Emergency obstetric hysterectomy in a Nigerian teaching hospital: a ten-year review.

BACKGROUND: Haemorrhage is a leading cause of maternal mortality worldwide and hysterectomy may become necessary to save life. This procedure is associated with significant morbidity and mortality. OBJECTIVE: To determine the, indications, risk factors and the management outcome for the procedure in our unit. METHODS: A retrospective case controlled study of 34 cases of emergency obstetric hysterectomy (EOH) performed at the Lagos University Teaching Hospital over a period often years was carried out. RESULTS: The incidence of EOH was 2.56 per thousand deliveries. Increasing parity, history of previous caesarean section, placenta praevia and current delivery by caesarean section were significant risk factors for the procedure. The indications were ruptured uterus (61.8%), intractable haemorrhage during caesarean section (32.4%), and uterine atony (5.9%). Majority (73.5%) of the patients had subtotal hysterectomy but the outcome indices were similar for the total and subtotal procedures. The case fatality rate was 11.8%. Post-operative complications included anemia (100%), urinary tract infection (UTI) (14.7%) and wound infection (11.7%). CONCLUSION: The incidence of EOH in our unit has increased since the last study published in 1983, but the associated mortality has decreased. The indications differed in proportion from those in developed countries although the risk factors were similar. The outcome indices were similar for the total and the subtotal procedures. EOH is still associated with considerable maternal morbidity and mortality which can be reduced by provision of better obstetric care for the population.

Morbidity and mortality in sickle cell pregnancies in Lagos, Nigeria: a case control study.

Women with sickle cell disorder are historically known to have significant maternal and perinatal complications but recent studies from developed countries show a change in this trend. This study was a retrospective, case-controlled study of 75 women with haemoglobin SS (HbSS) and 150 with haemoglobin AA (HbAA). Data were analysed using chi(2)-test and independent t-test as appropriate. There were more perinatal (18.7 vs 8.8, p<0.05) and maternal (5.3% vs 0, p<0.05) deaths in HbSS women compared with HbAA. Birth weight, gestational age at delivery and 1 and 5 min Apgar scores were also significantly lower in the HbSS women. There was no significant difference in the incidence of pre-eclampsia and urinary tract infection between the two groups. Pregnancy in HbSS women is still fraught with maternal and fetal complications. Prospective studies may help clarify the relationship between SCD and specific maternal complications.

The acceptance rate of intrauterine contraceptive device (IUCD) amongst family planning clinic users in Lagos University Teaching Hospital (LUTH).

BACKGROUND: Intrauterine Contraceptive Device is an effective reversible long-term contraceptive method that is popular and widely used in this environment. OBJECTIVES: To determine the characteristics of women using this mode of contraception, their main reasons for acceptance, complications arising from usage and the discontinuation rate as well as reasons for discontinuing the method. METHODS: A review of case records of all the new contraceptive acceptors attending the Department of Obstetrics and Gynaecology Family Planning Clinic of the Lagos University Teaching Hospital (LUTH) from 1st January 1990 to 31st December 1994 was examined and the clients that accepted the intrauterine contraceptive device, (IUCD) during this period were identified. The records of those that opted for IUCD were thoroughly reviewed to identify the follow up events through the subsequent ten years visits to determine outcome of the contraceptive usage. RESULTS: Amongst the 2754 new contraceptive acceptors during the study period, 1602 (58.17%) clients accepted the Intrauterine Contraceptive Device (IUCD). Of these IUCD acceptors, the mean age was 31.3 +/- 5.5 years, mean parity was 3.9 +/- 2 and mean number of children alive was 3.6 +/- 1.8. Seven hundred and forty nine (46.8%) of them had previously used contraceptives and 1175 (73.3%) of them still wanted more children, thus child spacing was the main reasons for accepting this method. By 12 months, the discontinuation rate was 13.9% with the cumulative discontinuation rate of 47% as at forty-eighth month. The commonest reason for discontinuation was planning to get pregnant in 426 (26.6%) of the clients. Menstrual disorders accounted for 108 (6.7%). The mean duration of IUCD was 25.4 +/- 18.8 months with an accidental pregnancy rate of 0.3%. CONCLUSION: Intrauterine Contraceptive Device is widely accepted amongst women in the study group. Devices that reduce menstrual loss and also have long duration of action like Levonorgestrel intrauterine system (LNG-IUS) qualifies to be considered.

Intravaginal misoprostol versus Foley catheter for cervical ripening and induction of labor.

OBJECTIVE: To compare the efficacy and safety of 100 microg of intravaginal misoprostol with intracervical Foley catheter for cervical ripening and induction of labor. METHOD: One hundred women being induced in the Lagos University Teaching Hospital, Nigeria, were randomized to receive a single 100 microg dose of misoprostol intravaginally or intracervical insertion of Foley catheter. Data analyses were by the Student's t-test and chi-square test. RESULT: Misoprostol was more effective in terms of induction to delivery interval (11.84+/-5.43 versus 20.03+/-4.68 h, P<0.05), change in Bishop score, and number delivered within 24 h, in patients with a one-time successful induction. Uterine hyperactivity and rupture were more frequent in the misoprostol group. CONCLUSION: A single 100 microg dose of intravaginal misoprostol is more efficacious than intracervical insertion of Foley catheter for cervical ripening and induction of labor. Further studies using lower doses are needed to determine the safest dose.

Grandmultiparity in Lagos, Nigeria.

The case-notes and records of grandmultiparous patients delivered at the Lagos University Teaching Hospital between 1st January, 1994 and 31st December, 1996 were analysed. The incidence of grandmultiparity was 4.11%. There were no cases of extreme grandmultiparity. The mean age +/- SD was 33.26 +/- 1.8 years, and the mean parity +/- SD 5.57 +/- 0.38. No patient was under 20 years and none had a parity greater than 9. Fifty-seven (42.22%) were booked patients and 78(57.78%) were unbooked. Anaemia and malpresentation were commonest in the antenatal period, whilst hypertension and disproportion were commonest intrapartum. Fifty per cent of the patients had a spontaneous vaginal delivery. The Caesarean section rate was 30.37%. The incidence of intrapartum complications, cephalopelvic disproportion, obstructed labour and Caesarean section, were found to be higher in the unbooked patients. There was an increased incidence of twin pregnancy and placenta praevia. The maternal mortality ratio was 44.4/1000 amongst the grandmultipara which was not statistically more significant than in the general obstetric population. The perinatal mortality rate was 169/1000 deliveries.

The impact of the Lagos manual vacuum aspiration (MVA) training courses on medical education.

The Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos commenced training programmes in the use of manual Vacuum Aspiration (MVA) for the treatment of septic abortion in 1989. The courses were evaluated using pre-tests and post-tests, and those of the participants from the first 5 years were analysed. 142 doctors and 72 nurses were trained from teaching hospitals, parastatal and private hospitals. The results of 154 participants (71%) were recovered and analysed. The training courses significantly increased the medical knowledge of both doctors and nurses; those from the Teaching Hospitals appearing to gain more. The amount of knowledge gained by those from the private sector, although showing a statistically significant increase was much less than the other participants. More emphasis should be placed on improving the performance of those from the private sector.

A review of referred IUCD related problems in Lagos University Teaching Hospital.

A review of 168 patients referred with IUCD related problems was done. The two most common indications for referrals were difficulty at removal (73.8%) and missing/lost IUCD thread 23.8%. In 22.5% (9) of cases referred as missing/lost IUCD, the threads were visible on inspection of the cervix during speculum examination 21.4% (36) of the referred patients had routine removal by simple traction, while the retrieval hook was successfully used in 75% of the cases, only 3 patients (1.7%) required removal under general anaesthesia. A proper speculum examination combined with uterine sounding and the use of the retrieval hook at the peripheral centres will greatly reduce the need for referring IUCD related cases to a tertiary centre.

The pattern of sickle cell disease in pregnancy in Lagos, Nigeria.

The outcome of pregnancy and labour in patients with sickle cell disease delivered at the Lagos University Teaching Hospital (LUTH) under one obstetrician between 1st January 1985 and 31st December, 1989 is analysed. There were 31 pregnancies in 28 patients with sickle cell anaemia (HbSS) and 10 pregnancies in seven patients with sickle cell haemoglobin C disease (HbSc). Six pregnancies in HbSS patients and two in HbSC were in patients who had not had specialized preconceptual care. There was one abortion in a patient with HbSC and one pair of twins in a patient with HbSS. The complication rate was high in HbSC patients as compared to a previous series but not as high as in patients with HbSS. The perinatal mortality rates were 233 and 111 per 1000 deliveries in HbSS and HbSC patients respectively. The maternal mortality rates were 129 and 111 per 1000 deliveries in HbSS and HbSC patients respectively. Two of the maternal deaths and four of the perinatal deaths occurred in HbSS patients who had had no preconceptual specialist care as opposed to those receiving specialist treatment. In the case of perinatal mortality, this was found to be statistically significant (p < 0.001).

PIP: Improvement in the medical care of patients with sickle cell disease has increased the numbers surviving into adulthood, increasing the numbers seen in pregnancy. Pregnancy aggravates the medical complications of the disease, and the disease complicates pregnancy, leading to high levels of maternal and perinatal mortality. There is evidence that the presence of the "S" gene affects the fetus adversely and rarely may contribute to maternal death. This paper reviews the pregnancies of patients with sickle cell disease who delivered between January 1, 1985, and December 31, 1989, at the Lagos University Teaching Hospital. All subjects were referred to one obstetrician. There were 31 pregnancies in 28 patients with sickle cell anemia (HbSS) and 10 pregnancies in 7 patients with sickle cell hemoglobin C disease (HbSc). 6 pregnancies in HbSS patients and 2 in HbSc were in patients who had not had specialized preconceptual care. There was one abortion in a patient with HbSC and one pair of twins in a patient with HbSS. The complication rate was high in HbSC patients compared to a previous series, but not as high as in patients with HbSS. Perinatal mortality rates were 233 and 111 per 1000 deliveries in HbSS and HbSC patients, respectively, while maternal mortality rates were 129 and 111 per 1000 deliveries in HbSS and HbSC patients, respectively. Two of the maternal deaths and four of the perinatal deaths occurred in HbSS patients who had had no preconceptual specialist care as opposed to those receiving specialist treatment.

Erect lateral pelvimetry and the outcome of labor in Lagos.

The erect lateral radiograph pelvimetry measurements was related to the outcome of labor in 173 patients. The most common indication for pelvimetry was one previous caesarean section in 90 (52%) patients. Sixty-nine (39.9%) pelvimetry measurements were performed because of suspected cephalopelvic disproportion, while 20 (11.6%) were done because of breech presentation. In patients with a cephalic presentation at delivery, the mean +/- standard deviation (SD) obstetric conjugate for the 87 women who delivered vaginally (group 1) was 11.42 +/- 1.5 cm, while that of the 45 women who had emergency caesarean section (group 2) was 10.77 +/- 1.5 cm. The mean +/- SD anteroposterior outlet diameter for groups 1 and 2 were 12.24 +/- 1.9 cm and 11.84 +/- 1.7 cm respectively. Both differences were found to be statistically significant (p < 0.001 and p < 0.05 respectively). The mean +/- SD birthweight of the babies in groups 1 and 2 were 3.34 +/- 0.79 kg and 3.42 +/- 0.86 kg respectively. There was no statistically significant difference between the two groups (p < 0.05). The critical obstetric conjugate for safe vaginal delivery was 9.88 cm while the corresponding value for the anteroposterior pelvic outlet diameter was 10.24 cm.

Failed contraception in Nigerian women: outcome of pregnancy and subsequent contraceptive choice.

The outcome of pregnancy in 56 patients who had contraceptive failure out of the 5,431 new acceptors at the Family Planning Clinic of the Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, between 1 January 1981 and 31 December 1989, were analysed. There were 40 IUD, 6 OC, and 4 injectable failures. Three patients had had voluntary surgical contraception (VSC) and 3 used barrier methods. The mean +/- SD age and parity were 32.2 +/- 4.4 years and 4.4 +/- 1.9, respectively. There were 17 (30.1%) live births, 34 (56.6%) terminations of pregnancy and 3 (5.2%) spontaneous abortions. Two (3.0%) patients were lost to follow-up. There was neither any statistically significant difference in the outcome of pregnancy between patients with 5 or more children and less than 5 children (p greater than 0.05), nor between patients less than 31 years of age and those older. Fifty per cent of the patients who had used the IUD continued with the method. Seven patients subsequently requested VSC. None of the patients using the injectable contraceptive or barrier methods continued with the method (p greater than 0.05).

PIP: Pregnancy outcome in 56 patients who experienced contraceptive failure out of a pool of 5431 acceptors at the Family Planning Clinic of the Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Nigeria was analyzed during the period January 1981-December 1989. There were 40 IUD, 6 oral contraceptive, and 4 injectable failures. 3 patients had undergone voluntary surgical contraception (VSC) and 3 used barrier methods. The mean +or- SD age and parity were 32.2 +or- 4.4 years and 4.4 +or- 1.9, respectively. There were 17 (30.1%) live births, 34 (56.5%) pregnancy terminations, and 3 (5.2%) spontaneous abortions. 2 (3.0%) patients were lost to follow up. There was neither any statistically significant difference in the outcome of pregnancy between those patients with 5 or more children and less than 5 children (p.05), nor between patients less than 31 years old and those who were older. 50% of those who had used the IUD continued with that method; 7 patients subsequently requested VSC. None of the patients using injectables or barrier methods continued with that method (p.05).

The attitude of fertile Nigerian women to sterilization.

PIP: 250 women selected at random from outpatients of the Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Nigeria, were interviewed about their attitudes toward female sterilization by nurses with a standard questionnaire. Factors affecting attitudes toward sterilization were multiple and results are reported as percentages. The study population excluded women with infertility, a common problem, and further differed from the general population because the women were older and more highly educated. The number of living children was 3 or more in 59%; the ideal family size was at least 5 in 48%. 48% had used some type of contraception. 87.6% had heard of female sterilization, most often from medical personnel. Factors reported as affecting attitudes included: number of living children (59.6%); age of patient (52%); experience with complications of pregnancy and labor (45.2%); other medical disorders (36%); effect on reincarnation (17.6%); sex of living children (17.2%); fear of impotence (7.2%); and religion or culture (3.2%). The average age for female sterilization is 40 in Nigeria. A more extensive study of resistance to sterilization is indicated.^ieng

The hemoglobinopathies and pregnancy in Lagos.

Thirty-four patients with abnormal hemoglobin were studied through 42 pregnancies under one obstetrician. There were 30 patients with sickle cell anemia (HbSS), two with sickle cell hemoglobin C disease (HbSC) and two with homozygous hemoglobin C disease (HbCC). There were 39 live births (including one pair of twins), and four perinatal deaths. The patients with HbSC and HbCC had five uncomplicated pregnancies and deliveries. Of the 36 pregnancies in patients with HbSS one aborted at 12 weeks. Intra-uterine growth retardation (14.3%) and pregnancy-induced hypertension (14.3%) were the most serious pregnancy complications. No patient had more than one crisis. Only one out of the 10 patients transfused needed more than two units of blood throughout pregnancy. The mean gestation at delivery was 37.5 +/- 3.2 (S.D.) weeks. The mean birth weight was 2.7 +/- 0.6 (S.D.) kg. The perinatal mortality was 114.3 per thousand live births and there was one maternal death.

Antenatal iron supplementation in sickle cell disease.

Fourteen pregnant women with sickle cell disease (11 SS and 3 SC) were randomized into two groups to receive routine antenatal supplementation either with ferrous gluconate or with placebo tablets. Their hemoglobin levels and bone marrow iron content were determined prenatally and 6 weeks post partum. The fetal weights and the incidence of pain crisis in both groups were recorded. Using an iron content grading from 0 to 5, no marrow of any subject showed iron depletion. The placebo group showed an aggregate postnatal loss of 4 grades of iron repletion while the iron supplemented group showed an aggregate gain of 2 grades. There were no significant differences between the birth weight or the incidence of pain crises in both groups. We conclude that routine iron supplementation is not justified in pregnant women with sickle cell disease, as it would tend to increase already adequate or excessive iron body stores. We recommend that a clear need for iron should be established before iron supplementation is prescribed to them.

Interval out-patient female sterilization in Lagos.

Out-patient sterilization services were introduced by the Family Planning Clinic of the Department of Obstetrics and Gynaecology, College of Medicine, Lagos, in September, 1981. This paper reviews the results of the first five years of its availability. There were 96 out-patient interval sterilizations, 47 were by the laparoscopic and 49 by the minilaparotomy procedures, representing 0.7% of maternities. Both local and general anaesthesia was used for the procedures. The patients' ages ranged from 28-52 years, all but three being above 31 years. Their parity ranged from 2-15 with between 2-10 living children. Only five patients had less than four children. 37.5% had used no contraception before. Termination of pregnancy was performed at the same time as tubal ligation in 12.5%, and 75% of these were secondary to contraceptive failure. Three patients had emergency laparotomy although in only one was it related to the sterilization procedure. Three patients were observed for 24 hours with no complications. Two patients were re-admitted after one week with pelvic peritonitis. The major complication rate was 3.1%. The failure rate was one per cent. There have been no requests for reversal. The results are compared with those of patients having puerperal sterilization during the same period, who totalled 2% of the maternities.

PIP: Outpatient sterilization services were introduced by the Family Planning Clinic of the Department of Obstetrics and Gynecology, College of Medicine, Lagos, in September, 1981. This paper reviews the results of the 1st 5 years of its availability. There were 96 outpatient interval sterilizations, 47 were by the laparoscopic and 49 by the minilaparotomy procedures, representing 0.7% of maternities. Both local and general anesthesia was used for the procedures. The patients' ages ranged from 28-52 years, all but 3 being above 31 years. Their parity ranged from 2-15 with between 2-10 living children. Only 5 patients had less than 4 children. 37.5% had used no contraception before. Termination of pregnancy was performed at the same time as tubal ligation in 12.5%, and 75% of these were 2ndary to contraceptive failure. 3 patients had emergency laparotomy although in only 1 was it related to the sterilization procedure. 3 patients were observed for 24 hours with no complications. 2 patients were re-admitted after 1 week with pelvic peritonitis. The major complication rate was 3.1%. The failure rate was 1%. There have been no requests for reversal. The results are compared with those of patients having puerperal sterilization during the same period, who totalled 2% of the maternities.

Contraceptive choice in an urban clinic in Nigeria.

PIP: Contraceptive choice in the 1st 1075 acceptors at an urban clinic in Lagos, Nigeria is studied using clinical notes of all patients who attended the clinic between September 1, 1980 and August 31, 1983. Details of previous and current contraception, age, parity and level of education are analyzed. The IUD was the most popular choice followed by the injectable contraceptive and the pill. Interval tubal ligation was chosen by some patients. Acceptors of injectables were older women of high parity and lower educational standard while pill acceptors were of lower parity and higher educational level. The IUD was acceptable to all ages and parities except those with only 1 child or none. Loss to follow-up and the wish to plan another pregnancy were the commonest reasons for discontinuing contraception. Medical reasons for discontinuing the IUD were pain, menstrual disorder, accidental pregnancy and expulsion/perforation; for discontinuing injectables the reasons were menstrual disorder, accidental pregnancy and raised blood pressure. Of acceptors of the 3 main methods, former pill and IUD users were more likely to choose the same method again. A strategy should be devised to encourage patients of lower parities and age to use contraceptives, while sterilization in patients of parity 3 and above should be even more actively advocated. Greater effort should be made to support patients through the 1st 6 months after starting any method as this is the time when a large number of discontinuations occur.^ieng