Maternal serum vitamin D levels and pregnancy outcomes: from Lagos, Nigeria.

In an attempt to investigate the effect of vitamin D deficiency on pregnancy complications including caesarean section and foetal outcome in our population, blood samples of 461 pregnant women who attended antenatal booking clinic between 10 and 28 weeks of pregnancy were taken for vitamin D estimation and followed up. Details concerning pregnancy complications, labour and foetal outcome were obtained after delivery. They were divided into three groups according to the serum vitamin D level: group 1 (0-20)ng/ml (deficiency), group 2 (21-30)ng/ml (insufficiency), and group 3 (more than 30 mg/ml) normal. The prevalence of vitamin D deficiency was 29%. There were no differences between the groups regarding complications during pregnancy, including preeclampsia and rate of caesarean section. A multicenter study was advocated to elucidate further the role of vitamin D during pregnancy in our population.

Factors influencing CD4 cell count in HIV-positive pregnant women in a secondary health center in Lagos, Nigeria.

BACKGROUND: Immunity in pregnancy is physiologically compromised, and this may affect CD4 count levels. It is well-established that several factors affect CD4 count level in pregnancy. This study aimed to determine the mean and reference range of CD4 count in human immunodeficiency virus (HIV)-positive pregnant women in Lagos, Nigeria. METHODS: A retrospective study was carried out at antenatal clinics of the Maternal and Child Center of a secondary health center in Lagos State, Nigeria. Records of HIV-positive pregnant women at various gestational ages, including CD4+ cell count at booking, packed cell volume (PCV) at booking and labor, gestational age at delivery, and infant weight and sex were retrieved. The descriptive data was given as mean ± standard deviation (SD). Pearson's chi-squared test and correlation were used for analytical assessment. RESULTS: Data were retrieved for a total of 143 patients. The mean age was 31.15±3.78 years. The mean PCV was 31.01%±3.79% at booking and 30.49%±4.80% during labor. The mean CD4 count was 413.87±212.09 cells/µL, with a range of 40 to 1,252 cells/µL. The mean infant weight was 3.05±0.45 kg, with a range of 2 to 5 kg. Age of the mother, gestational age, and PCV at booking were not statistically significantly associated with CD4 count. CONCLUSION: Maternal age, gestational age, and PCV at booking had no significant effects on CD4+ cell count levels in pregnancy. The mean CD4+ cell count of HIV-positive pregnant women in Lagos is 413.87±212.09 cells/µL.

Risk factors and pregnancy outcome in different types of placenta previa.

OBJECTIVE: To compare risk factors and pregnancy outcome between different types of placenta previa (PP). MATERIALS AND METHODS: We conducted a retrospective study of 306 women presenting with PP over a 10-year period from January 1996 to December 2005. Differences between women with major and minor PP regarding age, parity, history of Caesarean section, antepartum hemorrhage, preterm deliveries, placenta accreta, Caesarean hysterectomy, operative complications, and neonatal outcome were identified using Mann-Whitney U test, chi-square test, and multivariate logistic regression. RESULTS: The overall incidence of PP was 0.73%. Major PP (complete or partial PP) occurred in 173 women (56.5%) and minor PP (marginal PP or low-lying placenta) in 133 women (43.5%). There were no differences between women with major and minor PP regarding age, parity, and previous miscarriages. After controlling for confounding factors, women with major PP showed a significantly higher incidence of antepartum hemorrhage (OR 3.18; 95% CI 1.58-6.4, P = 0.001), placenta accreta (OR 3.2; 95% CI 1.22-8.33, P = 0.017), and hysterectomy (OR 5.1; 95% CI 1.31-19.86, P = 0.019). Antepartum hemorrhage in women with PP was associated with premature delivery (OR 14.9; 95% CI 4.9-45.1, P < 0.001), more commonly in women with major PP. The only significant difference between women with major and minor PP regarding neonatal outcome was that major PP was associated with a higher incidence of admission to the neonatal intensive care unit (P = 0.014). CONCLUSION: Complete or partial placenta previa is associated with higher morbidity than marginal placenta previa or low-lying placenta.

Breech delivery before and after the term breech trial recommendation.

OBJECTIVE: To compare the outcome of breech delivery at term in women before and after the term breech trial (TBT) recommendation. METHODS: A retrospective study carried out at Abha Maternity Hospital, Abha, Kingdom of Saudi Arabia comprising 796 women with breech presentation at term who delivered at our hospital between May 1997 and February 2005 divided into 2 groups. Group 1 consisted of 394 patients who were delivered 4 years before the recommendation of the TBT, and group 2 comprised 402 patients delivered 4 years after the recommendation. RESULTS: There were no statistically significant differences between the 2 groups with regards to the mean maternal age and birth weight, p>0.05, however, parity, gestational age at delivery, booking status, and cesarean section (CS) rate reached statistically significant levels, p<0.05. Assisted vaginal delivery was conducted in 106 (26.9%) of patients in group 1 and 69 (17.1%) in group 2, this also was statistically significant. No statistically significant differences were found between the 2 groups regarding the perinatal mortality, low Apgar score, <7 at 5 minutes and complications during delivery, p>0.05. CONCLUSION: There was a dramatic increase in the rate of CS without a corresponding improvement in the neonatal outcome in the years following the TBT recommendation in our hospital. We suggest that the policy is formulated to reduce the number of unbooked patients with breech presentation at term in our community to reduce the CS rate in these groups of patients.

Removal of cervical mucus prior to embryo transfer improves pregnancy rates in women undergoing assisted reproduction.

The removal of cervical mucus during embryo transfer has been postulated to increase the pregnancy and implantation rates by not interfering with embryo implantation. Even so, this is a time-consuming procedure that may increase the incidence of difficult transfers by removing the naturally lubricant mucus. In addition, any cervical manipulations at the time of embryo transfer may cause unwarranted uterine contractions. In this prospective, controlled study, 286 women undergoing embryo transfer between January and May 2006 were divided into two groups according to whether the cervical mucus was scheduled to be aspirated (group A) or not (group B). The two groups were similar with regards to the demographics, cause of infertility, characteristics of ovarian stimulation and embryos transferred. Even so, the clinical pregnancy rate was significantly higher in group (A) than group (B) (OR = 2.18, 95% CI = 1.32-3.58), although there were easier transfers in group (B) than group (A) (OR = 3.00, 95% CI = 1.05-8.55). This demonstrates that even though embryo transfers were easier to perform when the cervical mucus was left in place, aspiration resulted in an increased chance of clinical pregnancy.

Multiple repeat caesarean sections: complications and outcomes.

OBJECTIVE: To compare the complications and outcomes of Caesarean section (CS) in women who have had three or more previous lower segment Caesarean sections with those in women with one previous CS. METHODS: We performed a retrospective study of 371 patients undergoing repeat CS. Of these, 115 (31%) had previously had three or more Caesarean sections (group 1) and 256 (69%) had previously had one CS (group 2). All 371 patients had the repeat CS performed at Abha Maternity Hospital, Saudi Arabia between June 2002 and May 2004. Demographic data, complications, and outcomes were compared using the Student t and chi-square tests. RESULTS: There were statistically significant differences between the two groups with respect to mean maternal age, parity, gestation at delivery, and experience of the surgeon (P < 0.05). CS was performed as an emergency in 38 (32.9%) and 186 (72.6%) of patients in groups 1 and 2 respectively (P < 0.05). The consultant was involved in the decision to perform CS in 215 (84.6%) of patients with one previous CS. There were significant differences between the two groups in the type of skin incision, the presence of dense adhesions during surgery, and bladder injury (P < 0.05). There were no statistically significant differences in birth weight, stillbirth rate, low Apgar score, blood loss during surgery, duration of surgery, or the duration of postoperative hospital stay. CONCLUSION: The prevalence of dense intra-abdominal adhesions and of bladder injury during CS was higher in women with a history of three or more previous CS than in women with one previous CS. Placenta previa and Caesarean hysterectomy occurred with equal frequency in each group, and wound dehiscence and uterine rupture were rare.

Emergency cervical cerclage. Does the gestational age make a difference?

OBJECTIVE: To investigate the effectiveness of emergency cervical cerclage in prolongation of pregnancy and its effect on pregnancy outcome in patients with cervical incompetence. METHODS: A retrospective review of patients who had an emergency cervical cerclage performed for cervical incompetence during the period from July 1995 to June 2002 was carried out in Abha General Hospital, Abha, Kingdom of Saudi Arabia. Twenty patients between 16 and 26 weeks of gestation with 1) cervical effacement, 2) cervical dilatation of < or =3 cm, 3) herniation of intact fetal membranes through the cervical os, 4) absence of established labor, and 5) absence of clinical evidence of infection were studied. The duration of cerclage in situ, gestation at delivery and birth weight were analyzed. RESULTS: The mean duration of cerclage in situ was 68.5 days. The mean gestation at delivery was 30.5 weeks and the mean birth weight was 1844 grams. The duration of cerclage in situ was significantly longer when the procedure was performed at or before 22 weeks of gestation with a p value of <0.02 (Mann-Whitney U test), but the difference in the gestation at delivery and birth weight was not significant. There was also a significant negative correlation between the gestation at cerclage and the duration of cerclage in situ (Spearman's correlation coefficient rs = -0.56, p<0.05). CONCLUSION: Emergency cervical cerclage in early second trimester effectively prolonged pregnancy compared to emergency cerclage performed in late second trimester.

Is recombinant follicle-stimulating hormone more effective in IVF poor responders than human menopausal gonadotrophins?

BACKGROUND: The objective of this study was to determine if the recombinant human follicle-stimulating hormone (rFSH) is more effective than human menopausal gonadotrophin (hMG) in IVF poor responders. MATERIAL/METHODS: A prospective comparative study over a 2-year period. The setting was the Tertiary IVF Center, King Faisal Specialist Hospital and Research Center. A total of 150 patients were selected from 277 patients with poor response in previous hMG-stimulated cycles who were willing to undergo another cycle of treatment. Seventy-five patients stimulated with rFSH were compared with 75 control subjects (matched for age, early follicular phase FSH, and body mass index) stimulated with urinary hMG. The number of follicles, number of oocytes retrieved, cycle cancellations, and pregnancy rates were the main outcome measures. RESULTS: There were no statistical differences in numbers of follicles (6.2 versus 5.7; p=0.97), oocytes recovered (4 versus 3.3; p=0.15), cycle characteristics, or pregnancy rates between hMG- and rFSH-stimulated cycles (p=0.32). CONCLUSIONS: Recombinant follicle-stimulating hormone (rFSH) has no advantage over urinary human menopausal gonadotrophin (hMG) on ovarian performance or the outcome of IVF-ET in poor responders' IVF cycles.

Right lower quadrant pain in females. Is it appendicitis or gynecological?

OBJECTIVE: To determine if a gynecological consultation is needed for patients who are labeled to have acute appendicitis. METHODS: A retrospective study carried out in Assir Central Hospital, Abha, Kingdom of Saudi Arabia. Fifteen female patients who were clinically diagnosed and operated upon for acute appendicitis were discovered intra-operatively to have unrelated gynecological lesions, are presented. RESULTS: Histopathological reports on the removed appendices revealed 80% "normal" and 20% "mildly inflamed". Seven (46.7%) of the patients had right ovarian cysts (one of them, bilateral); 4 (26.7%), corpus luteum cysts, and 4 had bilateral salpingitis, bilateral pyosalpinx, right ovarian cyst with bilateral salpingitis and ruptured right tubal pregnancy each. The majority (60%) of the women were in the 20-30-year-age bracket. CONCLUSION: The need for gynecological review of female patients of childbearing age presenting with lower abdominal pain is stressed. Ultrasonography is an important adjunct in improving diagnostic accuracy in such cases.

Assisted breech delivery, is the art fading?

OBJECTIVE: To review the modes of breech delivery over a 5 year period in Khamis Civil Hospital, Khamis Mushayt, Kingdom of Saudi Arabia, and to evaluate the trend and associated complications. METHODS: Relevant data was extracted from the delivery room records of all women delivered in Khamis Civil Hospital, Khamis Mushayt, Kingdom of Saudi Arabia, from 1st January 1996 through 31st December 2000. Available data was analyzed. RESULTS: There were 375 breech deliveries, constituting 2.8% of the entire deliveries in the hospital. Eighty-two percent of the breeches were delivered by cesarean section while 18% had assisted vaginal delivery (p=0.0193). Amongst 72 primigravidae breeches, 68 (94.4%) were delivered by cesarean section while 238 (78.5%) out of 303 multigravidae were delivered by cesarean section. There were 2 unexplained neonatal deaths among the vaginal delivery group in multigravidae. Cesarean delivery was associated with less morbidity compared to vaginal delivery. CONCLUSION: This study has demonstrated a significant increase in delivery of breeches by cesarean section and the resultant drop, in the number available for assisted breech delivery. Less obstetricians will therefore be exposed practically to the art of assisted breech delivery. Most practicing obstetricians seem to be more inclined towards delivering breeches by cesarean section. If this trend continues, the art of assisted breech delivery may fade.

Non puerperal inversion of the uterus in a teenager.

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