Efficacy of Tranexamic Acid in Reducing Myomectomy-Associated Blood Loss among Patients with Uterine Myomas at Federal Teaching Hospital Abakaliki: A Randomized Control Trial.

Background: Myomectomy can be associated with life-threatening conditions such as bleeding. Excessive bleeding usually necessitates blood transfusion. Interventions to reduce bleeding during myomectomy will help reduce the need for blood transfusion with its associated complications. Tranexamic acid has been used to reduce bleeding in other surgical procedures, and its usage during myomectomy merits evaluation. Objective: To assess the efficacy of tranexamic acid in reducing myomectomy-associated blood loss. Materials and Methods: This is a prospective double-blinded randomized trial conducted on women who had abdominal myomectomy. Patients were randomized into two groups. The study group received perioperative intravenous tranexamic acid (TXA) while the control group received a placebo. Intraoperative blood loss was calculated by measuring the volume in the suction apparatus and weighing the surgical swabs. In addition, blood collected postoperatively from the wound drains and drapes were measured. Haemoglobin concentrations were determined preoperatively and on second postoperative day for all cases. Any adverse effect was noted in both groups. The data was processed using Epi Info software (7.2.1, CDC, Atlanta, Georgia). The relationships between categorical data were analyzed using X2 and Student's t-test to determine relationships between continuous variables, with a P value of 0.05 considered statistically significant, and correlation coefficients were calculated using Pearson's formula, and probability of 0.05 was set for statistical significance. Results: Symptomatic uterine myomas constituted 17.3% of all gynaecological admissions and 21.3% of gynaecological operations at Federal Teaching Hospital Abakaliki. The mean intraoperative blood loss among patients that had perioperative tranexamic acid infusion was 413.6 ± 165.6 ml, while that of patients with placebo infusion was 713.6 ± 236.3 ml. Perioperative tranexamic acid infusion therefore reduced mean intraoperative blood loss by 300 ml, and this was statistically significant (SMD = -0.212, 95% CI: -403.932 to -196.067, P < 0.0001). Perioperative tranexamic acid reduced mean total blood loss by a value of 532.3 ml, and this is statistically significant (SMD = 30.622, 95% CI: 393.308 to 670.624, P < 0.0001). Tranexamic acid also improved postoperative haemoglobin concentration by 1.8 g/dl compared with placebo, and this is statistically significant (SMD = -0.122, 95% CI: 1.182 to 2.473, P < 0.0001). Tranexamic acid infusion decreased hospital stay by about 2 days, and this difference was statistically significant (SMD = -3.929, 95% CI: -3.018 to -0.983, P = 0.0003). There was no adverse drug reaction in the course of the study. Conclusion: The use of tranexamic acid during myomectomy reduced intraoperative and postoperative blood loss. It is also associated with decreased hospital stay. This trial is registered with NCT04560465.

What is needed to improve quality of implant removal services in Nigeria? results of a landscape assessment.

Introduction: Stunning recent increases in subdermal contraceptive implant use, especially in sub-Saharan Africa, necessitate availability of quality implant removal services. In Nigeria, service delivery capacity and coverage for removal are lacking, despite strong government commitment and rapid uptake; there is a dearth of knowledge about barriers to quality implant removals in Nigeria. Methods: To determine access to and quality of contraceptive implant removal services, a landscape assessment was conducted in two states in Nigeria, focusing on four conditions for quality delineated in the Global Implant Removals Task Force framework. This mixed-methods approach integrated results from a desk review, a survey of health facilities and family planning managers, review of implant service statistics, and key informant interviews with providers and diverse stakeholders. Results: Seventy percent of providers (N = 21 of 30) had experienced problems performing implant removal, usually due to deeply inserted implants and equipment shortages. Providers had low confidence in performing removal and poor knowledge of implant removal steps. No facilities assessed had comprehensive equipment required for implant removal. Few facilities maintained systems or referral pathways to support difficult removals; difficult removals are absent from training manuals, and no formal trainings have been conducted. While most facilities collect data on removals, family planning dashboards do not capture it; few facilities use data for quality improvement. Conclusion: This study identified numerous challenges to quality implant removal, including poorly trained providers, inadequate supplies, underutilization of data on removals, and inability to manage difficult removals. As demand for implant removals skyrockets, providers need improved training in implant removal, appropriate job aids, supportive supervision, and effective procurement systems to ensure availability of supplies and equipment for removal. Tracking removals and reasons for removal in information systems and the Family Planning dashboard could sensitize providers to need for implant removals and improve data for decision-making in facilities and health systems.

Analgesic efficacy and safety of paracervical block versus conscious sedation in the surgical evacuation of the uterus following first-trimester incomplete miscarriages: A randomised controlled trial.

Objective: To compare the analgesic efficacy and safety of paracervical block and conscious sedation in the surgical evacuation of the uterus following a first-trimester miscarriage. Methods: This is an open-label, randomised control trial comparing pain relief by paracervical block versus conscious sedation during manual vacuum aspiration of first-trimester incomplete miscarriages. One-hundred and sixty-two women were equally randomised into two groups. Group A (paracervical group) received a paracervical block of 4 ml of lidocaine each at the 4 and 8 o'clock positions. Group B (conscious sedation group) received intravenous 30 mg pentazocine and 10 mg diazepam. Data obtained were presented using a frequency table, student t-test, chi-square and Mann-Whitney test and bar chart. A P-value of ⩽0.05 was taken to be statistically significant. Results: The mean pain score was lower in the paracervical block group compared to the conscious sedation group (P < 0.05); however, there was no significant difference in women's satisfaction between the groups (P ⩾ 0.05). Conscious sedation had more negative side effects compared to paracervical block which was significant (P < 0.05). Conclusion: Paracervical block has better pain control compared with conscious sedation and has a good side effect profile. Trial registration: Pan African Clinical Trial Registry (registered trial no. PACTR202108841661192). Synopsis: Paracervical block for manual vacuum aspiration (MVA) during first-trimester miscarriage is associated with less pain among women compared with conscious sedation.

A standardised Phase III clinical trial framework to assess therapeutic interventions for Lassa fever.

BACKGROUND: Only one recommendation currently exists for the treatment of Lassa fever (LF), which is ribavirin administered in conjunction with supportive care. This recommendation is primarily based on evidence generated from a single clinical trial that was conducted more than 30 years ago-the methodology and results of which have recently come under scrutiny. The requirement for novel therapeutics and reassessment of ribavirin is therefore urgent. However, a significant amount of work now needs to be undertaken to ensure that future trials for LF can be conducted consistently and reliably to facilitate the efficient generation of evidence. METHODOLOGY: We convened a consultation group to establish the position of clinicians and researchers on the core components of future trials. A Core Eligibility Criteria (CEC), Core Case Definition (CCD), Core Outcome Set (COS) and Core Data Variables (CDV) were developed through the process of a multi-stakeholder consultation that took place using a modified-Delphi methodology. RESULTS: A consensus position was achieved for each aspect of the framework, which accounts for the inclusion of pregnant women and children in future LF clinical trials. The framework consists of 8 core criteria, as well as additional considerations for trial protocols. CONCLUSIONS: This project represents the first step towards delineating the clinical development pathway for new Lassa fever therapeutics, following a period of 40 years without advancement. Future planned projects will bolster the work initiated here to continue the advancement of LF clinical research through a regionally-centred, collaborative methodology, with the aim of delineating a clear pathway through which LF clinical trials can progress efficiently and ensure sustainable investments are made in research capacity at a regional level.

Birth Preparedness and Complication Readiness among Pregnant Women in a Secondary Health Facility in Abakaliki, Ebonyi State, Nigeria.

BACKGROUND: Birth preparedness and complication readiness (BP/CR) concept is based on the premise that preparing for birth and being ready for complications reduce all three phases of delay to a bad obstetric outcome. OBJECTIVES: To determine the knowledge of BP/CR with its determinants and BP/CR index among pregnant women in Abakaliki, southeast Nigeria. METHODS: A cross-sectional survey was done between 1st March 2019 and 31st July 2019 among 450 randomly selected antenatal attendees at Mile Four Hospital, Abakaliki, Nigeria. The data were obtained using a pretested interviewer-administered structured questionnaire adapted from the maternal and neonatal health program handbook of the Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO). The data obtained were analyzed using percentages, chi-square, and odds ratios. The level of significance is at P value < 0.05. RESULTS: The birth preparedness and complication readiness index was 41.9%. Only 44.9% and 36.9% of the study population had adequate knowledge of birth preparedness (BP) and complication readiness (CR), respectively. Upper social class, lower educational level, urban residence, and less than 30 years of age were associated with increased odds of respondents having adequate knowledge of BP and CR (P > 0.05). However, only booking in the 1st or 2nd trimester was a significant determinant of the respondent's adequate knowledge of BP (AOR = 0.63, 95% CI 0.40-0.98) and CR (AOR = 0.62, 95% CI 0.39-0.97). Identification of transport and saving of money was the commonest birth plan while the commonest danger sign known to the participants was bleeding. CONCLUSION: This study revealed that knowledge of BP/CR is suboptimal. The determinant of this knowledge is antenatal booking. It is recommended that women should have adequate antenatal care education to improve their knowledge of BP/CR. This will help to increase the low BP/CR index seen in our study.

Lassa fever in pregnancy with a positive maternal and fetal outcome: A case report.

BACKGROUND: The signs and symptoms of Lassa fever are initially indistinguishable from other febrile illnesses common in the tropics and complications of pregnancy. Surviving Lassa fever during pregnancy is rare. Only few cases have been documented. The antiviral drug of choice is ribavirin. CASE DESCRIPTION: A 25-year-old multigravida farmer with fever who was initially thought to have malaria in pregnancy at 29 weeks gestation. Further changes in her clinical state and laboratory tests led to a confirmation of Lassa fever. The Liver enzymes were markedly deranged and the packed cell volume was 27%. She commenced on ribavirin and subsequently was delivered of a live male neonate who was RT PCR negative for Lassa fever virus. Her clinical state improved, repeat RT PCR on day 15 was negative and she made full recovery. DISCUSSION: The case reported had similar clinical features of fever and abdominal pain and resulted in the initial diagnoses of Malaria in pregnancy. When she failed to respond to antimalarial and antibiotics treatments, a strong suspicion of viral hemorrhagic fever was made. At this time the patient was in advanced stage of the disease with bleeding from vagina and puncture sites. On the third day of admission she was delivered of a live male neonate who remained negative after 2 consecutive RT PCR tests for Lassa fever virus. Lassa fever carries a high risk of death to the fetus throughout pregnancy and to the mother in the third trimester. Mothers with Lassa fever improved rapidly after evacuation of the uterus by spontaneous abortion, or normal delivery. She was clinically stable following delivery. Her laboratory investigations were essentially normal. Throughout her management transmission based precautions were observed. None of the six close contacts developed symptoms after been followed up for 21 days. CONCLUSION: This report adds to the body of literature that individuals can survive Lassa fever during pregnancy with good maternal and fetal outcome.

Eclampsia in rural Nigeria: The unmitigating catastrophe.

INTRODUCTION: Eclampsia is one of the most dreaded causes of adverse outcomes of pregnancy worldwide. It is one of the greatest causes of maternal and perinatal morbidity and mortality world over. We do not know the prevalence, management outcome, and the devastation caused by this dreaded disease in our center hence the need for this work. MATERIALS AND METHODS: This is a 7-year retrospective review of all cases of eclampsia managed in Mater Misericordiae Hospital Afikpo, a rural secondary cum referral Catholic Mission Hospital in Afikpo, Ebonyi State in Southeastern Nigeria. RESULTS: The prevalence of eclampsia in our center is 1.12% or one case of eclampsia for every 89 women that delivered in our facility. The majority of the women that had eclampsia in our center 56 (71.8%) were primigravidae. Seventeen women (21.8%) had various antenatal complications with 4 or 23.6% presenting with intrauterine fetal deaths and two (11.8%) each with intrauterine growth restriction, and domestic violence, respectively. Thirty-five or 44.9% of the women were delivered by emergency lower segment cesarean section. Fifteen or 17.9% babies were dead giving a perinatal mortality rate of 174 per 1,000After delivery, and 3 (3.8%) of the women had postpartum hemorrhage. Two women (2.6%) died giving a maternal mortality ratio of 2564 per 100,000 deliveries. CONCLUSION: Eclampsia is a dreaded obstetric disease with adverse fetal and maternal consequences that are not mitigating, and no effort should be spared in managing it effectively including public enlightenment.

Evaluation of obstetricians' surgical decision making in the management of uterine rupture.

BACKGROUND: Uterine rupture is an obstetric calamity with surgery as its management mainstay. Uterine repair without tubal ligation leaves a uterus that is more prone to repeat rupture while uterine repair with bilateral tubal ligation (BTL) or (sub)total hysterectomy predispose survivors to psychosocial problems like marital disharmony. This study aims to evaluate obstetricians' perspectives on surgical decision making in managing uterine rupture. METHODS: A questionnaire-based cross-sectional study of obstetricians at the 46th annual scientific conference of Society of Gynaecology and Obstetrics of Nigeria in 2012. Data was analysed by descriptive and inferential statistics. RESULTS: Seventy-nine out of 110 obstetricians (71.8%) responded to the survey, of which 42 (53.2%) were consultants, 60 (75.9%) practised in government hospitals and 67 (84.8%) in urban hospitals, and all respondents managed women with uterine rupture. Previous cesarean scars and injudicious use of oxytocic are the commonest predisposing causes, and uterine rupture carries very high incidences of maternal and perinatal mortality and morbidity. Uterine repair only was commonly performed by 38 (48.1%) and uterine repair with BTL or (sub) total hysterectomy by 41 (51.9%) respondents. Surgical management is guided mainly by patients' conditions and obstetricians' surgical skills. CONCLUSION: Obstetricians' distribution in Nigeria leaves rural settings starved of specialist for obstetric emergencies. Caesarean scars are now a rising cause of ruptures. The surgical management of uterine rupture and obstetricians' surgical preferences vary and are case scenario-dependent. Equitable redistribution of obstetricians and deployment of medical doctors to secondary hospitals in rural settings will make obstetric care more readily available and may reduce the prevalence and improve the outcome of uterine rupture. Obstetrician's surgical decision-making should be guided by the prevailing case scenario and the ultimate aim should be to avert fatality and reduce morbidity.

Knowledge, Attitude and Practice of Healthcare Managers to Medical Waste Management and Occupational Safety Practices: Findings from Southeast Nigeria.

INTRODUCTION: Awareness of appropriate waste management procedures and occupational safety measures is fundamental to achieving a safe work environment, and ensuring patient and staff safety. AIM: This study was conducted to assess the attitude of healthcare managers to medical waste management and occupational safety practices. MATERIALS AND METHODS: This was a cross-sectional study conducted among 54 hospital administrators in Ebonyi state. Semi-structured questionnaires were used for qualitative data collection and analyzed with SPSS statistics for windows (2011), version 20.0 statistical software (Armonk, NY: IBM Corp). RESULTS: Two-fifth (40%) of healthcare managers had received training on medical waste management and occupational safety. Standard operating procedure of waste disposal was practiced by only one hospital (1.9%), while 98.1% (53/54) practiced indiscriminate waste disposal. Injection safety boxes were widely available in all health facilities, nevertheless, the use of incinerators and waste treatment was practiced by 1.9% (1/54) facility. However, 40.7% (22/54) and 59.3% (32/54) of respondents trained their staff and organize safety orientation courses respectively. Staff insurance cover was offered by just one hospital (1.9%), while none of the hospitals had compensation package for occupational hazard victims. Over half (55.6%; 30/54) of the respondents provided both personal protective equipment and post exposure prophylaxis for HIV. CONCLUSION: There was high level of non-compliance to standard medical waste management procedures, and lack of training on occupational safety measures. Relevant regulating agencies should step up efforts at monitoring and regulation of healthcare activities and ensure staff training on safe handling and disposal of hospital waste.

A 10-year appraisal of cesarean delivery and the associated fetal and maternal outcomes at a teaching hospital in southeast Nigeria.

BACKGROUND: The global rise in cesarean delivery rate has been a major source of public health concern. AIM: To appraise the cesarean deliveries and the associated fetal and maternal outcomes. MATERIALS AND METHODS: The study was a case series with data collected retrospectively from the records of patients delivered by cesarean section at the Ebonyi State University Teaching Hospital, Abakaliki over a 10-year period, from January 2002 to December 2011. Ethical approval was obtained. RESULTS: Of 14,198 deliveries, 2,323/14,198 (16.4%) were by cesarean deliveries. The overall increase of cesarean delivery was 11.1/10 (1.1%) per annum from 184/1,512 (12.2%) in 2002 to 230/986 (23.3%) in 2011. Of 2,097 case folders studied, 1,742/2,097 (83.1%) were delivered at term, and in 1,576/2,097 (75.2%), the cesarean deliveries were emergencies. The common indications for cesarean delivery were previous cesarean scars 417/2,097 (19.9%) and obstructed labor 331/2,097 (15.8%). There were 296 perinatal deaths, giving a perinatal mortality rate of (296/2,197) 134.7/1,000 births. Also, 129/2,097 (6.1%) maternal case fatalities occurred, giving a maternal mortality rate of 908.6/100,000 total births. Hemorrhage 57/129 (44.2%) and sepsis 41/129 (32.6%) were the major causes. CONCLUSION: The study recorded a significant increase in cesarean delivery rate. Previous cesarean scars and obstructed labors were the main indications. Perinatal and maternal case fatalities were huge. Hence, there is need for continued community education for its reduction.

The preference and practice of Nigerian obstetricians regarding focused versus standard models of prenatal care.

OBJECTIVE: To determine preferences, practices, and acceptance of focused versus standard prenatal-care models among Nigerian obstetricians. METHODS: A cross-sectional survey was performed among clinicians who attended a conference held in Lagos, Nigeria, between November 27 and 29, 2013. The questionnaire assessed sociodemographic characteristics and opinions on prenatal care. RESULTS: A total of 201 delegates returned complete questionnaires. All respondents were aware of both models of prenatal care. Although 70 (34.8%) respondents stated a preference for focused care, only 6 (3.0%) used this model in clinical practice. The main reason for their preference was the evidence base (23.4%). Overall, 185 (92.0%) respondents stated institutional protocol determined preference for and practice of standard care, 108 (53.7%) believed patients preferred standard care, and 89 (44.3%) felt standard care had health benefits. Preference for one model over the other was significantly associated with type and level of the healthcare practice (P=0.002 and P<0.001, respectively). Modification of the focused model to meet local, national, and cultural needs was recommended by 171 (85.1%) respondents. CONCLUSION: Most obstetricians are skeptical about focused prenatal care and have not embraced this model owing to personal, institutional, and sociocultural factors.

Obstetric analgesia for vaginal birth in contemporary obstetrics: a survey of the practice of obstetricians in Nigeria.

BACKGROUND: Contemporary obstetrics in sub-Saharan Africa is yet to meet the analgesic needs of most women during child birth for a satisfactory birth experience and expectedly, obstetricians have a major role to play in achieving this. METHODS: This was a questionnaire-based, cross-sectional study of 151 obstetricians and gynecologists that attended the 46th Annual General Meeting and Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) held in Abakaliki, southeast Nigeria in November, 2012. SOGON is the umbrella body that oversees the obstetric and gynecological practice in Nigeria. Data was collated and analyzed with Epi-info statistical software, and conclusions were drawn by means of simple percentages and inferential statistics using Odds Ratio, with P-value < 0.05 at 95% Confidence Interval (CI) taken to be statistically significant. RESULTS: Of the 151 participants, males predominated; 110 (72.9%) practiced in government-owned tertiary hospitals in urban locations. Only 74 (49%) offered obstetric analgesia. Among users, only 20 (13.3%) offered obstetric analgesia routinely to parturients, 44 (29.1%) sometimes and 10 (6.6%) on patients' requests. The commonest analgesia was opioids (41.1%). Among non-users, the commonest reasons adduced were fear of respiratory distress (31.1%), cost (24.7%) and late presentation in labour (15.6%). CONCLUSION: The routine prescription and utilization of obstetric analgesia by obstetricians in Nigeria is still low. Obstetricians are encouraged to step up its use to make childbirth a more fulfilling experience for parturients.

A six-year study of the clinical presentation of cervical cancer and the management challenges encountered at a state teaching hospital in southeast Nigeria.

Cervical cancer is still a major contributor to cancer-related mortality amongst women living in poor, rural communities of developing countries. The objective of this study is to establish the clinical presentation of cervical cancer and the management challenges encountered in Abakaliki, southeast Nigeria, with a view to finding intervention strategies. This study is a retrospective descriptive assessment of cases of clinically diagnosed cervical cancer managed at a state teaching hospital over six years. Of 76 cases managed, 61 (80.3%) cases notes were available for study. The mean age and parity of patients were 53.8 years and 6.8 years, respectively. The majority (75.4%) were illiterate. All had been married, but 42.6% were widowed. The main occupations were farming or petty trading. One patient (1.6%) had had a single Pap smear in her life. The major presenting complaints were abnormal vaginal bleeding (86.9%), offensive vaginal discharge (41.0%), and weight loss. Twenty patients (32.8%) were lost to follow-up prior to staging. Of the remaining 41 patients, 16 (39.0%) had stage III disease and 17.1% stage IV. Fifteen patients (24.6%) with late stage disease accepted referral, and were referred for radiotherapy. Those who declined were discharged home on request, though 4 (9.8%) died in the hospital. There was no feedback from referred patients confirming that they went and benefitted from the referral. The presentation followed known trends. Illiteracy, poverty, early marriages, high parity, widowhood, non-use of screening methods, late presentation, non-acceptance of referral, and lack of communication after referral were some of the major challenges encountered. These underscore the needs for health education and awareness creation, women educational and economic empowerment, legislation against early marriages and in protection of widows, and creation of a well-staffed and well-equipped dedicated gynecologic oncology unit to forestall further referral.

Cervical cancer awareness and cervical screening uptake at the Mater Misericordiae Hospital, Afikpo, Southeast Nigeria.

BACKGROUND: Cervical cancer is the most common genital tract malignancy among women in developing countries. OBJECTIVE: To assess the awareness of cervical cancer among Igbo women in a rural population of Southeastern Nigerian and determine their uptake of cervical screening services. MATERIALS AND METHODS: A questionnaire-based descriptive cross-sectional study. Structured questionnaires were administered to female attendees to the antenatal and gynecological clinics of a secondary hospital in the outskirts of Afikpo, Southeast Nigeria over a six-month period (1 st July to 31 st December 2007). Data analysis was by SPSS. RESULTS: Five hundred questionnaires were given out. Three hundred and sixty were correctly filled (72%) and analyzed. The mean age of respondents was 36.2 years, 25.0% had tertiary education and 40.3% were self employed. All the respondents were sexually active. There were high incidences of premarital sex, multiple sexual partners and abnormal vaginal discharge and low condom use. Awareness of cervical cancer (37.5%), its preventable nature (31.9%), cervical screening (25%) and screening centers (20.8%) were generally low and screening uptake (0.6%) was abysmally low. Lack of awareness, non-availability of screening centers locally, cost and time were the main reasons adduced by respondents for not being screened. Overall, 62.5% of all the respondents indicated willingness to be screened. CONCLUSION: The exposure to conditions that predispose women to cervical cancer was high, and the levels of awareness of cervical cancer and cervical screening uptake were low. Continued awareness creation, local provision of cheap and affordable services and poverty alleviation are needed to improve cervical screening uptake with the hope of reducing the incidence of cervical cancer in the long term.

Bilateral tubal ectopic pregnancies: a report of two cases.

Bilateral tubal ectopic pregnancies are rare occurrences. Two recently managed cases are discussed. The first was a single, sexually active 23-year-old nullipara with family history of twinning who presented with eight weeks amenorrhea, positive pregnancy test, lower abdominal discomfort and other clinical and ultrasound findings suggestive of unruptured left tubal pregnancy. Intra-operatively, unruptured bilateral tubal pregnancies were found and bilateral salpingotomy performed with uneventful recovery. Histology of the specimens confirmed the intra-operative diagnosis. She was appropriately counseled. Case 2, a 30-year-old multiparous housewife who had been on clomid for secondary infertility, presented with signs and symptoms of ruptured tubal ectopic. Intra-operatively, ruptured left and unruptured right tubal pregnancies were found and salpingectomy and salpingotomy were done respectively, with uneventful recovery. The diagnosis was also confirmed histologically and counseling given as in case 1. Bilateral tubal ectopic pregnancies appear to be increasing with twin proneness and use of fertility drugs as risk factors. Whether spontaneous or induced, the hallmarks of good management include early presentation, high index of suspicion, meticulous ultrasound scanning, good case selection, judicious intra-operative inspection of the contralateral tube, histology of specimens and appropriate patient counseling.