Incidence, Determinants, and Outcomes of Spontaneous Preterm Birth at Tertiary Hospitals in Enugu, Southeast, Nigeria: A Cross-Sectional Study.

BACKGROUND: In the past five years, observational evidence suggests that the rates and determinants of preterm birth may have changed due to the effect of the coronavirus disease 2019 (COVID-19) pandemic and other humanitarian crises in our environment. AIM: This study aimed to determine the incidence, associated factors, and outcomes of preterm birth in tertiary hospitals in Enugu, southeastern Nigeria. METHODS: This cross-sectional study included 238 pregnant women from the University of Nigeria Teaching Hospital (UNTH), Enugu State University of Science and Technology Teaching Hospital (ESUT-TH) Parklane, and Mother of Christ Specialist Hospital (MOCSH), Enugu, from April 2022 to March 2023. Eligible and consenting participants were recruited from 28-36 weeks +6 days of gestational age and followed up until delivery. Relevant outcome variables, such as sociodemographic characteristics, gestational age at delivery, and pregnancy outcomes, were recorded in a pro forma. These data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) statistics for Windows, version 22.0, Armonk, NY: IBM Corp. RESULTS: The incidence of preterm birth was 16.6% (37/223), with spontaneous preterm birth constituting 24 of 37 (64.5%) cases. The mean age of participants was 30.3 ± 4.8 years. Advanced maternal age (>35 years) (P = 0.01, adjusted odds ratio (AOR) =0.01, confidence interval (CI): 0.00-0.144), low socioeconomic status (P = 0.04, AOR = 0.40, CI: 0.11-1.46), and history of miscarriage (P = 0.02, AOR = 0.06, CI: 0.01-0.59) were the factors associated with spontaneous preterm birth. Neonatal death occurred in 21.6% (8/37) of cases within the first 24 hours. Rates of cesarean section and low birth weight were 73% (27/37) each. CONCLUSIONS: The incidence of preterm birth is high in Enugu, and associated factors were advanced maternal age, low socioeconomic status, and a history of miscarriage.

The feasibility of introducing early pregnancy assessment unit in Nigerian hospitals: A pilot study from a private hospital in Enugu, Southeast Nigeria.

Background: Early pregnancy assessment unit (EPAU) is a dedicated unit that provides specialist care such as definitive ultrasonographic and biochemical assessment to women who have or have had vaginal bleeding or pain before 16 weeks of pregnancy. Such patients usually have a positive pregnancy test with a scan showing pregnancy of an unknown location, previous ectopic pregnancy, recurrent miscarriages, or previous molar pregnancy. Such a holistic and prompt approach leads to better outcome in the management of women with early pregnancy and other complications. Aim: This study aimed to describe the diagnosis and outcome of early pregnancy pain and bleeding, managed by rapid ultrasonographic and biochemical assessments by a dedicated gynecological team in a private hospital to determine the feasibility of establishing early pregnancy assessment units (EPAUs) in Nigeria. Materials and Methods: This is a cross-sectional study of eligible cases of early pregnancy bleeding and pain in a private gynecological hospital in Enugu, Nigeria. Results: During the 9-year study period, 160 women with early pregnancy pain or bleeding were analyzed. The mean age of the participants was 32.3 ± 7.2 years, and they were mostly multipara (68.7%) and Christians and of the Igbo tribe (91.3%). The final diagnosis after clinical and radiological evaluations showed that the majority had miscarriages (82.5%), while 17.5% had ectopic gestations. All the participants had their definitive diagnosis and treatment within 24 hours of presentation. There was no recorded case of maternal death. Conclusion: EPAUs are feasible in a Nigerian setting provided that trained, dedicated staff and equipment are provided.

Serum immunoglobulins, C-reactive protein, and trace element level in preeclamptic Nigerian subjects.

Background: The mechanism involved in the pathogenesis of preeclampsia (PE) remains uncertain, and the research into a better understanding, its possible prediction, and subsequent prevention continues. Aim: This study evaluated changes in serum immunoglobulins (IgG, IgA, and IgM), C-reactive protein, and trace elements (Zn, Cu, and Mn) in preeclamptic, normotensive pregnant, and non-pregnant females. Subjects and Methods: The study was conducted among 150 subjects consisting of 50 preeclamptic subjects, 50 healthy normotensive pregnant women in their third trimester, and 50 non-pregnant women, all within the same age bracket. The serum concentration of the immunoglobulins and C-reactive protein were measured using standard immunoturbidimetric methods, whereas the trace elements were assayed using the atomic absorption spectrophotometric method. Results: Serum IgG and IgM levels were observed to be significantly lower (P < 0.05) in preeclamptic subjects (101.22 ± 4.44 and 769.43 ± 1.43 mg/dl), respectively, when compared to the normotensive pregnant women (123.87 ± 1.81 and 881.71 ± 2.80 mg/dl), respectively. There was a non-significant difference in immunoglobulin A levels between the groups (P > 0.05). The C-reactive protein was significantly higher, whereas the trace elements were significantly lower (P < 0.05) in preeclamptic subjects compared to the normotensives. There was a positive correlation between the immunoglobulin G and Zn levels (r = 0.334; P = 0.046) and also between immunoglobulin G and C-reactive protein levels (r = 0.340; P = 0.043) and a negative correlation between systolic blood pressure and manganese levels in preeclamptic subjects (r = -0.375; P = 0.024). Conclusion: This study therefore reveals significantly lower levels of immunoglobulins and trace elements among the preeclamptic subjects. These micronutrient deficiencies and low levels of immunoglobulins could be risk factors for the development of high blood pressure and PE.

Maternal near-miss and death associated with abortive pregnancy outcome: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey.

OBJECTIVE: To investigate the prevalence of life-threatening complications related to pregnancies with abortive outcome and the associated health service events and performance in Nigerian public tertiary hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy-related complications. METHODS: All cases of severe maternal outcomes (SMO: maternal near-miss or death) due to abortive pregnancy complications (defined as spontaneous or induced abortion, and ectopic pregnancy) were prospectively identified over 1 year using uniform identification criteria. MAIN OUTCOME MEASURES: Prevalence of SMO, mortality index (% maternal death/SMO), case fatality rate, time until death after admission, and health service performance. RESULTS: Of 5779 women admitted with abortive pregnancy complications, 444 (7.9%) experienced an SMO: 366 maternal near-misses and 78 maternal deaths. Intra-hospital maternal mortality ratio from complicated abortive pregnancy outcome was 85/100 000 live births. Case fatality rate was worst for abortion-related infections (19.1%). A quarter of maternal deaths occurred on the same day of admission; however, the peak time of occurrence of death was 3-7 days of admission. Women experiencing cardiovascular, renal or coagulation organ dysfunction were less likely to survive. Higher level of maternal education and closer residence to a health facility improved chance of maternal survival. CONCLUSIONS: Abortive outcome remains a major contributor to SMO in Nigeria. Although early hospital presentation by women is critical to surviving abortive pregnancy complications, improved, appropriate, and timely management is essential to enhance maternal survival. TWEETABLE ABSTRACT: 78 maternal deaths and 366 near-misses occurred from abortions and ectopic pregnancies in 42 Nigerian referral hospitals in 1 year.

Risks associated with subsequent pregnancy after one caesarean section: A prospective cohort study in a Nigerian obstetric population.

CONTEXT: Aversion for cesarean delivery is common in our practice and risks associated with caesarean section may contribute to this phenomenon. OBJECTIVE: The objective of this study was to estimate the risks associated with subsequent pregnancies in women with one previous cesarean section in a low resource setting. SETTING AND DESIGN: A prospective cohort study carried out at two major tertiary maternity centers in Enugu. MATERIALS AND METHODS: Maternal and perinatal outcomes were compared between women with one previous caesarean and women who had only previous vaginal deliveries. STATISTICAL ANALYSIS USED: Analysis was performed with SPSS statistical software version 17.0 for windows (IBM Incorporated, Armonk, NY, USA) using descriptive and inferential statistics at 95% of the confidence level confidence. RESULTS: A total of 870 women were studied. These were divided into 435 cases and 435 controls. The absolute risk of cesarean section in a subsequent pregnancy in women with one previous cesarean was 75.8% (95% confidence interval [CI]: 72.0, 80.0). Cesarean section was significantly commoner in women with one previous cesarean compared with those who had previous vaginal delivery (Relative risk [RR] =3.78; 95% CI: 1.8, 6.2). Placenta praevia (RR = 5.0; 95% CI: 2.6, 7.2.), labor dystocia (RR = 6.4, 95% CI: 3.2, 11.2) intrapartum hemorrhage (RR = 5.0, 95% CI: 2.1, 9.3) primary postpartum hemorrhage (RR = 5.0, 95% CI: 1.5, 4.3.), blood transfusion (RR = 6.0, 95% CI: 3.4, 10.6) and Newborn special care admission (RR = 2.5; 95% CI: 1.1, 4.9) were significantly more common in women with one previous cesarean compared with those with previous vaginal deliveries. The absolute risk of failed trial of vaginal birth after a cesarean was 45% (95% CI: 38.5, 51.5). CONCLUSION: Women who have one previous C-section face a markedly increased risk of repeat caesarean sections and feto-maternal complications in subsequent pregnancies. There is a need for doctors in Nigeria to be mindful of these risks while offering primary cesarean section in this low resource setting.

Prevalence, presentation and management of polycystic ovary syndrome in Enugu, south east Nigeria.

BACKGROUND: Polycystic ovary syndrome is the most common gynaecological endocrine disorder in women of reproductive age yet, its prevalence and management has not been documented in our area. OBJECTIVE: To determine the prevalence, presentation and management of polycystic ovary syndrome among women in Enugu, south east Nigerian. METHOD: A prospective descriptive study of women with polycystic ovaries seen in two major Infertility Clinics in Enugu, South East Nigeria over a 2 year period. RESULT: A total of 342 women presented with infertility in the centres within the two year period, out of whom 62 had PCOS. PCOS occurred in 18.1% of women in the infertility clinics of the two institutions. The common modes of presentation were: inability to conceive (infertility) in 52 (83.9%), oligomenorrhoea in 45 (72.6%), obesity in 32 (51.6%), LH/FSH ratio > 2 in 28 (45.2%), hyperprolactinaemia in 26 (41.9%) and hirsuitism in 19 (30.6%) women. Ovulation induction was carried out in 42 of the 50 women with anovulatory infertility only. For those 42 women, the mean number of induced cycles was 2.6 = 1.7 (range: 1-6) with 33 (78.6%) of the women being able to do only 3 induced cycles or less. The ovulation induction agents used were clomiphene citrate and human menopausal gonadotrophin either singly or in combination with tamoxifen or bromocryptine. Adjunctive treatments offered consisted of weight reduction in 20 (40.0%) women, metformin in 11 (22.0%) women and dexamethasone in 10 (20.0%) women. CONCLUSION: PCOS is fairly common occurring in approximately one in six infertile Nigerian women. Infertility, oligomenorrhoea, obesity, LH/FSH ratio > 2, hyperprolactinaemia and hirsutism are the commonest presenting features. On individualized management, about two-fifths of them conceive either spontaneously or following ovulation induction, despite poor compliance to recommended drug regimen.

The role of ultrasonography in in-vitro fertilization and embryo transfer (IVF-ET).

BACKGROUND: Although ultrasonography was introduced into Obstetrics and Gynaecology by a British Gynaecologist over five decades ago, the requirements for formal training in its use by gynecologists in Nigeria is just beginning to catch on, despite its indispensible role in various aspects of our clinical practice. OBJECTIVE: To describe the role of ultrasonography in in-vitro fertilization and the indispensability of the instrument to reproductive medicine. METHOD: A review of literature written in English language on the use and application ofultrasonography. in in-vitro fertilization was done. The review covered articles published between 1980-2012. RESULTS: Ultrasound is the most versatile method for pre-treatment assessment in IVF being the dominant instrument for assessing ovarian reserve, pelvic pathologies and for assessing the uterine cavity. The ability of ultrasonography to measure endometrial thickness in addition to detecting uterine masses gives it an edge over laparoscopy/hysteroscopy as a diagnostic procedure in uterine cavity assessment, although hysteroscopy has the advantage of therapeutic potential. Similarly, ultrasonography is superior to biochemical methods for follicular monitoring because of its ability to demonstrate the number and sizes of follicles, and guide preparations for oocyte retrieval. The relative ease of ultrasound guided oocyte retrieval; its less technical demands and the possibility of conducting the procedure under local anaesthesia have made ultrasound guided oocyte retrieval more popular across the world. Randomized controlled trials show that ultrasound-guided transfer techniques have better outcomes than the clinical touch technique in terms of on-going pregnancies and Clinical pregnancies. Ultrasonography is now the key instrument for diagnosing and monitoring pregnancy following embryo transfer, biochemical methods being complimentary. CONCLUSION: Ultrasonography is now the single most important instrument in in-vitro fertilization .programmes and gynaecologists with interest in reproductive medicine need necessarily to obtain a formal training in its use.

The impact of health education on the awareness and acceptability of strategies for preventing mother to child transmission of HIV in Enugu, Nigeria.

BACKGROUND: Majority of Pacdiatric HIV/AIDS are from infected mothers and adequate prevention of mother to child transmission (PMTCT) of HIV is a critical factor in the control of paediatric HIV/AIDS. Success of PMTCT strategies will require a high level of acceptability of these strategies by pregnant women. METHODS: A cross sectional descriptive study of the impact of health education on the awareness of strategies for PMTCT was undertaken using interviewer administered questionnaire on antenatal women recruited from three health institutions in Enugu. RESULTS: A total of 150 antenatal clients were studied. Their mean age was 29.9 1 +/- 4.0. Ninety four point seven percent (94.7%) were married and 60% of them had post secondary education. There was high level of awareness and acceptability of PMTCT measures amongst the respondents. Out of the 150 respondents, 123 (82.0%) identified correctly the meaning of HIV, 140 (93.3%) were aware it can affect the newborn, 105 (75%) knew how it is transmitted and 135 (90.0%) had awareness that we can prevent mother to child transmission of HIV. 130 (86.6%) of the respondents would accept some measures for PMTCT. Awareness that HIV can affect new born increased from 140 (93.3%) to 145 (96.7%) following health education while those who would accept PMTCT measures increased from 130 (86.6%) to 146 (97.3%). These increases were statistically significant (P<0.05). CONCLUSION: Health education has a positive and significant impact on the awareness and acceptability of Prevention of Mother to Child transmission of HIV amongst antenatal clients in Enugu.

Trends in the twinning rate in Enugu, Nigeria.

Nigeria has the highest twinning rate in the world. Increasing twinning rates have been reported from various parts of the world as a result of assisted reproductive technologies. In order to determine whether Nigeria is part of this epidemic, the current study assessed the trends in twinning rates as seen at the University of Nigeria Teaching Hospital, Enugu, South-east Nigeria. It was a retrospective analysis of twin deliveries in the hospital over a 21-year period (1985-2005). No significant change was observed in the twinning rate within the study period. It was concluded that Nigeria is not yet part of the epidemic of multiple births affecting other parts of the world.

Advocating the new WHO antenatal care model in a free maternity care setting in a developing country.

In a free maternity care setting the number of antenatal clients can be overwhelming for the obstetric staff. Using the World Health Organization (WHO) classifying form, most of the women can be triaged for the basic component of the new WHO antenatal care model. Our aim was to evaluate the risk status of pregnant women in a tertiary health institution providing free maternity care in Nigeria. We interviewed 1022 randomly selected clients using the WHO classifying form at our booking clinic over a 12-month period. The analysis was performed using the epi info statistical program. Seven hundred and sixty-five clients (74.9%) were found eligible for the basic component of the new antenatal care model. The associated risk in pregnancy increased with increasing parity. The basic component of the new WHO antenatal care model can safely be implemented in centres such as ours.