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Tropical Journal of Obstetrics and Gynaecology

Volume 18, Number 2, October 2001
Abstracts

Reproductive Health at the Turn of the Millennium: A Periscopic View of the Future

Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria.

After the tremendous changes in reproductive health care that occurred in the last century, it is a distinctly challenging task to try and predict what may lie beyond the horizon in the discipline. While recognising the roles of all stakeholders in the field of reproductive health, obstetricians and gynaecologists have a unique task in the provision of reproductive health care because pregnancy and childbirth are at the very core of the reproductive process. Gynaecologists also tend disorders of the female genital tract that may compromise this instinctual activity. The various sub-specialities of gynaecology that have evolved to deal with these health problems can be expected to develop further in the coming decades. With increasing super-specialisation, rapid advances can be expected. Hopefully, the humanity of specialists in the discipline will always take precedence over the application of scientific advances.

Key Words: Reproductive Health; Maternal Care; Genetics. [Trop J Obstet Gynaecol, 2001, 18: 50-51]

Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Nigeria.

Background: The outcome of labour depends to a large extent on the quality of intrapartum care given. Prompt arrival in hospital is essential for optimal care of parturient women. The causes and consequences of late arrival in labour have not been analysed in our setting.

Objective: To determine the causes and consequences of late arrival in hospital during labour.

Study Design and Setting: A case-control study in a university teaching hospital.

Methods: Data was collected from patients who delivered vaginally immediately after arrival in the labour ward (Subjects: N=150) and the next two consecutive patients who presented early in labour (cervical dilatation of 3-5cm) and had vaginal delivery (Controls: N=300)

Outcome Measures: Maternal complications such as perineal tears, frequency of episiotomy, blood loss and duration of stay in hospital. Apgar scores at 1 and 5 minutes, and neonatal hospital admission.

Results: Late arrival to the labour ward was significantly associated with high parity, low educational status, poor antenatal attendance and increased peripartum blood loss. However, early arrival was associated with a higher risk of having an episiotomy (Relative Risk: 2.5). The neonatal outcome was similar in both groups of patients.

Conclusion: High parity, low educational status and poor utilization of antenatal facility are risk factors for late arrival in hospital during labour. Late presentation was associated with increased blood loss at delivery.

Key Words: Labour, Late Presentation, Pregnancy Outcome. [Trop J Obstet Gynaecol, 2001, 18: 52-55]

Departments of ^#Medicine and *Obstetrics & Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria.

Context: Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance of variable severity, with onset or first recognition during the index pregnancy. Previous studies of the problem of pregnancy and diabetes in parts of Nigeria failed to distinguish between GDM (as defined) and pregnancy occurring in a previously diagnosed diabetic. Thus the actual prevalence of GDM in Nigeria antenatal populations is not known.

Objectives: To determine the prevalence of gestational diabetes mellitus and the pattern, behaviour, level of care and outcome of GDM pregnancies in a Nigerian antenatal population.

Study Design & Setting: Cohort observational study in a university teaching hospital.

Main Outcome Measures: Prevalence of GDM, glycaemic profile of GDM pregnancy, maternal and fetal complications, mode of delivery and outcome of GDM pregnancies.

Results: The GDM prevalence was 2.98 per 1000 pregnancies. Maternal age and gestational age at diagnosis (mean + SD) were 31.0 ± 2.4 years and 23.88 ± 8.2 weeks respectively. Fasting venous blood glucose level at diagnosis was 7.76 ± 1.6 mmol/L while the cumulative mean FVBG throughout pregnancy was 6.56 ± 0.79 mmol/L. Pre-eclampsia 26.7%, mid-trimester abortion 6.7%, intrauterine fetal death (IUFD) 6.7% were the major antenatal complications. Caesarian section rate was 10%, gestational age at delivery - 37.55 ± 1.94 weeks and birthweight - 3.75 ± 0.55 kg.

Conclusion: Prevalence of GDM in this antenatal population remains low (but within the global range of 0.15 — 3.0%). Overall care and metabolic control of GDM pregnancies in our population remain sub-optimal with attendant poor feto-maternal outcomes.

Key Words: Gestational Diabetes, Pregnancy Outcome, Glycaemia. [Trop J Obstet Gynaecol, 2001, 18: 56-60]

Departments of *Obstetrics & Gynaecology and **Medical Microbiology, University of Ilorin Teaching Hospital, P.M.B. 1339, Ilorin, Kwara State, Nigeria.

Context: Urinary tract infections (UTI) are commonly encountered in women and, often, antibiotics are prescribed before bacteriological results are available. There is therefore a need to determine empirical antibiotics suitable in such situations.

Objective: The aims of the study were to identify the pathogens causing UTI in pregnant and non-pregnant women, determine their antimicrobial sensitivity patterns and suggest appropriate empirical antimicrobial agents for use in such patients.

Study Design and Setting: A cross-sectional study at the Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Nigeria.

Methods: Urine samples of women suspected to have UTI were sent for microscopy, culture and sensitivity tests. The results were analyzed and the differences between the results of pregnant and non-pregnant patients were assessed, using the chi-square test.

Results: Escherichia coli was the predominant cause of UTI in both groups of women. Staphylococcus aureus (0.05>p>0.01), Proteus species (0.05>p>0.01) and Pseudomonas (0.05>p>0.01) were more likely to be isolated in non-pregnant women. Sultamicillin, azithromycin, nitrofurantoin, nalidixic acid, gentamycin and cotrimoxazole demonstrated ‘good’ to ‘very good’ effectiveness against the organisms. The more recent, expensive antibiotics like ofloxacin, ciprofloxacin, ceftriaxone and cefuroxime demonstrated ‘excellent’ effectiveness against the organisms. Antibiotics were generally more effective in clearing UTI in pregnancy.

Conclusions and Recommendation: Antibiotics for empirical treatment of UTI in this environment should be those with good to excellent activities as listed above. Consideration should be given to the severity of the infection, drug safety in pregnancy and cost-effectiveness in making the appropriate choice for each patient.

Key Words: Bacteria; Susceptibility; Urinary Tract Infection; Women. [Trop J Obstet Gynaecol, 2001, 18: 61-65]

Department of Obstetrics & Gynaecology, University of Calabar Teaching Hospital, Calabar.

Context: Eclampsia remains an important cause of maternal and perinatal morbidity and mortality throughout the world, particularly in developing countries. A constant review of treatment outcomes is therefore needed.

Objective: To document the relative risk of adverse pregnancy outcome in eclamptic women who delivered in our hospital (vaginal vs. abdominal) and to proffer measures for risk-reduction.

Study Design, Setting and Subjects: A comparative review of pregnancy outcome in women with eclampsia at the University of Calabar Teaching Hospital (UCTH), Calabar, over a 10-year period was conducted. Eighteen women who had abdominal delivery were compared with a control group of 11 who had vaginal delivery. Six women who had regional anaesthesia for abdominal delivery were compared with a control group of 12 cases that underwent general anaesthesia.

Outcome Measures: Adverse maternal outcome including maternal death; adverse fetal outcome.

Results: The relative risk (RR) of adverse fetal outcome with abdominal delivery was higher for parameters such as birth asphyxia (RR: 2.42), low birth weight (RR: 1.84) and neonatal death (RR: 1.22). The risk for adverse maternal outcome with abdominal delivery was also higher: hemiplegia (RR: 1.22), oliguria (RR: 1.84) and maternal death (RR: 1.22). The use of regional anaesthesia for abdominal delivery was associated with a risk of failed anaesthetic technique (RR: 2.00) and aspiration of gastric contents (RR: 1.20).

Conclusion: Eclampsia is a serious but preventable obstetric complication associated with poor pregnancy outcome. Current treatment protocol in our hospital has not resulted in improved outcome, especially in eclamptics delivered by caesarean section.

Key Words: Pregnancy, Eclampsia, Anaesthesia, Outcome. [Trop J Obstet Gynaecol, 2001, 18: 66-68]

Departments of *Obstetrics & Gynaecology, **Paediatrics and ***Pathology, Federal Medical Centre, Abeokuta, Nigeria and ^#Regional Centre for Quality of Health Care, Makerere University, Kampala, Uganda.

Context: Haemolytic disease of the newborn, a problem that has not been sufficiently investigated in the Nigerian population, leads to significant perinatal morbidity and mortality.

Objectives: To determine the incidence of Rhesus (Rh) isoimmunization and the utilisation rate of Rh-immunoprophylaxis in our population.

Methods: A review of the clinical records of all Rh-negative pregnancies, booked at the Federal Medical Centre, Abeokuta between July, 1996 and June, 2000. The mothers’ and infants’ records were analysed for age, parity, ante-natal antibody status and some selected characteristics in the infant.

Results: Seventy-seven Rh-negative pregnancies were managed, accounting for 2.6% of the total obstetric population. Those who received immuno-prophylaxis following previous abortions and deliveries were 15.4 % and 38.2% respectively. Initial testing, at booking, for sensitization was not done in 36.5% of the women, while 63.4% had no follow-up testing. The incidence of ante-natal sensitization was 1.3%. The time of onset of neonatal jaundice was 26.5 + 14.6 hours (mean + SD) in Rh-positive infants, compared to 44.4 + 17.8 hours in Rh-negative infants (p = 0.07). The haematocrit of both groups of infants were similar [42.8 + 5.8 versus 44.5 + 5.3; p = 0.6]. There was no perinatal death. The partners’ Rh-status was determined in 59.7% and the infants’ Rhesus group in 71.6%. Immunoprophylaxis rate was poor (44.8%). The majority of those who declined immunoprophylaxis did so for financial reasons.

Conclusion: The risk of haemolytic disease of the newborn with its attendant perinatal morbidity and mortality is real in our community, yet the rate of Rh-immunoprophylaxis remains quite low in our obstetric population.

Key Words: Rhesus Blood Group, Pregnancy, Isoimmunisation. [Trop J Obstet Gynaecol, 2001, 18: 69-72]

Department of Obstetrics & Gynaecology, University of Ilorin Teaching Hospital, Maternity Hospital Wing, Ilorin, Nigeria

Context: Teenage pregnancy is a major health and social problem the world over and its incidence is on the increase. One important contributory factor to the increase is non-use of contraception.

Objective: To determine knowledge of and previous contraceptive use by pregnant teenagers in Ilorin, Nigeria.

Subjects and Methods: Between 1^st January and 30^th June, 1999, 326 consecutive pregnant teenagers that booked for antenatal care at University of Ilorin Teaching Hospital, Ilorin, Nigeria were interviewed with the aid of a pre-tested questionnaire administered by resident doctors. Information obtained included demographic characteristics, knowledge of and previous use of contraception.

Results: Respondents displayed a high level of contraceptive knowledge, as 277 (91.7%) were aware of it. The condom and the combined oral pill were the two contraceptive methods most commonly known, by 254 (85.5%) and 225 (78.8%) of the respondents respectively. Only 53 (16.3%) had previously used any contraceptive method. The combined oral pill was the commonest method ever used by the respondents 29 (54.7%). Friends were the most common source of information about contraception in 135 (45.5%). None of the respondents used any contraceptive method prior to or during their first sexual experience. Fear of side effects was the commonest reason for non-use of contraception

Conclusion: Pregnant teenagers are quite knowledgeable about contraceptive method but are poor users. Family life education, including contraception should be provided for teenagers and incorporated into the curricula of schools and colleges. Clinics where comprehensive reproductive health services are provided for teenagers should also be established.

Key Words: Contraception, Teenagers, Pregnancy, Knowledge. [Trop J Obstet Gynaecol, 2001, 18: 73-77]

*Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria and ** Park Lane General Hospital, Enugu, Nigeria

Context: Cervical malignancy is the commonest genital tract malignancy in Nigeria. In the absence of a national screening programme, any hope of minimising death from invasive cervical carcinoma in Nigeria is through increased opportunistic cervical screening by physicians. Recent evidence showed a high awareness but a low practice of cervical screening among Nigerian women, a situation that the respondents attributed to poor physician referral.

Objective: To study the attitude toward and practice of cervical cancer screening amongst Nigerian gynaecologists, on whom the burden of treating cervical cancer rests.

Study Design, Setting and Subjects: A self-administered, questionnaire survey of 113 Nigerian gynaecologists who attended the Annual General Meeting and Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) held in Abuja in November 2000.

Results: The 86 (76.1%) gynaecologists who practised in centres with cervical screening services estimated that they screened 15.0 + 18.9% of their gynaecology patients. Pap smear was available to 85 (76.1%) gynaecologists, colposcopy to 28 (32.6%), direct visual inspection (after applying 5% acetic acid solution) to 16 (18.6%), human papillomavirus (HPV) DNA testing to 2 (2.3%) and cervicography to 1 (1.2%). Thirty gynaecologists had definite cervical screening programmes, most of which were selective and based on specific indications. All the respondents favoured a national cervical screening programme.

Conclusion: Despite general agreement amongst Nigerian gynaecologists on the need for a national cervical screening programme, their level of opportunistic screening of patients is currently low. A plea is made for increased opportunistic screening pending the establishment of a national screening programme.

Key Words: Cervical Screening, Smears, Gynaecologists, Nigeria. [Trop J Obstet Gynaecol, 2001, 18: 78-81]

Departments of *Obstetrics & Gynecology, and ^#Anaesthesiology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria,

Background: Ectopic pregnancy continues to be a major surgical emergency in gynaecology.

Objective: To determine the incidence, clinical pattern, surgical management, morbidity and mortality from ectopic pregnancy in a Nigerian tertiary health care center.

Study Design, Setting and Subjects: The case files of 149 patients who had ectopic pregnancy between 1990 and 1997 at a University Teaching Hospital, were reviewed for biological, social and clinical data.

Results: The frequency of ectopic pregnancy was 1 in 71 deliveries (1.4%). Being married, in the age group 25-29 years, nulliparous and never practiced contraception were found to be risk factors. Abdominal pain (87.2%) and abnormal vaginal bleeding (57.4%) were the commonest symptoms, while circulatory collapse occurred in 10.7% of patients. Diagnostic differentials ranged from acute pelvic inflammatory disease (PID) and threatened abortion to ruptured uterus. Nearly all (96%) of the gestational sacs were ruptured before presentation. In 97 (67%) of the patients, there was macroscopic evidence of PID. More than 90% of the pregnancies were tubal, with 88% of these being located in the ampulla. Abdominal pregnancy occurred in 4 patients. Unilateral partial salpingectomy was done in 104(69.79%) patients, and 2 live mature fetuses were delivered at laparotomy. One maternal death occurred among the patients.

Conclusion: The frequency of ectopic pregnancy is still high in this environment. Early presentation, high index of suspicion and use of modern diagnostic techniques will improve overall clinical outcome in patients. Promotion of family planning, early treatment of PID and good quality obstetric care could be important preventive intervention measures.

Key Words: Pregnancy, Gestational Sac, Ectopic, Tubal, Rupture. [Trop J Obstet Gynaecol, 2001, 18: 82-86]

Departments of *Obstetrics & Gynaecology, **Medical Microbiology, ^#Surgery (Urology Unit) and ^##Histopathology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria.

Context: Infertility is a frequent reproductive health problem in this environment. Abnormalities of seminal fluid may be found in up to 60% of infertile couples. Various factors are known to be responsible for seminal fluid abnormalities. Local studies on this very important health problem are few.

Objective: The objective of this study was to determine the magnitude of male contribution to infertility in North Eastern Nigeria and the factors responsible.

Study Design, Setting and Subjects: A descriptive study of 704 males with abnormal seminal fluid profile who were investigated at a university teaching hospital over a 12-month period. Relevant past medical history, physical examination and investigation results were extracted from the patients’ case records.

Results: A total of 1201 seminal fluid analyses were conducted during the study period. Abnormalities were detected in the seminal fluid of 704 (58.6%) patients. Male factors were the only identifiable cause of infertility in 70% of the cases. Azoospermia (12.8%) and oligozoospermia (26.8%) were the most frequent semen abnormalities found. Varicocoele (13.9%), previous groin surgery (16.8%) and chronic urethritis and/or male accessory gland infection (5.5%) were the main associated clinical findings in the patients.

Conclusion: Male factor contributes significantly to infertility in this environment. The treatment of infertility using conventional methods have very low success rates while recent technologies are expensive and not readily available in this environment. It is therefore necessary for us to understand the various factors that contribute to male infertility in our environment so as to develop preventive strategies.

Key Words: Male Factor, Infertility, Semen Analysis. [Trop J Obstet Gynaecol, 2001, 18: 87-90]

Extrauterine Decidual Reaction in Pregnancy Presenting as an Acute Abdomen: A Case Report

John E. Ekabua*, Itam H. Itam*, Etim E.J. Asuquo*, Saturday J. Etuk*, A.U. Eiuma^# and P Jubrin^##

Departments of *Obstetrics and Gynaecology, ^# Surgery and ^##Pathology, College of Medical Sciences, University of Calabar Teaching Hospital, Calabar.

Ectopic decidua is usually an incidental finding at caesarean section and is not usually associated with symptoms. A 37-year-old multiparous patient presented with features of acute abdomen in the third trimester of pregnancy. Laparotomy revealed haemoperitoneum of about 2 litres, multiple pelvic adhesions and nodular lesions (measuring 2-4mm across) on the serosa of the uterus. Histology of biopsy specimens from the lesions showed them to be decidual in nature. Postnatal examination at 6 weeks revealed a healthy looking lady with complete involution of pelvic organs.

Key Words: Decidua, Acute Abdomen, Haemoperitoneum. [Trop J Obstet Gynaecol, 2001, 18: 91-92]

Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria.

A rare case of vulva fibroma in a 35 year-old woman is presented. She had a non-tender, firm mass arising from the superior aspect of the left vulva. It was about 24cm long, with fleshy pedicle that had a club-like ending with a crater-like area of ulceration. She also had uterine fibroids. Histological examination of the tissue following excision confirmed its benign nature.

Key Words: Vulva, Fibroma, Ulceration