Postoperative vomiting and fever following tonsillectomy in Enugu, Nigeria.

OBJECTIVE: To determine the incidence of postoperative vomiting and fever in patients that had tonsillectomy in our centre over a five year period. METHODS: The hospital records (case files) of patients that had tonsillectomy with or without adenoidectomy under general anaesthesia at the University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria from January 2004 to December 2008 were retrieved and analyzed. Patients that had an adenoidectomy only were excluded. The patients were of the American Society of Anesthesiologists (ASA) I to III status. RESULTS: There were fifty two (52) patients that had tonsillectomy and adenotonsillectomy under general anaesthesia during the period under review. Forty one (41) patients were between the ages of 1-13 years (78%) and eleven (11) patients between the ages of 18-62 years (12%). There were 32 males and 20 females. The average age for all the patients was 9.03 years. There were seven (7) patients with post operative vomiting (13.4%). These included four (4) patients in the paediatric population (9.75%) and three (3) in the adult population (27.2%). Twenty one (21) patients (40.3%) developed postoperative fever. There were no deaths The other significant morbidity was postoperative pain. CONCLUSION: The number of patients that had tonsillectomy in our center was small compared to other studies. The incidence of postoperative vomiting in this study is lower than that reported from Western World, showing possible racial variations, a trend that has been reported in some earlier studies in Black populations.

Anaesthetic and obstetric challenges of morbid obesity in caesarean deliveries--a study in South-eastern Nigeria.

BACKGROUND: Morbid obesity of parturient has become very important in perinatal medicine because of a worldwide obesity epidemic. Morbid obesity of parturient is reportedly associated with severely increased anaesthetic and obstetric risk. OBJECTIVE: To determine the prevalence rate, anaesthetic and obstetric complications in morbidly obese parturient that had caesarean delivery in a Nigerian tertiary care centre. METHODS: The obstetric theatre records and case files were reviewed for caesarean deliveries in the University of Nigeria Teaching Hospital, Enugu, Nigeria from May 2008 to December 2010. A sample size of 250 patients, calculated based on a prevalence rate of 19%, confidence interval of 95% , a power of 80% and a finite population of zero was used to determine the prevalence rate of morbid obesity (Body Mass Index of greater than or equal to 35 kg/m(2)). RESULTS: There were thirty-one patients with morbid obesity (12.4%). The average Body Mass Index (BMI) was 38.3 kg/m(2)(SD ± 2.99). Other findings included macrosomia (7 or 25.8%), gestational diabetes (13%) and pregnancy induced hypertension (7 or 22.5%).There were two neonatal deaths but no maternal deaths. CONCLUSION: The prevalence rate of morbid obesity is about 10% in Nigerian women of child bearing age. This mirrors a World Health Organisation report published in the World Health Organisation Global Information Base.

Cesarean delivery in preeclampsia and seasonal variation in a tropical rainforest belt.

BACKGROUND: The pathogenesis of preeclampsia is poorly understood and recent evidence suggests that the incidence varies depending upon the season. AIM: This study was carried out to determine whether there is a seasonal variation in the presentation of preeclamptics undergoing cesarean delivery in a tropical rainforest belt. SETTING: A university teaching hospital. STUDY DESIGN: Retrospective. MATERIALS AND METHODS: The hospital records of consecutive patients (July 1996-June 2006) with preeclampsia, who underwent cesarean delivery in a tertiary care centre, were reviewed. Data collected included patient demographics, total number of deliveries, number of cesarean deliveries, and number of preeclampsia patients and time of presentation for cesarean section. Approval of the local ethical committee was obtained. STATISTICAL ANALYSIS: The EPI info software program was used for statistical analysis. RESULTS: A total of 6798 deliveries were recorded during the study period resulting in 6485 live births. There were 1579 cesarean deliveries during the period. Of these, 196 patients had toxemia of pregnancy (166 with preeclampsia and 30 with eclampsia). One hundred and forty-one patients (9% of cesarean deliveries) had cesarean delivery during the rainy season and 55 (3.5%) during the dry season (P < 0.05). Amongst preeclampsia patients, 115 presented (7%) during the rainy season and 51 (3.2%) during the dry season (P < 0.05). In the eclampsia group, 26 (1.65% of cesarean sections) presented during the rainy season and four (0.25%) during the dry season (P < 0.05). CONCLUSIONS: There was a seasonal variation in the cesarean delivery required for preeclampsia/eclampsia patients. This may help in counseling women on when to plan their pregnancy in order to reduce the morbidity and mortality associated with this apparent seasonal disease.

Challenges in critical care services in Sub-Saharan Africa: perspectives from Nigeria.

Critical care services in Nigeria and other West African countries had been hampered by economic reversals resulting in low wages, manpower flight overseas, government apathy towards funding of hospitals, and endemic corruption. Since then things have somewhat improved with the government's willingness to invest more in healthcare, and clampdown on resource diversion in some countries like Nigeria. Due to the health needs of these countries, including funding and preventive medicine, it may take a long time to reach reasonably high standards. Things are better than they were several years ago and that gives cause for optimism, especially with the debt cancellation by Western nations for most countries in the region. Since most of the earlier studies have been done by visiting doctors, mainly outside the West African subregion, this paper seeks to present a view of the challenges faced by providers of critical care services in the region, so that people do not have to rely on anecdotal evidence for future references.

Trends of different forms of anaesthesia for caesarean section in South-eastern Nigeria.

General anaesthesia is recognised as a cause of maternal mortality/morbidity in caesarean deliveries, and regional anaesthesia is believed to reduce anaesthesia-related maternal/fetal morbidity and mortality. The aim of this study is to present the trends of different forms of anaesthesia for caesarean section in Eastern Nigeria. We conducted a retrospective survey of hospital records of caesarean deliveries in this unit over a 4-year period from January 2003 to December 2006. There were 2,968 deliveries and 3,140 births (2,959 live births), with 729 women (24%) delivered by caesarean section. There was a yearly increase in the use of regional anaesthesia from 18% in 2003 to 48% in 2004 and 72.6% in 2005, but it fell to 71% in 2006. There were 59 stillbirths giving a stillbirth rate of 81/1,000 caesarean deliveries. The total number of stillbirths in the hospital during the study period was 179 giving a stillbirth rate of 60/1,000 deliveries. A total of 42 (71%) stillbirth deliveries were associated with general anaesthesia and 17 (29%) associated with spinal anaesthesia. Of the 32 neonates with an Apgar score of 3-5 at 5 min after birth, 21 (66%) delivered under general anaesthesia and 11 (34%) delivered under spinal anaesthesia. There were eight hysterectomies in patients with ruptured uterus, all under general anaesthesia. There was one maternal death in a patient who was delivered under general anaesthesia. The fetal loss in this study is high and may indicate that most data on stillbirths from parts of the developing world may be underestimates. In conclusion, in developing country such as Nigeria there is a changing trend towards the use of regional anaesthesia during caesarean section. Its use should be encouraged in the developing world, especially resource-poor environments because it is cheaper to provide.

Management of pituitary adenoma with mass effect in pregnancy: a case report.

A middle aged primigravida was managed at the University of Nigeria Teaching Hospital, Enugu, Nigeria for a pituitary macroadenoma. She was admitted at 33 weeks gestational age following a history of blurred vision and generalized headache, worse on bending down. After neurological consultation and investigations, a diagnosis of pituitary macroadenoma with mass effect was entertained. A plan for neurosurgery after delivery was made and the patient put on bromocriptine to reduce tumour size. Premature labour at 35 weeks resulted in caesarean delivery of a live baby. She was managed in the intensive care unit for three days where oral bromocriptine was resumed before she was transfered to the postnatal ward. Within ten hours of the transfer, she developed accelerated hypertension with encephalopathy and had a cardiac arrest shortly afterwards. This rare case highlights both the possible role of bromocriptine as a cause of postpartum hypertension and the possible development of a sudden catastrophic intramoural infarction or hemorrhage (pituitary apoplexy) in a patient with a macroadenoma.

Critical care management of eclamptics: challenges in an African setting.

We conducted a retrospective study of the management and outcome for eclampsia patients in the intensive care unit (ICU) of National hospital, Abuja between November 2001 and April 2005 (42 months). The patients' case files and ICU records were used to extract the necessary data. During the study period, there were a total of 4857 deliveries, with 5051 total births (including multiple births) and 4854 live births. Forty eclamptics were admitted to the ICU, giving an ICU admission rate of 8.2/1000 live births. The records of two patients were incomplete. The average age of the patients was 28.4 years (range 17-4 years). Six patients (15.8%) were booked and 32 (84.2%) were not. The average duration of stay in ICU was 5 days. Twenty patients (52.6%) had antepartum eclampsia, 12 (31.6%) had postpartum eclampsia and six (15.8%) presented with intrapartum eclampsia. Twenty-nine (76.3%) gave birth via caesarean section and nine (23.7%) delivered per vagina augmented by oxytocin infusion. Seventeen (45%) received mechanical ventilation; 20 (53%) received oxygen via nasal prongs, nasal catheters or variable performance facemask. One patient (2%) did not receive oxygen therapy. All the patients were admitted postpartum. There were 11 maternal deaths, giving a case fatality rate of 29%. There were five (45.4%) deaths due to haemolysis, elevated liver enzymes and low platelet count syndrome and two (18.2%) due to disseminated intravascular coagulation. The remaining deaths were due to cerebrovascular accident (9.1%), lobar pneumonia (9.1%), acute renal failure (9.1%) and multiple organ failure (9.1%). All patients were admitted postpartum. This fatality rate is higher than that detailed in the reports reviewed in this study. Early referral of eclamptics or at risk patients to a tertiary care institution may help reduce morbidity and mortality. In addition, early referral to a facility providing basic essential obstetric care or comprehensive essential obstetric care is also important. Another important factor is the correct diagnosis of pre-eclampsia during antenatal and postpartum care by screening, noting blood pressure levels, performing urinalysis for protein and asking about warning signs such as headache, blurred vision, epigastric pain, etc.

Critical care management of gynaecological patients in Enugu, Nigeria.

A retrospective study of the management of gynaecological patients admitted to the general intensive care unit (ICU) of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, over a 6-year span was carried out. Out of a total of 816 patients admitted to the ICU during the study period, 21 (2.6%) were gynaecological patients with the following diagnoses: generalized sepsis, postoperative respiratory distress, hypovolaemic shock, preoperative anaemia and mennorhagia, and major surgery with potential for major complications. The mortality rate was 28.6% with six deaths, sepsis being the major cause of death (four fatalities).

Maternal outcome in eclamptic patients in Abuja, Nigeria--a 5 year review.

OBJECTIVE: To assess the outcome ofwomen admitted with eclampsia in the National Hospital, Abuja, Nigeria. STUDY DESIGN/SETTING: A retrospective analysis. The medical records register in the accident and emergency department, labour ward, maternity ward and the intensive care unit were searched to identify cases of eclampsia admitted at the National Hospital,Abuja (NHA) between 1st March 2000 and 28th February 2005. RESULTS: The incidence of eclampsia was 7.8 per 1000 deliveries. Eclampsia significantly occured in nulliparous and unbooked mothers (p < 0.001 & p < 0.0001 respectively). Most (71.5%) of mothers delivered by Caesarean section and the most common indication for this was an unfavourable cervix (cervix thick, firm and closed when assessed at presentation in the labour ward). Nineteen (41.3%) of mothers developed complications with HELLP (hemolysis, elevated liver enzymes, low platelets) occurring in six patients (31.6%). There were 13 maternal deaths giving a case fatality rate of 28.3% and a maternal mortality ratio for eclampsia of222/100,000. HELLP syndrome was responsible for 46.2% of deaths in the study. CONCLUSION: The maternal outcome of eclamptics in Abuja, Nigeria is poor and HELLP syndrome is a major contributor to the high fatality rate. Emphasis should be on primary preventive measures such as early, continuous, good antenatal care and improvement of intensive care facilities. More widespread use of Magnesium sulphate for anticonvulsant prophylaxis is advocated.

Anaesthesia for uterine rupture in a Nigerian teaching hospital: maternal and fetal outcome.

BACKGROUND: An observational retrospective study was conducted at the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria to determine the outcome for patients with rupture of the gravid uterus who had anaesthesia for laparotomy over a four-year period, July 2000 to June 2004. METHODS: The hospital records (case files, labour ward and theatre records) of patients over a four-year period with rupture of the uterus were reviewed. RESULTS: A total of 2707 deliveries took place at UNTH, Enugu, Nigeria. There were 2556 live births (94.8% of deliveries) and 714 (26.4%) caesarean deliveries. Twenty-three cases of uterine rupture occurred, giving a prevalence of 8.5/1000 deliveries. In nine patents (39.1%) the uterus was already scarred. The patients' mean age was 30.2 years. No nulliparous patients suffered ruptured uterus. General anaesthesia with muscle relaxants was administered to all patients. Twenty-two patients (95.6%) received blood transfusions. All the patients received normal saline and one patient also received Haemacel. Five (21.7%) patients had preoperative hypotension and two (8.6%) had intraoperative hypotension. There was one maternal death which occurred three days after the cesarean section. Twenty-three (96.3%) fetal deaths, including the loss of a set of twins, were recorded. Fetal deaths from ruptured uterus represented 32.4% of all fetal loss following caesarean section during the study period. There were no neonatal deaths. CONCLUSION: Rupture of the gravid uterus presents the anaesthetist with the unique challenge of maintaining haemodynamic status before haemostasis is secured, often with the patient in shock. Choice of anaesthetic drugs and availability of blood are important, as well as the skill and experience of the anaesthetist. The maternal mortality rates in other West African studies reviewed were generally higher than those in this series. The maternal outcome re-emphasises the vital role of prompt intervention and availability of blood in reducing maternal mortality following rupture of the uterus.

Cerebrovascular accident with quadriplegia following postpartum eclampsia.

A 26-year-old woman (para 1 + 0) was managed at the National Hospital, Abuja, Nigeria for postpartum eclampsia with quadriplegia following referral from a peripheral hospital with a history of a solitary tonic/clonic seizure and unconsciousness. Her antenatal period had been uneventful until she presented with labour pains, where examination revealed an elevated blood pressure. She fitted once after delivery and remained unconscious for more than 12 h, hence the referral. The patient was managed in the intensive care unit (ICU), where she was found to be quadriplegic. She received mechanical ventilation for 21 days as part of her management in the ICU. Despite multidisciplinary care, she remained quadriplegic until a doctors' strike precluded further in-patient management. This rare complication of eclampsia is discussed, together with the patient's management.

Acute renal failure due to HELLP syndrome and acute renal failure in mid gestation.

A 34-year-old grand multipara (para 7, 4 alive) was managed at the National Hospital, Abuja, Nigeria for acute renal failure due to HELLP syndrome following referral from a peripheral hospital. She presented with a history of vomiting, headache, epigastric pain, loss of consciousness and tonic/clonic seizures. Though she was unsure of her exact dates, clinically the gestational age was estimated at 22 weeks. She was managed in the intensive care unit, following delivery of a macerated fetus within 15 h of hospital admission. The patient received mechanical ventilation and three sessions of haemodialysis as part of her successful management while in the intensive care unit. The uncommon presentation of eclampsia and HELLP syndrome before obvious preeclampsia is discussed, as well as the other signs and symptoms and patient management. The case also highlights the resource-poor environment of peripheral and tertiary hospitals in Nigeria.

Lightning injuries and acute renal failure: a review.

Lightning strikes cause multimodal injuries in victims, and although the number of deaths due to lightning is reportedly in the area of 1,000 deaths per year, they cause significant morbidity in many others. A major complication of a lightning strike is acute renal failure (ARF). The true incidence of ARF due to lightning injuries worldwide is difficult to ascertain because of significant underreporting, due in large measure to cultural and sociodemographic factors. Its incidence is reportedly rare in some literature and significant in others. However, lightning's potential to cause ARF due to myoglobinuria has been noted by many authors. Prompt treatment of myoglobinuric patients prevents the development of ARF. ARF due to direct organ damage by lightning is virtually unheard of. In this article, the current mechanisms of lightning injuries leading to muscle damage, myoglobinuria, and subsequent ARF are discussed, as well as signs and symptoms, laboratory investigations, and patient management.

Maternal and fetal outcome of anaesthesia for caesarean delivery in preeclampsia/eclampsia in Enugu, Nigeria: a retrospective observational study.

BACKGROUND: Maternal mortality, for which preeclampsia is a major cause, is a problem in Nigeria. Accurate data are available for caesarean sections in the University of Nigeria Teaching Hospital, Enugu. We therefore studied the outcome of caesarean section among these high-risk patients. METHOD: We conducted a retrospective survey of hospital records of patients with preeclampsia/eclampsia who had caesarean delivery in this unit over a four-year span from July 1998 to June 2002. RESULTS: There were 3926 deliveries and 4036 births (3611 live births), with 898 women (23%) delivered by caesarean section. Of these, 125 (14%) had preeclampsia/eclampsia, 103 (82.4%) presenting for emergency caesarean delivery and 22 (17.6%) elective. General anaesthesia was used in 116 patients (92.8%) and spinal in nine. The major indications for surgery were severe preeclampsia/eclampsia in patients with unfavourable cervix (68%), fetal distress/intrauterine growth restriction (7.2%) and previous caesarean section (6.4%). There were six maternal deaths, all with general anaesthesia, giving a case fatality rate of 5.2% of general anaesthetics or 4.8% of caesarean deliveries. The cause of death was anaesthetic in three patients, cerebrovascular accident and pulmonary oedema in two and intraoperative haemorrhage in one. There were 13 stillbirths and 10 neonatal deaths. CONCLUSION: Maternal and fetal mortality were high. Poverty, late presentation, lack of equipment and inexperienced management were major contributory factors. Use of spinal anaesthesia should be encouraged in view of recent favourable reviews and cheaper cost.

Admission pattern and outcome in critical care obstetric patients.

We undertook a six-year retrospective study to determine the pattern of admission and outcome for obstetric patients admitted to the intensive care unit of the University of Nigeria Teaching Hospital, Enugu. The hospital records (case notes and intensive care unit records) were used to extract the necessary data. A total of 816 patients were admitted to the intensive care unit during the period under review. Eighteen (2.2%) were obstetric patients. Nine (50%) were preeclamptic and eclamptic patients. Four patients (22.2%) had obstetric haemorrhage. Five others presented with the following: asthma, postoperative respiratory distress, cervical incompetence, gestational diabetes and hypertension, and caesarean section for terminal carcinoma of the breast. There were six deaths (mortality rate 33.3%). Preeclampsia/eclampsia accounted for four deaths (44% mortality rate amongst preeclamptics/eclamptics), while two deaths accounted for a 50% mortality rate in the obstetric haemorrhage group. This study confirmed similar reports from the advanced nations and Asia that preeclampsia/eclampsia and obstetric haemorrhage are the leading causes of admission to the intensive care unit. The mortality rate in this study is however higher.