Neonatal jaundice incidence, risk factors and outcomes in 54 referral-level facilities in Nigeria.

OBJECTIVE: To determine the incidence, risk factors and outcomes of babies with neonatal jaundice in a network of referral-level hospitals in Nigeria. DESIGN: A cross-sectional analysis of perinatal data collected over a 1-year period. SETTING: Fifty-four referral-level hospitals (48 public and 6 private) across the six geopolitical zones of Nigeria. POPULATION: A total of 77 026 babies born at or admitted to the participating facilities (67 697 hospital live births; plus 9329 out-born babies), with information on jaundice between 1 September 2019 and 31 August 2020. METHODS: Data were extracted and analysed to calculate incidence and sociodemographic and clinical risk factors for neonatal jaundice. MAIN OUTCOME MEASURES: Incidence and risk factors of neonatal jaundice in the 54-referral hospitals in Nigeria. RESULTS: Of 77 026 babies born in or admitted to the participating facilities, 3228 had jaundice (41.92 per 1000 live births). Of the 67 697 hospital live births, 845 babies had jaundice (12.48 per 1000 live births). The risk factors associated with neonatal jaundice were no formal education (adjusted odds ratio [aOR] 1.68, 95% CI 1.11-2.52) or post-secondary education (aOR 1.17, 95% CI 0.99-1.38), previous caesarean section (aOR 1.68, 95% CI 1.40-2.03), booked antenatal care at <13 weeks or 13-26 weeks of gestation (aOR 1.58, 95% CI 1.20-2.08; aOR 1.15, 95% CI 0.93-1.42, respectively), preterm birth (aOR 1.43, 95% CI 1.14-1.78) and labour more than 18 hours (aOR 2.14, 95% CI 1.74-2.63). CONCLUSIONS: Hospital-level and regional-level strategies are needed to address newborn jaundice, which include a focus on management and discharge counselling on signs of jaundice.

Maternal morbidity and death associated with pregnancy loss before 28 weeks in Nigeria.

OBJECTIVE: To determine the prevalence of maternal morbidity and death from pregnancy loss before 28 weeks in referral-level hospitals in Nigeria. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Fifty-four referral-level hospitals. POPULATION: Women admitted for complications arising from pregnancy loss before 28 weeks between 1 September 2019 to 31 August 2020. METHODS: Frequency and type of pregnancy loss were calculated using the extracted data. Multilevel logistic regression was used to determine sociodemographic and clinical factors associated with early pregnancy loss. Factors contributing to death were also analysed. MAIN OUTCOME MEASURES: Prevalence and outcome of pregnancy loss at <28 weeks; sociodemographic and clinical predictors of morbidity after early pregnancy loss; contributory factors to death. RESULTS: Of the 4798 women who had pregnancy loss at <28 weeks of pregnancy, spontaneous abortion accounted for 49.2%, followed by missed abortion (26.9%) and ectopic pregnancy (15%). Seven hundred women (14.6%) had a complication following pregnancy loss and 99 women died (2.1%). Most complications (26%) and deaths (7%) occurred after induced abortion. Haemorrhage was the most frequent complication in all types of pregnancy loss with 11.5% in molar pregnancy and 6.9% following induced abortion. Predictors of complication or death were low maternal education, husband who was not gainfully employed, grand-multipara, pre-existing chronic medical condition and referral from another facility or informal setting. CONCLUSION: Pregnancy loss before 28 weeks is a significant contributor to high maternal morbidity and mortality in Nigeria. Socio-economic factors and delays in referral to higher levels of care contribute significantly to poor outcomes for women.

Effect of Carbetocin on Uterine Tone during Cesarean Section: A Comparison between Subarachnoid Block and General Anesthesia.

Background: Postpartum hemorrhage remains a challenge in obstetric practice in developing climes and contributes immensely to the horrendous figures of maternal mortality worldwide. Aim: The aim was to compare the effect of intravenous (IV) carbetocin on uterine tone under different anesthetic techniques for elective cesarean section. Methods: Four hundred and seventy-eight consecutive women scheduled for elective cesarean section were recruited into two groups by convenience. While 445 parturients received subarachnoid block (SAB), 33 had general anesthesia (GA). At delivery, IV carbetocin was administered. The uterine tone was assessed manually and blood loss from intraoperative period to the 24th h was determined. Other variables such as hemodynamic profiles and Apgar scores were determined and recorded. Results: The bio-characteristics between the two groups were essentially the same in terms of age, weight, height, body mass index, preoperative hemoglobin, and gestational age. While the response to the administered carbetocin was slower in the GA group, there was no need for additional dose. The mean estimated intraoperative blood loss under SAB was 250.44 ± 50.59 ml and that under GA was 470.89 ± 35.70 ml, P = 0.000000. The ephedrine consumption was 6.25 ± 2.05 mg in the SAB group while it was 11.25 ± 2.49 mg, P = 0.000000. There was no further maternal blood loss observed after the intraoperative period until the end of 24-h period. The hemodynamic profiles were significantly different in terms of mean systolic blood pressure, mean diastolic blood pressure, and mean arterial blood pressure, P = 0.006, P = 0.002, and P = 0.003, respectively. However, the difference in the mean heart rate was not statistically significant, P = 0.304. While the Apgar scores between groups were not statistically significant, the mean umbilical pH was 7.34 ± 0.09 in the SAB group, it was 7.35 ± 0.02 in the GA group, P = 0.071. Conclusion: Intraoperative maternal blood loss was more among the parturients who received GA than subarachnoid blood. This could probably be due to the effect of the halogenated vapor used for the GA on the uterine tone. There was no further blood loss after the intraoperative period. The hemodynamic profile was better under SAB as evidenced by the total ephedrine consumption.

Résumé Contexte: L'hémorragie post-partum reste un défi dans la pratique obstétricale dans les pays en développement et contribue énormément à l'horrible chiffres de la mortalité maternelle dans le monde. Objectif: L'objectif était de comparer l'effet de la carbétocine intraveineuse (IV) sur le tonus utérin sous différentes techniques d'anesthésie pour la césarienne élective. Méthodes: Quatre cent soixante-dix-huit femmes consécutives devant subir une césarienne élective section ont été recrutés en deux groupes par commodité. Alors que 445 parturientes ont reçu un bloc sous-arachnoïdien (SAB), 33 ont eu une anesthésie générale (AG). À l'accouchement, de la carbétocine IV a été administrée. Le tonus utérin a été évalué manuellement et la perte de sang de la période peropératoire à la 24e heure a été déterminé. D'autres variables telles que les profils hémodynamiques et les scores d'Apgar ont été déterminées et enregistrées. Résultats: Les bio-caractéristiques entre les deux groupes étaient essentiellement les mêmes en termes d'âge, de poids, de taille, d'indice de masse corporelle, d'hémoglobine préopératoire et d'âge gestationnel. Tandis que le la réponse à la carbétocine administrée était plus lente dans le groupe GA, aucune dose supplémentaire n'était nécessaire. Le sang peropératoire moyen estimé la perte sous SAB était de 250,44 ± 50,59 ml et celle sous GA était de 470,89 ± 35,70 ml, P = 0,000000. La consommation d'éphédrine était de 6,25 ± 2,05 mg dans le groupe SAB alors qu'il était de 11,25 ± 2,49 mg, P = 0,000000. Il n'y a pas eu d'autre perte de sang maternel observée après la période peropératoire jusqu'à la fin de la période de 24 h. Les profils hémodynamiques étaient significativement différents en termes de tension artérielle systolique moyenne, de tension artérielle diastolique moyenne et la pression artérielle moyenne, P = 0,006, P = 0,002 et P = 0,003, respectivement. Cependant, la différence de fréquence cardiaque moyenne était pas statistiquement significatif, P = 0,304. Alors que les scores d'Apgar entre les groupes n'étaient pas statistiquement significatifs, le pH ombilical moyen était de 7,34 ± 0,09 dans le groupe SAB, elle était de 7,35 ± 0,02 dans le groupe AG, p = 0,071. Conclusion: La perte de sang maternel peropératoire était plus importante chez les parturientes ayant reçu GA que le sang sous-arachnoïdien. Cela pourrait probablement être dû à l'effet de la vapeur halogénée utilisée pour l'AG sur le tonus utérin. Il n'y avait pas perte de sang supplémentaire après la période peropératoire. Le profil hémodynamique était meilleur sous SAB comme en témoigne la consommation totale d'éphédrine. Mots-clés: Perte de sang, anesthésie générale, carbétocine intraveineuse, bloc sous-arachnoïdien, tonus utérin.

The Case for Early and Universal Screening for Gestational Diabetes Mellitus: Findings from 9314 Pregnant Women in a Major City in Nigeria.

INTRODUCTION: Risk-based screening has been replaced by universal screening as the recommended course of care for gestational diabetes mellitus (GDM). As of 2016, no state in Nigeria had implemented a policy of universal screening for GDM. This research aimed to assess findings from a universal screening programme and its implication for scaling up universal and early screening for GDM. METHODS: This was a descriptive cross-sectional study conducted in Rivers State Nigeria between February 2017 and January 2020. Multistage sampling was used to recruit 9314 pregnant women from 30 primary, secondary, and tertiary health facilities in the state. An interviewer-administered structured questionnaire was used by trained healthcare workers to collect socio-demographic, obstetric and medical information. All study participants had a plasma glucose test on their first hospital visit and a diagnosis made using the World Health Organization (WHO) criteria. Data obtained was analysed using the IBM Statistical Package for Social Sciences (SPSS) version 23. RESULTS: Most women [5683 (61.0%)] were aged 25-34 (mean 29.60 ± 5.64) years. The prevalence of GDM in this study was 5.2% with a prevalence of GDM in the first, second and third trimesters of 4.9%, 4.2% and 6.7%, respectively. The prevalence of GDM among persons with a family history of diabetes was 13.2% (97 persons) while 4.6% (391 persons) without family history were diagnosed with GDM. Gestational age, family history of diabetes and age group were found to be significant predictors of GDM among the study participants after adjusting for confounding variables. CONCLUSION: The practice of universal screening was useful in identifying GDM in 1 out of 20 pregnant women in the study sample. Screening at all trimesters was useful in identifying GDM. There is an urgent need to scale up early and universal screening for GDM across sub-Saharan Africa.

Tuberculosis (TB) in pregnancy - A review.

Tuberculosis (TB) is a common infectious pathology especially in low-income countries, which may complicate pregnancy. Although pulmonary TB is more common in pregnancy than extra pulmonary TB (EPTB), EPTB is becoming more common especially in those living with human deficiency virus (HIV) co infection or have other comorbidities. The diagnosis of TB may be delayed in pregnancy due to the masking of its symptoms by those of pregnancy. If diagnosed and treated on time both pulmonary TB and EPTB are associated with excellent maternal and perinatal outcome. If, however, there is delay in diagnosis and treatment then there could be adverse maternal and fetal consequences like preterm labour, fetal growth restriction and even stillbirths. Similarly severe forms of TB like disseminated disease (miliary TB) or multi drug resistant TB (MDR TB) are associated with poor outcome. Diagnosis and management is same as in non-pregnant patients. Both drug sensitive pulmonary TB and EPTB are treated with four drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) orally daily for 2 months followed by three drugs (isoniazid, rifampicin and ethambutol) orally daily for 4 months. Drug resistant TB is treated with second line drugs with caution, as some of these drugs are teratogenic. Optimum antenatal care and nutrition therapy along with anti-tuberculosis drugs provide for optimum maternal and perinatal outcome. This review discusses maternal and perinatal outcomes, diagnosis and management of pulmonary TB and extrapulmonary TB as well as perinatal tuberculosis.

Maternofetal outcome of asymptomatic bacteriuria among pregnant women in a Nigerian Teaching Hospital.

INTRODUCTION: Asymptomatic bacteriuria has been reported to be associated with adverse pregnancy outcome. This study sought to determine the prevalence and complications of asymptomatic bacteriuria amongst parturient in the University of Port Harcourt Teaching Hospital (UPTH). METHODS: The study was a prospective cohort study involving 220 eligible antenatal attendees. Urine culture and sensitivity was conducted for each participant and the fetomaternal outcome between affected and unaffected women were compared and p value <0.05 was considered significant. RESULTS: Sixty-five of the participants had asymptomatic bacteriuria giving a prevalence of 29.5%. Twenty-three (35.4%) cultures yielded Klebsiella spp while Fifty-eight (89%) of the cultured organisms were sensitive to Nitrofurantoin. There was no statistical difference in the rate of prelabour rupture of membranes, preeclampsia, preterm delivery, birth asphyxia and low birth weight between affected and unaffected women. CONCLUSION: Contrary to widely held view, there was no significant increase in adverse pregnancy outcome amongst affected women.

A 3-year retrospective review of mortality in women of reproductive age in a tertiary health facility in Port Harcourt, Nigeria.

PURPOSE: To determine the causes of death and associated risk factors among women of reproductive age (WRA) in a tertiary institution in Port Harcourt, Nigeria. PATIENTS AND METHODS: This was a retrospective survey of all deaths in women aged 15-49 years at the University of Port Harcourt Teaching Hospital that occurred from January 1, 2013 to December 31, 2015. Data retrieved from ward registers, death registers, and death certificates were analyzed with Epi Info version 7. Comparison of socioeconomic and demographic risk factors for maternal and nonmaternal deaths was done using a multivariate logistic regression model. RESULTS: There were 340 deaths in the WRA group over the 3-year period. The majority (155 [45.6%]) of the women were aged 30-39 years. There were 265 (77.9%) nonmaternal deaths and 75 (22.1%) maternal deaths. Among the nonmaternal deaths, 124 (46.8%) had infectious diseases, with human immunodeficiency virus being the most common cause of infection in this group. Breast cancer (13 [4.9%]), cervical cancer (12 [4.5%]), and ovarian cancer (11 [4.2%]) were the most common malignant neoplasms observed. Hypertensive disorders of pregnancy (31 [41.3%]) and puerperal sepsis (20 [26.7%]) were the most common causes of maternal deaths. Age and occupation were significantly associated with deaths in WRA (p<0.05). Older women aged >30 years (odd ratio =1.86, 95% CI =1.07-3.23) and employed women (odds ratio =2.55, 95% CI =1.46-4.45) were more likely to die from nonmaternal than maternal causes. CONCLUSION: Most of the deaths were nonmaternal. Infectious diseases, diseases of the circulatory system, and malignant neoplasms were the major causes of death among WRA, with maternal deaths accounting for approximately a quarter. Public health programs educating women on safer sex practices, early screening for cancers, benefits of antenatal care, and skilled attendants at delivery will go a long way to reducing preventable causes of deaths among these women.

Effect of Age on Childbearing in Port Harcourt, Nigeria.

OBJECTIVES: To determine the effect of maternal age on pregnancy outcomes in women aged 40 years and above at the University of Port Harcourt Teaching Hospital. METHODS: A retrospective comparative study was conducted on women aged ≥40 years (n=249) and a control group aged 20-29 years (n=249) who delivered at ≥28 weeks gestation between January 1, 2008 and December 31, 2012. The medical records of the patients were analyzed using Epi Info 6.04d. Association between maternal age and selected obstetrical variables were assessed using the chi-squared and the two-tailed Fisher exact test. Differences were considered statistically significant when p≤0.05. RESULTS: The mean age of the women in the study group was 41.2 ±1.75 versus 26.10 ± 2.37 in the control group. Advanced maternal age was associated with a significantly higher rate of hypertensive disorders of pregnancy (p=0.01), diabetes mellitus (p<0.01), abnormal lies/presentation (p=0.04), caesarean deliveries (p<0.01) and low birth weight (p=0.04). CONCLUSION: Older parturients have a higher risk of medical disorders of pregnancy. They are more likely to deliver by caesarean section and have low birth weight babies than their younger counterparts.

Diagnosis and management of ectopic pregnancy.

Ectopic pregnancy remains to be an important cause of maternal morbidity and mortality worldwide, although the incidence has remained unchanged especially in developed countries over the last decade. Several factors are responsible for this, including misdiagnosis and failure to institute timely appropriate treatment aimed at preserving fertility and minimizing the associated morbidity. Recent advances in imaging and biomonitoring have reduced the number of women presenting with ruptured ectopic pregnancy. Any attempt to reduce the consequences of ectopic pregnancies must, therefore, focus on improving the diagnosis of the unruptured type and evidenced-based treatment, which is cost effective. In this review, the authors discuss the diagnosis and treatment of this complication in the light of the recent evidence highlighting how improvements can be made to reduce the consequences.

Changes in maternal serum transforming growth factor beta-1 during pregnancy: a cross-sectional study.

Changes in circulating levels of maternal serum transforming growth factor beta-1 (TGF-ß1), collected from 98 women (AGA) at different gestational ages (10-38 weeks) were measured and comparisons were made between levels in pregnant and nonpregnant controls and also between 10 women with small-for-gestational age (SGA) and 7 with appropriate-for-gestational age (AGA) fetuses. Maternal serum TGF-ß1 levels at all stages of pregnancy were higher than those in normal healthy nonpregnant adults. The mean TGF-ß1 levels in SGA pregnancies at 34-week gestation (32.5 + 3.2 ng/mL) were significantly less than those in AGA pregnancies (39.2 + 9.8 ng/mL) while at 38-week gestation, the levels were similar in the two groups (36.04 + 4.3 versus 36.7 + 7.0 ng/mL). This differential change in TGF-ß1 levels is probably an important modulating factor in the aetiopathogenesis of abnormal intrauterine fetal growth.