[Epidemioclinical and legal aspects and cost management of sexual abuse among minors in Dakar, Senegal]. / Aspects épidémiocliniques, juridiques et coût de la prise en charge des abus sexuels chez les mineurs à Dakar, Sénégal.

OBJECTIVES: Specify epidemioclinical and legal aspects of sexual abuse among minors and evaluate the cost of care in Dakar. MATERIALS AND METHODS: This is a retrospective multicenter cross-sectional study on sexual abuse among minors over a period of four years from 1st January 2006 to 31st December 2009. Four maternities were targeted: the Social Hygiene Institute of Medina, health center Roi-Baudouin Guédiawaye, the Pikine hospital and health center Youssou-Mbargane-Diop of Rufisque. RESULTS: During the study period, 252 child victims of sexual abuse were supported at four health facilities on a total of 272 sexual abuses of all ages, a frequency of 92.64%. The epidemiological profile of our patients was a child of 11 years old on average, female (100%) and living in the suburbs of Dakar (68.1%). Children were often abused during working hours (31.7%), outside the family environment and often by someone known to the victim (72.6%). Genito-genital contact was the most common mode of sexual contact (80.9%) with vaginal penetration in 61% of cases. Almost all of the victims (92.1%) came to consult, accompanied by their parents, between the 1st and 4th day after the sexual abuse (70%). The examination usually revealed a hymenal trauma (59.9%) of which nearly half (49%) consisted of old lesions. 56.9% of victims had a post-traumatic stress disorder and 31.1%, mutism. We recorded six (6) pregnancies, 2% of our sample. A case of HIV infection was recorded on a sample taken 72hours after sexual abuse. Control of three months HIV serology was requested in 7.1% of cases and only 20% of children had received antiretroviral prophylaxis. Antibiotic prophylaxis had been performed in 13.7% of cases using doxycycline as drug of choice (75%). Only 29% of our patients had received emergency contraception progestin and psychological care concerned only 22% of children. On the legal aspects, 46% of our patients had filed a complaint. Prosecutions were 38%, 45% of which were convicted and 21% were acquitted. The rate of out-of-court settlement was 35% and the time limit for settlement by the justice was on average 6 months with extremes of one month and 24 months. The average cost of care was estimated at 17,010 CFA francs (26 euros) taking into account the consumables used for clinical examination (sterile gloves, catheter, syringe), analysis and prescription drugs. CONCLUSION: The sexual abuse of minors is a disturbing reality that raises rightly universal reprobation. In Senegal, this mainly affects children and its magnitude is increasing over the years. Improved support for victims necessarily involves raising public awareness through the media and the development of specialized structures in the management of sexual abuse.

[Epidemiology and prognosis of caesarean sections in University Hospital of Dakar]. / Epidémiologie et pronostic des césariennes au CHU de Dakar.

Caesarean section is our first activity in obstetrical surgery. Due to his high frequency and the maternal and foetal prognostic, we have undertaken to do a prospective, longitudinal, exhaustive study concerning all women whose delivery necessitated a caesarean section, between 01 January and 31 December 2001 in Gynaecological and Obstetrical Clinic of University Hospital Center Le Dantec. Our objectives were: describe the epidemiological aspects, evaluate the maternal and foetal prognosis of caesarean sections performed in University Hospital Center. The study revealed that 25.1% of births necessitated a caesarean section. The average age was of 26; the mean parity of 2; the medium height of 161cm. 26.4% of patients were evacuated and coming from the health centers in majority (41.9%) with unmedicalised evacuation in 44.9% of cases. 78.7% of patients have realised at least 3 antenatal consultations. The mains indications were cephalopelvic disproportions (34.9%) and foetal distress (18.9%). The classification per indications group revealed that 37.2% were "prudence caesarean section", 40.1% were "obligator's caesarean section" and 22.7% "necessity's caesarean section". The mean Apgar's score at the birth was 6,5 at first minute. 12 maternal deaths were noted, means 0.8% of global lethality; the morbidity was at 10.5% of cases, represented mainly by postoperative infection (64.3%). The per natal mortality was estimated to 5.9% and neonatal morbidity to 32%. About the quality of caesarean sections, the temporal (24h/24) and financial(kit of caesarean section) accessibilities are more satisfying; otherwise the quality of surgical act and the postoperative follow-up was not optimal. An inflationist advancement is actually noted about the rate of caesarean section, and due to the widening of the indications to the foetal interest. Nevertheless, despite agreed efforts, the quality is still insufficient because the maternal and per natal morbidity and mortality are still high.

[Threatened preterm labour: assessment of its management at the Dakar University Teaching Hospital]. / Evaluation de la prise en charge des menaces d'accouchement prématuré au CHU de Dakar.

The objective is to specify epidemiological profile of pre term labour birth and evaluate the efficiency of the tocolysis protocol of Dakar University Teaching Hospital. It's a retrospective study which included 155 cases of spontaneous premature birth registered from January 1st 2000 to December 31 2002 in obstetrician clinic. The incidence is 15 per 1000 childbirth. The epidemiological profiles on a pauciparous woman (mean age: 25 years), of low economic and social level (90%), admitted with a bad antenatal follow-up and a pathology associated with pregnancy dominated by arterial hypertension (25%). The mean age of gestation is 30 weeks; severe forms are prevalent and tocolysis score of Baumgarten is equal or higher than 4 in 71.6%. The three principal etiologists are toxaemia, premature rupture of membranes and infections. An association Salbutamol-Phloroglucinol is carried out in 28 cases (18%) or with Phloroglucinol in 25 cases (16.1%). In summary, 138 patients (89%) were finally confined by low way after 5 hours a median time. Perinatal mortality was 347.2 per 1000; it's related to the large premature ones particularly having a weight of birth less than or equal to 1300 grams (78%). The threats of pre term labour are often diagnosed tardily. The access to the tocolysis in emergency is limited and it's effectiveness practises very weak. Use of calcic inhibitors and the systematisation of corticotherapy should improve the forecast of prematurity.

[Uterine rupture in Senegal. Epidemiology and quality of management]. / Rupture utérine au Sénégal. Epidémiologie et qualité de la prise en charge.

The purpose of this prospective longitudinal study was to analyze data concerning patients treated for uterine rupture at surgical maternity hospitals in Senegal between January 1 to December 31, 1996. A total of 50 cases of uterine ruptures were recorded during the study period, i.e., 1 rupture for every 45 cesarian sections. Typical epidemiological features were rural residence (68%), age over 30 years (66%), multiparity (64%), and presence of obstetrical risks factors (76%). In 96% of cases, rupture usually occurred after failure or natural delivery assisted by personnel with limited skills in non-surgical facilities. Treatment consisted of uterine suture in 22% of cases and obstetrical hysterectomy in 78%. As a result of poor facilities for emergency transportation (68% of cases), mean delay between the indication for operative treatment and intervention was 11 hours. Maternal mortality and morbidity were 16% and 14% respectively. Neonatal mortality was 95%. The incidence of uterine rupture could be lowered by improving emergency obstetrical care and identifying risk factors for dystocia during prenatal examinations.

[Uterine perforation after an illegal abortion]. / Perforation utérine après avortement provoqué.

This study focuses on problems related to the management of peritonitis following non-medically assisted abortions in developing countries. Between January 1, 1997 and December 31, 1998, four cases of peritonitis due to perforation of the uterus occurred in a consecutive series of 101 women treated following non-medically assisted abortions at the Gynecology and Obstetrics Clinic of the University Hospital Center in Dakar, Senegal. Abortions were performed by untrained persons using dangerous instruments (wood or metal probes) for prices ranging from 5000 to 30,000 CFA francs. The mean interval between abortion and hospitalization was seven days. All patients presented in poor condition with low-grade symptoms of peritonitis. In 3 of 4 cases, the site of perforation was located in the isthmus (anterior, posterior, and lateral). Extensive necrotic lesions required hysterectomy. Postoperative complications occurred in 3 cases including parietal infection in one case, repeat peritonitis requiring re-operation in one case, and fatal iliomesenteric infarction in one case. Prevention could best be achieved by reducing unwanted pregnancies by better sex education and access to contraceptive techniques.

[Cesarean sections in Senegal: coverage of needs and quality of services]. / Césariennes au Sénégal: couverture des besoins et qualité des services.

A prospective longitudinal study was carried out of all women undergoing Cesarean section in the surgical maternity hospitals of Senegal between January 1 and December 31 1996. The epidemiology and quality of Cesarean sections were investigated. For each case, the following data were recorded: marital status, prenatal monitoring, conditions of hospitalization, indications for and outcome of surgery, maternal and neonatal follow-up one month after the operation. 2,436 Cesarean sections were performed. Of these, 2,269 cases were indexed and filed and 1,612 received a postnatal checkup one month after the operation. The mean age of the women involved was 26 years. The referral system is not effective, with 58% of patients being rushed to a surgical maternity unit in medically unsuitable forms of transport. Cesarean section is not widely available either geographically or economically. The mean national rate of Cesarean section was 0.6% of expected births but there were differences between regions. The main indications for Cesarean section were the fetus being too large to pass through the pelvic girdle (30%) and fetal suffering (18%). The maternal mortality rate was 3% and one third of the women who died did so immediately after the operation. Maternal morbidity occurred in 10% of cases, mainly due to postoperative infection. The rate of perinatal stress was 25%, most deaths being caused by neonatal distress (33%) or infection (18%). Thus, overall, both the availability and quality of Cesarean section in Senegal are poor.

PIP: A prospective study was conducted of all women delivering by cesarean section in Senegal's 22 surgical maternity hospitals during 1996. Adequate data were available to include 2269 of the 2436 cesareans performed. 13 hospitals performing 55% of the cesareans were in the Dakar area. Two of Senegal's 9 regions had no surgical maternity hospital and 4 had no gynecologists. 19.5% of the mothers were adolescents, and the average maternal age was 26 years. 46.5% were primiparous. 64% of the mothers were urban. 65% had at least 3 prenatal consultations and 12% had none. Only 28% were referred for cesareans before the onset of labor, and 57% were emergency evacuations. 6.7% of the women had to be re-evacuated from supposedly ultimate referral hospitals due to lack of supplies or personnel. 41% were transported to the hospital in ambulances, 14% in private cars, and 44% by public transportation. The 2436 cesareans corresponded to a rate of 0.6% of expected births, only 20% of the minimum need for cesareans estimated at 3%. Regional cesarean rates ranged from 1.3% in Dakar to 0.1% in Kaolack-Fatick. Feto-pelvic disproportion (30.4%) and fetal distress (18.2%) were the most common indications. 73 maternal deaths occurred, for a rate of 3%. 10% of the women had complications, with 55% involving infection. There were 9 cases of vesicovaginal fistula. The perinatal mortality rate was 25%, with 13% intrapartum and 13% neonatal. Neonatal distress and infection were the main causes of early neonatal death. Accessibility of cesareans is poor both geographically and economically.

[Antibiotic prophylaxis à la carte in self-contaminated gynecologic and obstetric surgery: importance of cefotaxime]. / Antibioprophylaxie à la carte en chirurgie gynécologique et obstétricale propre contaminée: intérêt du céfotaxime.

Infections represents 5% of our post-operative morbidity and result in the use of expensive antibiotics and longer hospital stays. As a less expensive alternative to systematic antibiotherapy for all patients, the authors propose a prospective and descriptive study of the effectiveness of antibioprophylaxis by administering 1 g of Cefotaxime pre-operatively. The study concerns a continuous series of 103 cases in gynaecology and obstetrics operated in the Dakar University Teaching Hospital, during a 13 months period (April 95-April 96). The average age of the patients is 30 years, the major types of surgery was cesarean sections, laparotomy for extra-uterine pregnancy and myomectomies. The duration of the surgery varied between 40 to 105 minutes with an average of 60 minutes. There was no intolerance to Cefotaxime. No cases of post operative infections were observed. All surgical wounds healed in 6 to 8 days except 2 minor cases of non-union of 1 cm. Antibioprophylaxis with Cefotaxime can therefore be considered as an effective means of preventing post-operative infections in clean surgery. It is easy to administer and also has the advantage of lower cost (4050 Fcfa compared to 29,000 Fcfa for classic antibiotherapy).

[Sexually transmitted diseases and female sterility at the University Hospital Center of Dakar: management and prevention]. / Maladies sexuellement transmissibles et stérilité féminine au CHU de Dakar: prise en charge et moyens de prévention.

It is a retrospective study supporting 82 cases continued series of feminine sterility and which objective is to evaluate the nursing management quality of genital infection in exploration and treatment of sterility. Women mean age is 26 years old, sterility is most primary frequently (68%) and from fallopian origin (80%). Followers examinations have been asked: vaginal taking (100%), urines cytobacteriology examination (56%), syphilis serology (23%), chlamydia serology (57%), mycoplasma serology (03%). Genital infection have been diagnosed in 75% of cases, in 33% of cases positive Chlamydia serology was found. Three molecules have been used principally in treatment: cyclines 50%, imidazoles derived 47%, lactamines 15%. The upper cost of diagnostic and treatments produce a wishest of prevention which based is the tracking and the precocious treatment of STD.

[Epidemiological surveillance and obstetrical dystocias surgery in Senegal]. / Surveillance épidémiologique et couverture chirurgicale des dystocies obstétricales au Sénégal.

Maternal morbidity and mortality remain major problems of public health in developing countries. Having long been neglected, maternal health is now being included among the priorities of a large number of countries. The rate of maternal mortality in Senegal is 850 per 100,000 live births, among the highest in the world. The main causes of maternal mortality in Africa are obstructed labour and uterine rupture, hypertensive disorders of pregnancy, puerperal infection and haemorrhage. An epidemiological survey of obstetric disorders was initiated in 1992 in Senegal to characterise the requirements for surgical coverage during pregnancy and delivery. In 1992, the national rate of caesarean section was low (0.66% of estimated births). However, rates differed greatly between regions, and between rural and urban areas. The indications for caesarean section were classified into three groups, each corresponding to a different public health issue. The rate of maternal mortality associated with surgery was high: 4.7%, of which 29% during surgery and 71% post op. Perinatal prognosis was also poor, with a mortality rate of approximately 30%. There are only 18 reference obstetrics units functioning, and they give a very uneven coverage of the country. These finding have led to new guidelines to improve the quality and cover of maternal care over the coming years.

PIP: Senegal's maternal mortality rate of about 850/100,000 is one of the highest in the world. A program of epidemiologic surveillance of obstetrical pathology and surgery was established in 1992 in Senegal's 18 obstetric services. The monitoring program targets extrauterine pregnancy; cesarean delivery; hysterectomy for rupture, infections, or hemorrhage; forceps or vacuum extraction delivery; and embryotomy. The National Office of Maternal-Child Health and Family Planning periodically calculates intervention rates based on standardized reports from the centers. Indications for cesarean were classified into three groups: obligatory, referring to conditions such as fetopelvic disproportion in which the delivery could not otherwise proceed; prudent, for cases such as scarred uteri or breech presentation in which cesarean is not indispensable but may provide a better prognosis for the mother or child; and necessity, in which dynamic dystocia, hypertension, or other usually preventable maternal condition has not been adequately treated and threatens to lead to emergency cesarean to save the mother's life. During 1992, around 3220 women underwent obstetrical surgery. 75% of the interventions were cesareans, 10% were forceps deliveries, 9% were extrauterine pregnancies, 3% were hysterectomies, 1% were embryotomies, and 2% were other. The average maternal age for all interventions and for cesareans was 26 years, 7 months. 18.2% of interventions were in women under 20. 36% were primiparas, 25% had 2-3 children, 16% had 4-5, and 23% had 6 or more. Average parity was 3.5. 67% of forceps or vacuum extraction deliveries were in primiparas, while 64% of hysterectomies for infection or hemorrhage and 40% for rupture were in grand multiparas. The principal study objective was to determine surgical coverage of obstetric pathology for the country and its regions. In 1992, 0.66% of deliveries in Senegal were cesareans, with rates ranging from 1.24% in Dakar to 0.24% in Tambacounda. 50% of the cesareans were for obligatory indications, 28% were for indications of prudence, and 22% were for indications of necessity. The proportion for different categories of indications differed greatly in different regions. The maternal mortality rate for all indications was 4.7%, representing over 150 deaths. 29% of deaths occurred during the intervention and 71% in the postoperative period. The maternal mortality rate was 0.8% for extrauterine pregnancy, 1.9% for forceps deliveries, 4.4% for cesareans, 29.3% for hysterectomies for rupture, and 32.0% for hysterectomies for infection or hemorrhage. The perinatal mortality rate for all indications except extrauterine pregnancy was nearly 30%. A goal of 3% of deliveries by cesarean has been established for Senegal to ensure that all situations defined as obligatory will be treated by cesarean. Steps must be taken to improve the accessibility and quality of obstetrical surgery throughout the country.