Sublingual misoprostol to decrease blood loss after caesarean delivery: a randomised controlled trial.

The aim of the study was to compare the efficacy of sublingual misoprostol in addition to intravenous oxytocin, with oxytocin alone, in reducing blood loss during and following caesarean section. A total of 120 women undergoing caesarean delivery at the University College Hospital, Ibadan, were randomised into two equal groups. In Group A, 20 IU of intravenous oxytocin was given after umbilical cord clamping, while in Group B, the women received 400 µg misoprostol sublingually and 20 IU oxytocin intravenously. The outcome measures were blood loss, additional uterotonics, change in packed cell volume and side-effect profile. Associations between variables were determined by the χ(2) and Student's t-test. Relative risks were calculated for side-effects; the level of significance was p < 0.05. Intraoperative and postoperative blood loss were significantly lower in Group B (451.3 ml vs 551.2 ml, p = 0.007; 22.7 vs 42.2 ml, p < 0.001, respectively). In Group B, women were 7.4 (p < 0.001) and 9.0 (p = 0.008) times more likely to experience shivering and fever, respectively. The need for additional uterotonics was greater in the oxytocin group (66.7% vs 27.6%, p < 0.001). The addition of sublingual misoprostol to intravenous oxytocin reduces postpartum blood loss and the need for additional uterotonics. There is however, an increased risk of shivering and fever with this combination.

Knowledge of hepatitis B virus infection, access to screening and vaccination among pregnant women in Ibadan, Nigeria.

The knowledge of pregnant women about Hepatitis B virus infection at three different levels of healthcare and their access to screening and vaccination was evaluated by a questionnaire-based cross-sectional study. There were 643 respondents with a mean age of 30.2 ± 5.2 years and mean gestational age of 26.1 ± 8.4 weeks. The distribution of respondents was 55 (8.6%, primary), 204 (31.7%, secondary) and 383 (59.6%, tertiary) women. The majority of respondents were traders (36%) or civil servants/professionals (28.6%). Overall, 76% of all women had inadequate knowledge about hepatitis B infection; 19.5% had been screened, while 9.7% had been vaccinated. There was an increased likelihood of adequate knowledge, previous screening and vaccination among health workers (p = 0.00). Other positive predictors of knowledge and vaccination were tertiary education (p = 0.04) and tertiary care (p = 0.00). There is inadequate knowledge among pregnant women in Ibadan about Hepatitis B infection, with significant differences at the various levels of care, particularly in non-tertiary settings where screening and vaccination is also sub-optimal. Information dissemination, universal screening and vaccination services for pregnant women in Nigeria require urgent consideration.

FEMALE GENITAL MUTILATION: ARE WE WINNING?

BACKGROUND: For more than 25 years, efforts have been geared towards curtailing the practice of female genital mutilation (FGM) in countries like Nigeria. This study was designed to see if all these efforts have made any impact in reducing the prevalence of FGM appreciably in the south-West of Nigeria. OBJECTIVE: To determine the prevalence of female genital mutilation and profiling the trends of FGM affected patients. DESIGN: A prospective study based on direct observation of the external genitalia by health-care workers . SUBJECTS: Five hundred and sixty five females less than 15 years of age. SETTING: The children emergency and gynaecological wards of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria from 1st of January to December 31s 2007. RESULTS: Forty one point nine percent of the patients examined had female genital mutilation, 93.2% of these had the procedure before attaining the age of one year. Type 2 FGM predominated (58.22%). The procedure was performed predominantly (64.6%) by traditional birth attendants. The decision to have the procedure done was influenced in 78% of cases by mothers and grandmothers. In 35.4% of cases, there were immediate and short term complications. Demands of tradition predominated (59.1%) as the most important reason for the practice of female genital mutilation. CONCLUSION: The practice of FGM appears to be still highly prevalent and resistant to change probably due to deep rooted socio-cultural factors. Strategies such as public education campaigns highlighting its negative impact on health and disregard for human rights should be evolved.

HELLP syndrome: the experience at Ile-Ife, Nigeria.

Between 1 January and 31 December, 2006, 34 consecutive cases of severe pre-eclampsia (12), imminent eclampsia (10) and eclampsia (12) who were admitted at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife in the south-western part of Nigeria, were investigated for the development of HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome in a prospective study. The ages of the women ranged from 18 to 38 years, parity 0-5 and the estimated gestational age from 18-41 weeks at presentation. A total of 26 (76.5%) of the patients were unbooked, six (17.6%) of the 34 cases developed HELLP syndrome. Four (33%) of the 12 eclamptics developed HELLP syndrome, while only one (10%) of the cases of imminent eclampsia and 1 (8.3%) of severe pre-eclamptic cases developed the syndrome. Using the Mississippi Triple class system, none of the HELLP syndrome cases belonged to Class I; 4 were categorised in Class II while 2 were in Class III. All of the four eclamptic cases with HELLP syndrome died giving a 100% fatality rate while none of the imminent eclamptic and severe pre-eclamptic patients with the syndrome died. Furthermore, there were six (15.8%) perinatal deaths among the 38 infants delivered by the 34 mothers with severe pre-eclampsia/eclampsia. Our data suggest that the development of HELLP syndrome is more likely in eclamptic patients and when it occurs in them, it is highly fatal. Most of the cases in this study were unbooked. Substandard care may have contributed to the progression of the disease state and consequently, to maternal mortality. It is imperative to draw up an action plan for the identification of the risk factors for the development of pre-eclampsia/eclampsia at peripheral hospitals and maternity centres and for prompt referral of such cases afterwards. Efforts should also be geared towards the minimising of treatment delay in all phases, so as to minimise both perinatal and maternal morbidity and mortality.

Leiomyosarcoma of the uterus: a clinicopathological report of two cases and review of literature.

Leiomyosarcomas of the uterus are highly malignant tumours that are rare and represent slightly over 1% of all uterine malignancies. The clinical presentation is fairly constant and includes abnormal vaginal bleeding, pains or both. Only two cases (0.6%) out of 337 uterine malignancies seen over a period of 15 years in Ile-Ife had histological diagnosis of leiomyosarcoma. Both patients were postmenopausal, aged 49 years and presented in advanced disease stage. Two months after surgery, one of the patients died from disease progression while the other defaulted while on chemotherapy. Leiomyosarcoma of the uterus though rare in our environment, when it occurs, presents with advanced stage of the disease. Poor compliance coupled with high cost of treatment portends poor prognosis thus making it rapidly fatal.

Evaluation of health workers' training in use of the partogram.

OBJECTIVE: To assess the impact of training on use of the partogram for labor monitoring among various categories of primary health care workers. METHODS: Fifty-six health workers offering delivery services in primary health care facilities were trained to use the partogram and were evaluated after 7 months. RESULTS: A total of 242 partograms of women in labor were plotted over a 1-year period; 76.9% of them were correctly plotted. Community health extension workers (CHEWs) plotted 193 (79.8%) partograms and nurse/midwives plotted 49 (20.2%). Inappropriate action based on the partogram occurred in 6.6%. No statistically significant difference was recorded in the rate of correct plotting and consequent decision-making between nurse/midwives and the CHEWs. CONCLUSION: Lower cadres of primary health care workers can be effectively trained to use the partogram with satisfactory results, and thus contribute towards improved maternal outcomes in developing countries with scarcity of skilled attendants.

Determinants of antenatal booking time in a South-Western Nigeria setting.

BACKGROUND: Utilisation of antenatal services and early booking are important factors in the reduction of maternal mortality and morbidity and these are influenced negatively by social, cultural and religions factors. OBJECTIVE: To determine factors that influence the booking time in South Western Nigeria with the intention of identifying areas needing educational intervention. METHODS: A descriptive cross-sectional study of 327 antenatal patients done between January to March 2005. Using both structured and semi-structured questionnaires information were collected on the socio-demographic and complete medical history. RESULTS: Two hundred and forty-six (90.4%) out of the 272 women who met the inclusion criteria were interviewed. The mean (SD) age of patients was 30.47 (5.52) years, of which 60% of the mothers were educated beyond secondary school level and 44.3% of the patients booked late. Late booking was thrice as common in multiparae as in nulliparae. Variables that were significantly associated with time of booking included educational level of the husband (P = 0.005), parity (P = 0.012), previous miscarriage (P < 0.001) and medical problem in the index pregnancy. Stepwise regression analysis showed the latter two factors as predictors of booking time. (Beta of -0.566 and -0.643, respectively). 57.3% of pregnant mothers felt that women should book by the first trimester but half of them actively booked late. Early detection of problems was the commonest reason for the choice of time of booking. CONCLUSION: The socio-cultural and religious determinants of health-seeking behaviours need to be researched further and unless these are modified by interventional campaigns good education may not easily translate to optimum utilisation of antenatal services.

Assessment of delays in receiving delivery care at a tertiary healthcare delivery centre in Nigeria.

This study reviewed the causes of delays when patients were admitted with obstetric emergencies in Ife-Ife, Nigeria.

Difficult delivery and some selected factors as predictors of early postpartum psychological symptoms among Nigerian women.

OBJECTIVES: The objectives of this study were to compare depressive and anxiety symptoms between Nigerian women with a difficult delivery (cesarean or instrumental) and those with an unassisted vaginal delivery during the puerperium and to highlight other factors of predictive value for symptoms. METHODS: Women (n=83) who had a difficult delivery (index group) were compared with matched control subjects (n=83) who had an unassisted vaginal delivery. They were all evaluated using the State-Trait Anxiety Inventory (state form) and Zung's Self-Rating Depression Scale. Information was also collected on their sociodemographic characteristics, obstetric factors, and general health problems. RESULTS: After delivery, 19 subjects from the index group (22.9%) obtained scores higher than the threshold for significant depressive symptoms, as compared with 13 subjects from the control group (15.7%). Six weeks later, the rates were 10 (12.0%) and 8 (9.6%), respectively. The mean anxiety and depressive symptom scores for the difficulty delivery group were significantly higher at birth. Although both groups improved over time, the differences were still significant after 6 weeks. Using stepwise regression analysis, we observed cesarean delivery and polygamy to predict depressive symptoms after birth but not after 6 weeks. Previous induced abortions were also observed to predict anxiety and depressive symptoms throughout. Depressive symptoms at 6 weeks were predicted by depressive symptoms at birth and by anxiety symptoms at 6 weeks. The same pattern was observed for anxiety symptoms. CONCLUSION: Although difficult delivery was associated with higher levels of symptoms, it was not predictive of postpartum depressive and anxiety symptoms at 6 weeks. Also, of other possible risk factors studied, only illegal abortions were observed to be important in the study population during the puerperium.

Outcome of pregnancy in a population of Nigerian women with sickle cell trait.

Although variable clinicopathological entities have been documented in sickle cell trait in pregnancy, such information is absent in this environment. This study therefore was aimed at examining the outcome of pregnancy in a population of Nigerian women with sickle cell trait. A prospective analytical study was carried at Ile-Ife, Nigeria comparing morbidities and mortalities between 210 pregnant women with sickle cell trait and 210 women with HbAA. Data were processed using SPSS 11.0 and PEPI packages, and the p value was set at =0.05. There were no significant differences between mothers with sickle cell trait and HbAA in terms of sociodemographic characteristics, the course of labour, deliveries and morbidity patterns. However, mothers with sickle cell trait had significantly fewer attacks of malaria in pregnancy (25.7% compared with 34.8%) and faster recovery of their newborn from birth asphyxia at 1 min (0.9% compared with 4.9%). Sickle cell trait may confer greater resistance to malaria in pregnancy and carries no extra risk to the outcome of pregnancy.

Changes in sexual practices and responses among ante-natal clinic attendees in a Nigerian teaching hospital.

A cross-sectional study was carried out among 134 antenatal clinic attendees in a Nigerian tertiary hospital to assess pregnancy-related sexual beliefs and changes in sexual frequency and response. Information was collected through a semi-structured questionnaire, and analysed by SPSS. Only 15% of women believed that religious, social or cultural reasons prevented sexual intercourse in pregnancy. Frequency of sexual intercourse decreased in pregnancy in 37.4% of the respondents, remained unaltered in 46.1% and increased in 16.5%. Age, marriage duration and gestational age were not associated with change in the pattern of coital frequency in pregnancy, but education was significantly associated. Sexual responsiveness diminished in approximately half of our respondents in terms of arousal (54.5%), orgasm (48.5%), pleasure (43.7%) and satisfaction (51.4%). The changes were not associated with pregnancy duration. We concluded that sex in pregnancy is well accepted in our environment, and health workers should promote sexual health and well-being in pregnancy.

Emotional distress and its correlates among Nigerian women in late pregnancy.

A cross-sectional study was carried out in a Teaching Hospital to compare women in late pregnancy and matched controls for emotional distress. Each of the 156 pregnant women was matched with a control and studied to determine the relationship of some obstetric and sociodemographic factors with anxiety and depression. All the subjects were evaluated using the state form of the State-Trait Anxiety Inventory (STAI-state) and the Zung's Self-Rating Depression Scale (SDS), which are standardised instruments for assessing depression and anxiety, respectively. The pregnant women had significantly higher levels of anxiety and higher levels of depression than their non-pregnant controls. Four of the factors evaluated (age, level of education, socio-economic status and parity) were not found to be significantly related to anxiety or depression among the pregnant women. However, four other factors, i.e. polygamy, previous abortions, mode of previous delivery (caesarean section and instrumentally-assisted delivery) and previous puerperal complications had positive and significant associations with anxiety and depression. The implications of these findings are discussed.

Liberalisation of abortion laws in Nigeria: the undergraduates' perspective.

Nothing in the field of health care generates more controversy than does the issue of abortion. The views of 396 undergraduates of Obafemi Awolowo University, Ile-Ife, Nigeria concerning the liberalisation of abortion laws were investigated in May 2001. Ninety respondents (22.7%) supported the liberalisation of abortion laws in Nigeria because they believed that it would lead to reduction in associated morbidity and mortality, encourage more qualified personnel to perform it, encourage women to request abortion openly and encourage accurate statistics on abortion. However, the majority of the respondents (59.6%) opposed the liberalisation of abortion laws due to the fear that it would increase promiscuity, sexually transmitted diseases and abortion rates. Religious opposition and the belief that liberalisation would not reduce the level of poverty, ignorance and poor reproductive health facilities were the common factors leading to unwanted pregnancy and unsafe abortion in Nigeria. Support for the liberalisation of abortion laws shows significant relationship with increasing age (P = 0.001), male sex (P = 0.001) and a science-orientated faculty (P<0.05), but not religion. There is every indication that the issue of abortion is one that will continue to be unresolved for the forseeable future.