile-Ife, Nigeria.

Our objective was to identify the independent risk factors of placenta accreta. The hospital records of 44 pregnancies complicated by placenta accreta, and 1371 controls over a 10-year period were reviewed. Univariate analysis was followed by multivariate logistic regression analyses with adjustment for potentially confounding variables to determine the statistically significant independent predictors of placenta accreta (p <.05). The following factors were associated with placenta accreta: maternal age of at least 35 years (P =.004), gravidity = 5 (P =.004), placenta praevia (P <.001), previous uterine curettage (P =.006) and previous caesarean delivery (P =.014). However, when examined with a multivariate model, only placenta praevia (Odds Ratio [OR] 49.3; 95% confidence interval [95% CI] 13.1, 119.0) and maternal age = 35 (OR 2.7; 95% CI 1.3, 7.9) reached a significant association. Independent risk factors of placenta accreta include placenta praevia and maternal age 35 and over.

Active management of labour in a district hospital setting.

The aim of this randomised trial was to determine the effect of the policy of active management of labour in all its components on the rate of caesarean section in a Nigerian district hospital setting. Two hundred and twenty-one nulliparous women fulfilling selected inclusion criteria were randomised to receive active management of labour, and 227 control women received routine labour management. Labour was significantly shortened by over 2 hours with active management of labour, and caesarean section reduced (9% vs. 16%, RR 0.57, 95% CI 0.34-0.95). There were no significant differences in maternal infectious morbidity, uterine hyperstimulation syndromes, ruptured uterus or neonatal Apgar scores between the two groups. We conclude that active management of labour shortens primigravid labour and reduces caesarean risk.

A multicentre evaluation of the two-layered repair of postpartum perineal trauma.

We set out to compare a policy of two-layered postpartum perineal repair leaving the skin unsutured with a policy of three-layered repair, which involved skin closure. Parturients who sustained a second-degree tear or an episiotomy in four Nigerian centers were randomised to have either a two-layered repair (417 women) or a three-layered repair (406 women). Fewer women in the two-layered group reported perineal pain at 48 hours (57% vs. 65%, relative risk [RR] 0.87, 95% confidence interval [CI] 0.78-0.97) and 14 days postpartum (22% vs. 28%, RR 0.77, CI 0.61-0.98). The two-layered repair was also associated with reduced risk of suture removal (6% vs. 10%, RR 0.62, CI 0.39-0.99), and less superficial dyspareunia at 3 months (6% vs. 12%, RR 0.52, CI 0.33-0.81). The rates of wound healing were similar between the two groups. Leaving the skin unsutured during postpartum perineal repair reduces perineal pain and dyspareunia.

A randomised controlled trial of misoprostol versus oxytocin in the active management of the third stage of labour.

Our objective was to compare oral misoprostol with intramuscular oxytocin in the prevention of postpartum haemorrhage. Four hundred and ninety-six women were randomised to receive either 600 microg misoprostol orally or 10 IU oxytocin intramuscularly after delivery. There were no significant differences between the misoprostol and oxytocin groups with regard to the incidence of postpartum haemorrhage (1% vs. 0% respectively, relative risk (RR) 3.02, 95% confidence interval (CI) 0.32-28.88) or drop in haemoglobin concentration (0.71 g/dl vs. 0.68 g/dl, respectively, P = 0.699). The length of the third stage of labour and the percentage of women requiring manual removal of placenta, further oxytocics or blood transfusion were also similar. Shivering was significantly higher with misoprostol (57% vs. 14%; RR 4.06, CI 2.93-5.62), but there were no differences in other side effects. We conclude that oral misoprostol can replace intramuscular oxytocin in reducing postpartum haemorrhage in low-risk women, in developing countries, especially as it is administered orally and it is thermostable in tropical conditions.

Low dose intravaginal misoprostol versus intracervical baloon catheter for pre-induction cervical ripening.

BACKGROUND: The efficacy and safety of low dose misoprostol as a ripening agent compared to the widely used balloon catheter in developing countries is undetermined. OBJECTIVE: To compare the safety and efficacy of a low dose intravaginal misoprostol and intracervical Foley's catheter for cervical ripening. DESIGN: A prospective randomized controlled trial. SETTING: Zonal General Hospital, Kwale, Nigeria from June 1, 1998 to May 30, 2001. METHODS: Candidates for pre-induction cervical ripening were randomized to receive either 250 mcg of intravaginal misoprostol every four hours (n = 60) or intracervical Foley's catheter (n = 61). MAIN OUTCOME MEASURES: Failure to achieve cervical ripening within 24 hours, need for augmentation, maternal and foetal complications. RESULTS: Failure to achieve cervical ripening within two hours was reduced with misoprostol (Relative Risk [RR] 0.63, 95% Confidence Interval [CI] 0.43 - 0.92). Need for oxytocin augmentation was less in the misoprostol group (RR 0.76, 95% CI 0.64 to 0.91). No significant differences existed in rates for uterine hyperstimulation, Caesarean section, maternal and neonatal morbidity. CONCLUSION: Intravaginal misoprostol in a low dose was compared to intracervical balloon catheter for pre-induction ripening of the cervix.