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

RISK FACTORS FOR HEPATITIS B VIRUS INFECTION DURING PREGNANCY IN SOUTH EASTERN NIGERIA.

OBJECTIVE: To determine the seroprevalence of hepatitis B surface antigen (HBsAg) and possible risk factors in pregnant women. DESIGN: A cross-sectional serological survey of women attending antenatal clinics. SETTING: Five antenatal clinics in Aba, South Eastern Nigeria. SUBJECTS: Eight hundred and ten consecutive and consenting antenatal clinic attendees over the period 15 June-15 November 2010. MAIN OUTCOME MEASURES: For each pregnant woman, the medical and sociodemographic data were documented. Hepatitis B surface antigen seropositivity determined. RESULTS: Twenty two (2.7%) of the 810 subjects were found to be HBsAg seropositive and asymptomatic. Maternal age, parity, educational level attained, marital status, history of blood transfusion, intravenous drug use, tattooing, jaundice in the past and Human Immunodeficiency Virus seropositivity did not show any association with HBsAg sseropositivity. CONCLUSION: HBsAg seropositive women in the study were asymptomatic and showed no associationwith the medical and sociodemographic characteristics examined. These findings affirm the recommendation for universal HBsAg screening in pregnancy and imply that screening on the basis of the presence of risk factors alone may be insufficient.

IS MISOPROSTOL A SUITABLE ALTERNATIVE TO THE SURGICAL EVACUATION OF INCOMPLETE ABORTION IN RURAL SOUTH-EASTERN NIGERIA?

BACKGROUND: Research has demonstrated the effectiveness of misoprostol for treatment of incomplete abortion. However, few studies have focused on the feasibility of treating incomplete abortion with misoprostol at the rural clinic level in sub-Saharan Africa. OBJECTIVE: To determine the effectiveness, safety and acceptability of misoprostol as an alternative to the surgical treatment of incomplete abortion at a rural clinic. DESIGN: Open-label randomised controlled trial. SETTING: A private clinic in Ekeakpara community, Osisioma Ngwa Local Government Area, Abia State, Nigeria. SUBJECTS: Women of reproductive age presenting with incomplete abortion. RESULTS: Regardless of treatment allocation, nearly all women had a complete uterine evacuation with either oral misoprostol or manual vacuum aspiration (misoprostol: 98.8%, MVA: 100%, P = 0.99). Misoprostol users were more likely to report that they were'very satisfied'with the method (75.6% versus 45%, P<0.001). In the 72 hours after treatment, women using misoprostol reported heavier bleeding but lower levels of pain than those treated with manual vacuum aspiration. Women in the misoprostol group were more likely to choose that treatment again (96.9 versus 55.6%; P<0.001) and would recommend it to a friend. CONCLUSION: For treatment of first-trimester uncomplicated incomplete abortion at a rural facility, both MVA and 600 µg oral misoprostol are safe, effective, and acceptable treatments. Depending on availability of each method and the desires of individual women, either option may be presented to women for the treatment of incomplete abortion.

Grandmultiparity and pregnancy outcome in Aba, Nigeria: a case-control study.

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and perinatal outcomes among women who had delivered five or more times (grandmultiparous) with those of age-matched controls who had delivered two to four times (multiparous). DESIGN: A case-control study. SETTING: A tertiary referral hospital in Aba, Nigeria. SAMPLE: Seven hundred and thirty-four grandmultiparous women were compared with 734 age-matched multiparous controls. METHODS: Maternal case records were retrieved from medical records department and analyzed with additional information obtained from the labor ward records. Statistical analysis was done using EPI info version 6; χ² test was used to analyze categorical variables. RESULTS: Grandmultiparity was associated with a significantly higher risk of antenatal anemia (P < 0.05), multiple pregnancy (P < 0.01), fetal macrosomia (P < 0.01), perinatal mortality (P < 0.01), and primary postpartum hemorrhage (P < 0.05). A significantly higher rate of cesarean deliveries was observed in the multiparous controls (P < 0.01), than the grandmultiparous women. CONCLUSION: Our study shows that there is an increased risk of antenatal anemia, multiple pregnancy, primary postpartum hemorrhage, and adverse perinatal outcomes in grandmultiparous women independent of maternal age.

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.

Rupture of the uterus in a primigravida: a case report.

Uterine rupture during a first pregnancy is rare. We present the case of spontaneous intrapartum uterine rupture in a 40 year old primigravida with no prior uterine surgery, and a structurally normal uterus. The patient had obstructed labor. Operative findings were a male fresh stillbirth weighing 3800 g, massive hemoperitoneum, and an anterior transverse rupture at the lower uterine segment. Repair of the rupture was done without bilateral tubal ligation. Although a rare event, the primigravid uterus is not immune to rupture as exemplified by this report.

Fetal macrosomia in African women: a study of 249 cases.

OBJECTIVES: To determine the incidence and risk factors of macrosomia in a Nigerian centre, and to assess the relation of maternal body mass index (BMI) at birth and of the total weight gain during pregnancy to macrosomia and adverse pregnancy outcome. DESIGN: A retrospective review of fetal macrosomia over a 5-year period. SETTING: Abia State University Teaching Hospital, Aba in Southeast Nigeria. SUBJECTS: A total of 9,970 parturients managed from 1 January 1999 to 31 December 2003. Out of 249 documented cases of infants with birth weights > or =4,500 g, 240 (96.4%) maternal and neonatal records of macrosomia were available for review. Maternal and neonatal characteristics of the 240 cases were compared with 8,800 other parturients with singleton fetuses in vertex presentation. RESULTS: Macrosomic babies represented 2.5% of the infants delivered (249 of 9,970). Most of the mothers (92.5%) were multiparous. Maternal median weight gain was 11 kg (7-15), while the mean weight gain was 12.5 kg. Maternal median BMI was 28.1 kg/m(2) at delivery, while the mean BMI was 30.3 kg/m(2) (range 23-40) at delivery. Macrosomia was suspected in 80% on the basis of clinical examination, sonography, and the presence of the following risk factors in association: previous delivery of an infant weighing >4,000 g (62.5%), maternal weight at booking of more than 80 kg (90%), maternal BMI before delivery of > or =28 kg/m(2) (50%), gestational diabetes mellitus (2.5%), and weight increase of more than 13 kg during pregnancy (5%). The mean birth weight of the babies was 4,750 g (4,500-5,000). The overall CS rate was 15%. The difference in the CS rate between these mothers and the control was not significant (P = 0.41). Only 9 (3.8%) mothers were successfully delivered with the aid of ventouse due to delayed second stage of labor. There was a significant difference in the complication rates between the mothers of large infants and the control (P < 0.001). Four maternal deaths were associated with macrosomia for a maternal mortality rate of 1667/100,000. Four infants had shoulder dystocia and associated injuries. The perinatal mortality rate was 112.5/1,000 births. CONCLUSIONS: The higher the total body weight at birth, the higher the rate of macrosomia. Macrosomia had implications for high morbidity and mortality in the mothers and their infants. Delivery methods need to be evaluated. Caesarean section should be more readily used.

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.

Knowledge of genital herpes infection among antenatal clinic attendees in South-Eastern Nigeria.

BACKGROUND: Herpes simplex virus (HSV) is a major cause of genital ulcer disease worldwide and a significant factor for increased risk of acquisition and transmission of the Human Immune Deficiency Virus (HIV). The determination of the level of knowledge of genital herpes is necessary for the design and implementation of its specific preventive strategies as well as the reduction of the contribution of genital herpes to HIV transmission. OBJECTIVE: To determine antenatal women's knowledge on genital herpes infection. DESIGN: A cross sectional descriptive study. SETTING: Antenatal clinic of Abia State University Teaching, Hospital, Aba, Nigeria. SUBJECTS: Three hundred and fifty consecutive and consenting antenatal clinic attendees of Abia State University Teaching Hospital (ABSUTH), Aba, South Eastern, Nigeria. RESULTS: Seventy nine respondents (22.6%) had ever heard of genital herpes whilst sixty two (17.7%) had ever had recurrent blisters around their genitals. Two hundred and sixteen respondents (61.7%) reported having had cold sores or blisters around the lips or mouth following an episode of fever. Seventy four (21.1%) of the respondents knew that the virus that causes cold sores or blisters can be sexually transmitted. Higher educational levels attained and occupations other than being a housewife or farmer were associated with a greater awareness of genital herpes (p < 0.05) among the subjects. CONCLUSION: The antenatal attendees showed a poor knowledge of genital herpes infection. Discussion of genital herpes should be considered in the antenatal clinic setting along with the counselling of pregnant women regarding genital herpes, HIV infection and maternal-to-child transmission of both HSV and HIV.

Pregnancy outcome in booked and unbooked mothers in South Eastern Nigeria.

BACKGROUND: In order for individual health institutions in Nigeria to contribute towards the achievement of the Millennium Development Goals (MDG) with regards to maternal health, there is need for research on the local causes of and factors influencing adverse maternal outcomes. This would enable care providers and policy makers appreciate the burden of the problem and know where to focus as they distribute resources. OBJECTIVES: To compare the socio-demographical characteristics, obstetrical complications and foetal outcome in booked verses unbooked mothers who delivered at this hospital. DESIGN: A hospital based retrospective study. SETTING: The Abia State University Teaching Hospital (ABSUTH), Aba in South Eastern Nigeria. SUBJECTS: Three thousand, seven hundred and thirty four mothers who delivered in the hospital between 1st January 2005 and 31st December 2007. RESULTS: Unbooked mothers constituted 17.0% of the 3734 deliveries in the studied period. Compared to booked mothers, unbooked mothers were younger in age (28.2 +/- 5.80 vs. 29.3 +/- 6.04; p<0.001) and had a lower educational status (P<0.001). Majority of the unbooked were of lower social class; p<0.001. Unbooked mothers had a statistically significant higher incidence of pre-eclampsia/eclampsia (OR 3.88; 95%CI 2.61-5.77; p<0.001) and were 13 times more likely to die in the hospital than booked patients (OR: 13.54; 95%CI: 6.89-27.03); p<0.0001). Unbooked mothers were about half as likely to deliver by spontaneous vaginal delivery compared to booked mothers (OR 0.64; 95%CI 0.55-0.73; P<0.001) and eight times more likely to be delivered by emergency laparotomy due to uterine rupture than booked mothers (OR 8.80; 95%CI 3.84-20.55; P<0.001). Unbooked mothers were nine times more likely to have babies with birth asphyxia. CONCLUSION: The study showed a positive correlation between lack of proper antenatal care and adverse pregnancy outcome with poorer outcomes in unbooked than booked patients. Improving the availability and accessibility of quality antenatal and delivery care services in our environment will improve pregnancy outcome.

Factors influencing the use of episiotomy during vaginal delivery in South Eastern Nigeria.

BACKGROUND: Given considerable evidence that routine episiotomy increases maternal morbidity and without evidence to support maternal or neonatal benefit, has episiotomy use changed among health care providers? To date, very limited information exists relating to the past and current practice of episiotomy in many developing countries. OBJECTIVE: To determine the prevalence of episiotomy at Aba in South Eastern Nigeria, examine factors influencing the performance of episiotomy and document complications associated with the procedure. DESIGN: A hospital based retrospective study. SETTING: The Abia State University Teaching Hospital (ABSUTH), Aba in South Eastern Nigeria, from January 2001 to December 2005. SUBJECTS: Four thousand, one hundred and seventy two mothers who delivered vaginally within the study period. RESULTS: There were 1877 episiotomies, for an episiotomy rate of 45%. Ninety per cent of the primigravid parturients had episiotomy. Women undergoing episiotomy were younger (mean age 24.7 years; range 16-37) than women without episiotomy (mean age 28.5 years, range 20-43). When controlled for parity and maternal age, other risk factors were occipito-posterior position, vacuum extraction, forceps delivery, vaginal breech delivery, and a history of Caesarean section. Episiotomy use was also associated with major perineal lacerations and increased length of hospital stay. CONCLUSION: The episiotomy rate of 45 per 100 vaginal deliveries in this study is obviously higher than evidence-based recommendations for optimal patient care. A policy of systematic reduction in the incidence of episiotomy can be pursued in this hospital. Greater attention needs to be paid to selection of women to undergo episiotomy.

Practice of antenatal clinical breast examination as a method of early detection of breast cancer by health care providers in a low resource setting.

BACKGROUND: Clinical breast examination (CBE) provides an important screening tool for the earlier detection of breast cancer among women in populations such as ours where mammography is not widely available as a screening tool. There is a paucity of data on the level of practice of antenatal CBE by health-care providers at Aba, South Eastern Nigeria. OBJECTIVE: To determine the level of practice of antenatal CBE by health-care providers as a method of early detection of breast cancer. METHOD: A descriptive study involving 100 consecutive and consenting patients at the antenatal clinic of Abia State University Teaching Hospital, Aba, South Eastern Nigeria over the period 1 June-15 June 2007 was carried out. Using a structured questionnaire, the respondents' socio-demographic data were obtained, as well as their knowledge of breast cancer and of what breast cancer examination screens for, and self-reported data on their having ever received CBE during the current antenatal period. RESULTS: The knowledge of breast cancer was poor. Although 99% of the women had heard of breast cancer, only 34% of them knew what breast examination screened for, whilst only 1 and 2% had received CBE by doctors and nurses, respectively, during the current antenatal period. No breast abnormalities or suspicious nodes were detected during the antenatal CBEs. CONCLUSION: The level of practice of routine antenatal CBE by health-care providers is very low in our setting. Health-care providers should perform a thorough breast examination at the first prenatal visit and maintain a high index of suspicion for breast cancer throughout pregnancy.