A 10-year Review of the Clinical Presentation and Treatment Outcome of Asherman's Syndrome at a Center with Limited Resources.

BACKGROUND: Many women suffer from some degree of intrauterine adhesions (IUAs) presenting with various clinical symptoms and signs. Hysteroscopy is the mainstay of diagnosis, classification, and treatment of the IUA. AIM: This study was undertaken to review the clinical features and treatment outcome in patients diagnosed with Asherman's syndrome at the University of Maiduguri Teaching Hospital (UMTH), Maiduguri, over a 10 years period, 1997-2006. SUBJECTS AND METHODS: This is a retrospective study of cases of Asherman's syndrome managed at the UMTH over a 10-year period, from January 1, 1997 to December 31, 2006. Case records of the patients were retrieved from medical records' Department. Sociodemographic and clinical information relating to clinical presentations, treatment modalities, and outcomes were collated. The data were analyzed using SPSS 16.0 Statistical Computer Package (SPSS Inc., IL, USA 2006). Chi-square and binary logistic regression were used for inferential statistics. RESULTS: Asherman's syndrome constituted 8.1% (81/996) of all gynecological operations in UMTH during the study period. The case records retrieval rate was 96.3% (78/81 folders). Most of the patients, 59% (46/78) were in their third decade and majority 85.9% (67/78) were married. The most common risk factor was pregnancy-associated, accounting for 61.5% (48/78). Infertility and hypomenorrhea were the most common mode of presentations in 55.1% (43/78) and 32.1% (25/78) of cases, respectively. Most of the patients 85.9% (67/78) were treated by blind dilatation and curettage (D/C), Foley's catheter insertion and estrogen-progesterone combination. Correction of menses was seen in 37.2% (29/78) of the patients while the pregnancy rate was 32.1% (25/78). On binary logistic regression age of the respondents, multigravidity, and previous pelvic surgeries for pregnancy (C/S and D/C for abortion) emerged as the only respondent's related risk factors associated with the development of Asherman's syndrome. CONCLUSION: Asherman's syndrome is relatively common due to complications of pregnancy and delivery, and blind D/C has a relatively poor outcome. Age of the respondents, multigravidity, and previous pelvic surgeries for pregnancy (C/S and D/C for abortion) were associated with the development of Asherman's syndrome. Therefore, other methods of adhesiolysis such as hysteroscopic adhesiolysis should be explored.

Autologous blood donation and transfusion in obstetrics and gynaecology at the University of Maiduguri Teaching Hospital Maiduguri, Nigeria.

OBJECTIVE: To evaluate the practicability of autologous blood donation and transfusion in the practice of obstetrics and gynaecology in our environment. METHOD: A prospective study of 1221 obstetric and gynaecological patients to which autologous blood donation and transfusion was carried out at the University of Maiduguri Teaching Hospital, Maiduguri over an 8 year period (January, 1998 to December, 2005). RESULTS: During the study period, there were 15,267 blood transfusions in the UMTH out of which 5,711 were for Obstetric and Gynaecological patients given a transfusion rate of 47.7% in the unit. Out of the 5711 transfusion in the obstetrics and gynaecology, 1221 were by autologous means; a rate of 21.4%. Of the 3010 transfusion in obstetrics 625 (20.7%) were of autologous blood and of the 2711 transfusion in gynaecological patients 596 (22.1%) were of autologous blood. Preoperative blood donation was done in 598 (95.8%) of the obstetrics autologous blood donation out of which, 40 (6.4%) predeposited 2 units. Five hundred and sixty (94.1%) gynaecological patients had preoperative blood donation out of which, 46 (7.7%) predeposited 2 units. Induction of labour constitutes the major indication 337 (53.9%) for the autologous blood donation in obstetric while the major indication in gynaecology patients was myomectomy (25.7%).The main complications encountered were dizziness, and fainting attack that necessitated re-infusion in one patient. CONCLUSION: Autologous blood donation and transfusion procedure is feasible in the setting of obstetrics and gynaecology and it does not require high technical procedure.

Methods of induction of labour at the University of Maiduguri Teaching Hospital, Maiduguri: a 4-year review.

BACKGROUND: Induction of labour is an important intervention in obstetrics. Misoprostol is increasingly being used for induction of labour in many obstetric units and it may replace the traditional Foleys catheter/oxytocin protocol. METHOD: This was a retrospective study of the 3 methods of induction of labour used at the University of Maiduguri Teaching Hospital (UMTH). A total of 468 women had induction of labour during the study period. Two hundred and twenty eight of them had induction with 50 microg of misoprostol, 57 women had 100 microg of misoprostol while 183 women had extra-amniotic Foleys catheter with oxytocin infusion. RESULT: Induction of labour constituted 6.6% (468/7086) of all deliveries during the study period. The commonest indication for induction of labour was prolonged pregnancy in 46.8%, followed by pregnancy induced hypertension in 33.5%. There was no difference in the achievement of vaginal delivery between the 3 methods of induction of labour (chi2 = 1.13, p = 0.57). The mean induction delivery time was shortest for those induced with 100 microg of misoprostol (6.38 +/- 2.25 hours), followed by 8.16 +/- 3.58 hours in those induced with 50 ug of misoprostol and 9.73 +/- 4.32. 43 hours in those induced with Foleys catheter/oxytocin (p < 0.001). The babies delivered to women induced with 100 microg of misoprostol were more asphyxiated 12.3% (7/57) compared to 9.2% (21/228) and 6.6% (12/183) in the 50 ug misoprostol and Foleys catheter/oxytocin respectively and was statistically significant (chi2 = 23.08, p = 0.01). The short induction delivery time in the group with 100 microg of misoprostol was advantageous but there was an associated higher risk of birth asphyxia, stillbirth, uterine hyperstimulation, perineal tear and uterine rupture. The normal delivery outcome was not significantly different from those induced with 50 microg of misoprostol and those induced with Foleys catheter/oxytocin (chi2 = 1.24, p = 0.94). Normal delivery rate was significantly higher in those induced with 50 microg of misoprostol compared with those induced with 100 microg of misoprostol (chi2 = 14.38, p = 0.01). CONCLUSION: Misoprostol appears to be safe and may be a suitable alternative for induction of labour by the traditional Foleys catheter/oxytocin protocol. The 50 microg dosing of misoprostol is safer than the 100 microg.

Survival of infants and children born to women who died from pregnancy and labour related complications.

OBJECTIVE: In response to concern raised on the high rate of maternal mortality in developing countries, this cross-sectional survey was conducted to assess the survival of infants born to mothers who died during the process of child birth. METHODOLOGY: The survey was conducted in Gwoza and Konduga Local Government Areas of Borno State, Nigeria over a 12 week period; January to March, 1996. RESULTS: Sixty four live-born infants of 76 deceased mothers were studied. The majority of the infants were either nursed by the deceased's sister or mother. Alternative or donor breast milk by a surrogate mother (usually the deceased close relation), goat or cow milk were the common form of feeding from birth to 6 months of age followed by groundnut enriched pap. Twenty (31.3%) of the infants survived upto 5 years of age while 44 (68.6%) did not. Factors favouring infant survival include nursing, up-bringing and breast-feeding by a surrogate mother (who is usually either the deceased's sister or mother), infant feeding with goat's or cow's milk, Immunization, hospital treatment of aliments, hospital delivery or maternal death in the hospital and finally when the caretaker is of low party and upper social class status. Factors responsible for infant death included prematurity, cause of maternal death was due to sepsis as a result of prolonged labour or premature rupture of fetal membranes, birth asphyxia, tetanus, respiratory problems, fever, convulsions, diaorrhea and vomiting and malnutrition. CONCLUSION: These babies are readily accepted by the society because it is believed that the caretaker would receive a lot of blessing from God. On the other hand, the death of such babies is considered a double loss even though there is a low expectation for their survival.

The value of the secondary yolk sac in predicting pregnancy outcome.

One hundred and five consecutive women had transvaginal sonography (TVS) at less than 12 weeks gestation to establish the normal size and shape of the secondary yolk sac (YS) and to assess the YS measurements in predicting pregnancy outcome in the first trimester. A yolk sac diameter more or less than two standard deviation (2SD) from the mean predicted abnormal pregnancy outcome with a sensitivity of 91.4%, specificity of 66% and a positive predictive value of 88.8%. A normal YS size predicted normal pregnancy outcome with a sensitivity of 66%, specificity of 91.4% and a positive predictive value of 95.6%. It is recommended that patients at risk of poor pregnancy outcome should have routine TVS before 12 weeks gestation to assess their YS and those with an abnormal yolk sac should be followed-up closely to exclude fetal abnormalities before 24 weeks gestation.

Dysmenorrhoea and menstrual abnormalities among postmenarcheal secondary school girls in Maiduguri Nigeria.

Four Hundred and fifteen post menarcheal secondary school girls selected randomly from six secondary schools in Maiduguri metropolis were interviewed with the aid of questionnaires to find out their ages at menarche and associated menstrual problems, regularity of menstrual cycle, menorrhagia and dysmenorrhoea within the first two years following menarche. Their ages ranged between 12 and 21 years. Twenty six students were three months post menarche, 187 were 4-12 months post menarche.'The mean menarcheal age was 13.6 years. Menorrhagia was a very rare form of menstrual abnormality. Early menarche especially between the ages of 12 to 14 years was found to be associated with higher frequency of irregular menstrual cycles while this improves with late onset menarche. About 45% had one form of menstrual abnormality, amenorrhoea (4.6%), oligomenorrhoea (18%) and polymenorrhoea (21%). These were almost uniformly associated with all groups. Over 80% had attained menarche by age of 14 years. Dysmenorrhoea was just slightly commoner by the ages of 15 and 16 years when it occurs more frequently.

Prevalence of rubella-specific IgG antibody in non-immunized pregnant women in Maiduguri, north eastern Nigeria.

The prevalence of IgG antibody specific to the rubella virus was assessed in 207 consenting pregnant women. The women were in the age range of 14 to 40 years (mean 25.8 years) and parity range of 0 to 8 (mean para 4), in their first and second trimesters of pregnancy. All attended the antenatal clinic of a tertiary health facility (University of Maiduguri Teaching Hospital) in northeastern Nigeria. Of the 207 serum samples tested, 112 (54.1%) were positive for rubella IgG antibody. In this area therefore, the proportion of susceptible pregnant women to rubella virus is up to 46%. The results from this study also indicated that with increased maternal age the percentage of immune women increased significantly (P = 0.04382) from 23.8% in the 14 to 19 years age group to 74.4% in the age group of 30 to 40 years. There was again a gradual increase in rubella seroprevalence from 43% amongst primigravidae to 59% and 78% in multiparous and grandmultiparous women respectively. The pregnancy outcome was normal in 27% of the women studied, with miscarriage occurring in 24.6% and 24.2% each had a premature delivery and stillbirth. There were 30 (58.8%) miscarriages, 27 (54%) premature deliveries and 30 (60%) stillbirths, with no clinically detectable malformations in 25 (44.6%) of all the deliveries from the immune women. There is therefore, an increase in the number of rubella immune women with each of the pregnancy outcomes compared to the non-iminune ones. Hence, the need to protect children of these susceptible women from contracting congenital rubella and its sequelae by including routine rubella vaccination of all women of childbearing age in the current programme on immunization.

Transvaginal ultrasound scan versus laparoscopy in the diagnosis of suspected ectopic pregnancy.

This is a prospective study comparing the performance of transvaginal ultrasound scan with laparoscopy as the last diagnostic tool in a clinically suspected ectopic pregnancy. Both diagnostic methods have the same sensitivity of 100%. Transvaginal ultrasound scan had a specificity of 73.7% and a positive predictive value of 89.8%. Laparoscopy had a specificity of 84.8% and a positive predictive value of 94.6%. The use of laparoscopy could avoid laparotomy in only 3.4% of patients. Since transvaginal ultrasound scan is easier, safer and cheaper than laparoscopy, more emphasis should be laid on its use in our environment than laparoscopy.

Histological types of ovarian tumours as seen in an African teaching hospital in north-eastern Nigeria.

During the period January 1989 to December 1997, there were 116 histological proven ovarian neoplasms seen in the University of Maiduguri Teaching Hospital, Maiduguri. Ninety-two (79.3%) patients had benign tumours while the remaining 20.7% had ovarian cancer. Epithelial tumour were the commonest histological type (40.7%) followed by germ cell tumours. Benign cystic teratoma (25.0%) was the commonest benign tumour while the commonest malignant tumour was serous cystadenocarcinoma (7.7%).

Antepartum haemorrhage: the influence of first trimester uterine bleeding.

The influence of first trimester uterine bleeding on the incidence of antepartum haemorrhage was evaluated in 374 patients. The incidence of abruptio placentae and placenta previa were 1.0% and 2.0% respectively in these patients. In the control group of patients who did not experience first trimester uterine bleeding, the incidence was 0.4% for abruptio placentae and 1.0% for placenta previa. The study indicates that first trimester threatened abortion is associated with 2 1/2 fold risk of abruptio placenta and placenta previa than in the general obstetric population. The possible reasons for these incidences are discussed.

PIP: A retrospective case-control study suggested that first-trimester threatened abortion is significantly associated with an increased risk of both abruptio placenta and placenta previa. The antenatal and delivery records of 374 women treated at University College Hospital in Ibadan, Nigeria, for period or threatened abortion in the first trimester of pregnancy were compared to those of 500 randomly selected control patients without a history of threatened abortion. Four cases (1.07%) and two controls (0.4%) developed abruptio placenta, while nine cases (2.41%) and five controls (1.0%) had placenta previa. Thus, the risk of both complications was increased 2.5-fold for women with threatened first-trimester abortion. Since bleeding usually indicates some degree of separation of the chorion from decidua, it is speculated that residual tissue defects or weak points remain between the placenta and decidua at the site of bleeding and cause villous, decidua, or chorionic damage. Women with threatened first-trimester abortion should be followed carefully to ensure placental localization.

Hypoglycaemia: a major biochemical complication in eclampsia- its risk factors and prognostic value.

In this two year prospective study, random blood glucose levels were determined in 52 eclamptic patients and 38 controls, at the University of Maiduguri Teaching Hospital and Specialist Hospitals in Maiduguri, Nigeria. Eclamptic mothers had lower glucose levels (mean value = 3.5 mmol/l) than controls (mean value = 6.8 mmol/l) (P < 0.001). Nineteen eclamptics (36.5%) had hypoglycaemic glucose levels (mean value = 2.3 mmol/l). These values returned to normal following intravenous administration of dextrose. Risk factors for hypoglycaemia identified in these mothers included lack of antenatal care, unsupervised labour at home, labour lasting more than 14 hours, obstructed labour, maternal hyperpyrexia, convulsions four or more times, deranged liver function especially HELLP syndrome (syndrome of haemolysis, elevated liver enzymes and low platelet count), poor energy supply in labour, low socio-economic class status and anaemia. A scoring panel derived from these risk factors was tested on a separate group of 48 eclamptics and this was found to be 96% sensitive. Infusion of 50% dextrose reversed coma in seven of eight comatose eclamptics and corrected fetal heart rate irregularities in 13 of 15 hypoglycaemic eclamptics. Seven of nine patients who suffered from posteclamptic psychosis had hypoglycaemic glucose levels. Three mothers with hypoglycaemia and HELLP syndrome died after developing hyperglycaemia following infusions of 50% and 10% dextrose. Hypoglycaemia should be considered a major biochemical complication of eclampsia. Its risk should be identified and its treatment be considered in the protocol of the management of eclamptics.

Antenatal complications in adolescent mothers aged below 14 years.

Antenatal complications in 340 booked and 710 unbooked adolescent mothers aged 12-14 years were evaluated over a 2-year period at the Specialist Hospital, Yola, Adamawa State, Nigeria. Emesis gravidarum was observed in 290 (85.3%) and 612 (86.2%) booked and unbooked mothers, respectively. While 112 (32.9%) booked mothers had malaria, this ailment was observed in 508 (71.5%) of unbooked mothers. Forty-six (13.5%) booked mothers suffered from anaemia as against 483 (68.0%) unbooked patients. It was observed that preeclampsia manifested in 62 (18.2%) booked and 158 (22.2%) unbooked mothers, while eclampsia occurred in 18 (5.3%) and 66 (9.3%) booked and unbooked mothers, respectively. The rates of premature deliveries were 16.20% in booked mothers and 22.82% in the unbooked group. Other notable complications observed in both groups include premature rupture of fetal membranes (PROM), preterm contractions, antepartum haemorrhage, and urinary tract infections. There were slightly higher frequencies of the above complications in 12-year-olds, and these decreased slightly towards the age of 14 years. Nine of the 10 above observed complications occurred more in the lower socioeconomic classes [3-4] than in the upper social economic classes [1-2] in significant proportions.

Antepartum haemorrhage: the influence of first trimester uterine bleeding.

The influence of first trimester uterine bleeding on the incidence of antepartum haemorrhage was evaluated in 374 patients. The incidence of abruptio placentae and placenta previa were 1.0% and 2.0% respectively in these patients. In the control group of patients who did not experience first trimester uterine bleeding, the incidence was 0.4% for abruptio placentae and 1.0% for placenta previa. The study indicates that first trimester threatened abortion is associated with about 21/2 fold risk of abruptio placenta and placenta previa than in the general obstetric population. The possible reasons for these incidences are discussed.

The unfavourable cervix: improving the Bishop score with the Foley's catheter.

The balloon Foley's Catheter applied in the extra-amniotic space was used to ripen the cervix prior to planned induction of labour or induced abortion in 88 patients. This procedure was effective in significantly improving the Bishops Score to inducible levels in 97% of the patients. The Foley's Catheter is cheap, easily available for use, associated with very minimal complications and therefore provide a readily available and efficacious method of cervical ripening.

Fetal decapitation: the application and safety of the stout embryotomy scissors.

Transverse lie with impacted shoulder and hand prolapse of the dead fetus was treated in 21 cases by decapitation of the fetus, performed with stout blunt-ended embryotomy scissors. Surgical complications were minimal and the procedure was simple, effective and safe.

Squamous carcinoma of the cervix metastatic to the umbilicus. Case report.

Sister Joseph's nodule is a rare feature of advanced cervical carcinoma. This case is reported from a Nigerian teaching hospital where over 100 new cases of cervical carcinoma are seen annually.