Perforated peptic ulcer (PPU) in pregnancy during Ramadan fasting.

BACKGROUND: Perforated Peptic Ulcer (PPU) is extremely rare in pregnancy. We report a case of perforated peptic ulcer in pregnancy during Ramadan fasting. PATIENT AND METHODS: The patient is a 16 years old primigravida who presented with features of peritonitis at 28weeks of gestation while fasting during Ramadan. Ultrasound scan reported a singleton live fetus at 28 weeks gestation. At laparotomy via upper midline incision; a 1 cm roundish perforation located on the duodenum anteriorly was found with about a litre of gastric juice mixed with blood and food particles in the peritoneal cavity. The perforation was close transversely with omental patch (Modified Graham's patch) and peritoneal lavage done with warm saline. She had a preterm delivery of a 1 kg baby 3 days post-operatively by a spontaneous vaginal delivery, but the baby died 3 days later. CONCLUSIONS: Perforated Peptic Ulcer(PPU) though rare in pregnancy can occur and fasting can be a risk factor.

The use of highly active antiretroviral therapy for the prevention of mother-to-child transmission of the human immunodeficiency virus in Nigeria.

Mother-to-child transmission of HIV accounts for 90% of paediatric HIV. The objective of this paper is to assess the outcome of preventing mother-to-child transmission of the human immunodeficiency virus (HIV), using highly active antiretroviral therapy (HAART). All pregnant women booking for antenatal care at the university of Maiduguri teaching hospital received voluntary counselling and testing for HIV. All HIV-positive mothers were placed on HAART for the prevention of mother-to-child transmission of HIV. All exposed babies received single dose nevirapine within 72 h of birth and zidovudine syrup for 6 weeks. The babies were then tested for viral DNA using the polymerase chain reaction (PCR) at 6 and 12 weeks of age. Among 5,461 mothers screened for HIV during the study period, 695 (12.7%) were confirmed HIV-positive. Out of 446 mother-baby pairs followed up to a minimum period of 6 months postpartum, only five (1.1%) babies were HIV-positive.

Hydatidiform mole as seen in a university teaching hospital: a 10-year review.

SUMMARY: Hydatidiform mole (HM), is a known cause of early pregnancy wastage and has the risk of malignant potential. This is a retrospective study of 71 patients who were managed for hydatidiform mole at the University of Maiduguri Teaching Hospital, (UMTH) Maiduguri over a 10-year period, from January 1996 to December 2005, inclusive. The objective of the study was to determine the incidence, risk factors, clinical presentations and histological types of HM. Case records of 71 histologically confirmed HM were studied. Their sociodemographic characteristics, clinical presentations and histology reports were obtained and analysed. The institutional incidence of molar pregnancy was 3.8/1,000 deliveries. Histological findings showed partial mole in 51 (71.8%) cases and complete mole in 20 (28.2%) cases. The peak age-specific incidence rate was 17.5 years. The leading presenting clinical feature was abnormal vaginal bleeding seen in 100%. No case of invasive mole was found. Maternal complications included severe haemorrhage requiring blood transfusion (30.0%) and infections (15.5%). There was no maternal death. In conclusion, the incidence of partial hydatidiform mole was found to be higher than that of complete variety in our environment and the identified risk factors were young age, low parity and previous history of HM.

Normal CD4 T-lymphocyte baseline in healthy HIV-negative pregnant women.

The CD4 count is frequently used as a surrogate marker for immune suppression associated with HIV infection and to monitor antiretroviral treatment. The aim of this study is to establish the normal reference values of CD4 count in healthy pregnant women in our environment. Pregnant women attending the antenatal clinic of the University of Maiduguri Teaching Hospital (UMTH) received voluntary counselling and testing for HIV. Those who tested negative had their CD4 count assessed using the cyflow method. Healthy non-pregnant women attending the family planning clinic of the UMTH as well as healthy men coming to donate blood at the blood bank of the same hospital were recruited as controls. A total of 128 pregnant women, 228 non-pregnant women and 185 men were recruited for the study. The mean CD4 count of the pregnant women was 751.41 cells/microl which was significantly lower than the mean CD4 count of 869 cells/microl for the non-pregnant women. Primigravidas had a lower mean CD4 count than both multiparas and grandmultiparas. Similarly, the mean CD4 count was higher in the first trimester than in the later parts of pregnancy. There was no significant difference in the mean CD4 count across all age groups. There is a slight fall in the mean CD4 count in pregnancy, which is more in the first trimester of pregnancy and in primigravidas. This should not affect the reference values for the initiation of antiretroviral drugs in pregnancy.

The safety of elective caesarean section for the prevention of mother-to-child transmission of HIV-1.

The benefits of elective caesarean section (ELCS) for the prevention of mother-to-child transmission (PMTCT) of HIV are now well known. However, the benefits of such a procedure must be weighed against the risks involved. This study examines the risks of ELCS for PMTCT at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria, from January-December 2006 inclusive. A total of 52 HIV-positive mothers who opted for ELCS for PMTCT were prospectively followed-up for any intra- and postoperative complication. A total of 52 cases of ELCS of HIV-negative mothers during the same period of study were used as controls. The HIV-positive mothers were found to be younger and of lower parity than the uninfected women. Unlike the uninfected mothers, they did not have co-morbid conditions, such as diabetes mellitus and severe pregnancy induced hypertension. There was no significant difference in intra- and postoperative morbidities between the two groups of mothers. The fetal outcome in terms of Apgar scores and birth weight was significantly better among the HIV-infected women. It is recommended that HIV-infected mothers in this environment should be offered the option of ELCS for the purpose of prevention of HIV from mother to child.

The value of the secondary yolk sac in predicting pregnancy outcome.

One hundred and five consecutive women had transvaginal sonography (TVS) at less than 12 weeks gestation to establish the normal size and shape of the secondary yolk sac (YS) and to assess the YS measurements in predicting pregnancy outcome in the first trimester. A yolk sac diameter more or less than two standard deviation (2SD) from the mean predicted abnormal pregnancy outcome with a sensitivity of 91.4%, specificity of 66% and a positive predictive value of 88.8%. A normal YS size predicted normal pregnancy outcome with a sensitivity of 66%, specificity of 91.4% and a positive predictive value of 95.6%. It is recommended that patients at risk of poor pregnancy outcome should have routine TVS before 12 weeks gestation to assess their YS and those with an abnormal yolk sac should be followed-up closely to exclude fetal abnormalities before 24 weeks gestation.

Cervical dysplasia in HIV infected women in Maiduguri, Nigeria.

The human immunodeficiency virus (HIV) infection has been shown to be a risk factor for premalignant and malignant conditions of the cervix. Patients attending the gynaecological clinic of the University of Maiduguri Teaching Hospital received voluntary counselling and testing (VCT) for HIV. All patients who were screened for HIV also had their pap smear taken. Cervical dysplasia was significantly commoner among HIV infected women than those that were HIV negative (31.3% vs 7.8%, respectively). The incidence of cervical dysplasia was also proportional to the degree of immunosuppression as women with low CD4 count had higher incidence of cervical dysplasia. The population studied was generally promiscuous irrespective of their HIV status, with over 90% of them having multiple sexual partners. It is recommended that health education in this population should be aimed at discouraging multiple sexual partners. Gynaecologists should be co-care providers to all HIV+ women in view of the menace of cervical dysplasia.

From low-lying implantation to placenta praevia: a longitudinal ultrasonic assessment.

A study of 895 consecutive pregnant women studied by transabdominal ultrasound scan showed an incidence of 14.6% of low-lying placenta at 12-14 weeks' gestation. Longitudinal follow-up of those with low-lying placenta showed that 85% of them had normally situated placenta at term. However, for those with partial or total placenta praevia at 30 weeks' gestation, 60% and 75%, respectively, persisted as major placenta praevia at term. A total of 45% of those with low-lying placenta at recruitment had threatened abortion while 15.7% had antepartum haemorrhage. The caesarean section rate was as high as 26% among the study population compared with 8.4% among the general population (P < 0.005). It is recommended that all antenatal women should have at least one ultrasound scan in the second or third trimester for placental localisation. Those found to have major placenta praevia in the third trimester should be closely followed-up.

Prevention of mother-to-child transmission of HIV at Maiduguri, Nigeria.

The human immunodeficiency virus (HIV) can be transmitted vertically through the placenta in utero, during labour and delivery and through breast milk. In Nigeria, about 5.8% of women attending antenatal clinics were HIV infected as of December 2002. It was projected that by the end of the year 2002, there were about 849,000 orphans resulting from AIDS and about 755,000 established paediatric AIDS in this country. Interventions to prevent mother-to-child transmission of HIV include voluntary counselling and testing (VCT), administration of antiretroviral drugs (ARV), modification of obstetric practices and infant feeding options in HIV infection. Over the period July 2002-June 2003, 262 pregnant women received VCT at the antenatal clinic of the University of Maiduguri Teaching Hospital, and 207 (79%) agreed to be tested. Thirty-one (11.8%) were HIV positive. The majority of the HIV positive mothers received nevirapine in labour while 35% had combination ARV drugs in pregnancy. All the infants received nevirapine suspension within 72 hours of delivery. Expensive and slow testing facilities, insufficient and inconsistent counsellors, lack of ARV drugs for both mother and baby as well as unaffordable caesarean delivery were some of the constraints being faced at this centre. It is recommended that the governments at various levels should show more commitment to the programme of preventing mother-to-child transmission of HIV.

Diagnostic features of cervical incompetence among women in Maiduguri.

The study was a review of the clinical features used to diagnose cervical incompetence. One hundred and forty-one clinical records of patients who had cervical cerclage inserted for cervical incompetence at the University of Maiduguri Teaching Hospital over a 5-year period, were studied retrospectively. Previous mid-trimester abortion occurred in 80.1% of the patients and was consecutive in 98 patients (69.5%). Sixty-eight (50.7%) patients had previous preterm deliveries, while 65 (46.1%) had a cervical cerclage inserted in a previous pregnancy. They had associated characteristic rapid painless expulsions of the fetus in previous pregnancies. One hundred and thirty-six patients had the McDonald's method of insertion (96.5%). There was a significant association between histories of previous midtrimester abortions, consecutive mid-trimester abortions and preterm delivery, with a significantly greater proportion of women with a previous history of preterm delivery having a recurrence in spite of the insertion of the cervical cerclage.

Cutaneous metastasis of gestational choriocarcinoma.

A 40-year-old woman presented with subcutaneous masses on her chest wall, abnormal vaginal bleeding and an enlarged uterus. Chest X-ray and liver ultrasound revealed metastatic disease to these sites, respectively. A urine human chorionic gonadotrophin assay was positive. A biopsy of the chest wall lesion and endometrium revealed choriocarcinoma. Treatment with methotrexate, actinomycin-D and cyclophosphamide led to complete resolution of the disease on examination, X-ray and ultrasound scans. The urinary pregnancy test became negative.

Severe burn injury in pregnancy in Northern Nigeria.

A total of 21 cases of severe burns in pregnancy managed at the University of Maiduguri Teaching Hospital, Maiduguri, over a 10-year period, spanning January 1991-December 2000 inclusively were reviewed. The pregnancy loss was 92.9%, with the pregnancies spontaneously terminated within 10 days of sustaining the injury. Maternal mortality was 47.6% with sepsis as the most common cause of death. It is advocated that viable pregnancies should be terminated as soon as the mother is resuscitated following severe burn injury. Prophylactic systemic antibiotics should be given to minimise the development of sepsis. Patients are best managed in the obstetrics ward during the first 2 weeks of injury. A multidisciplinary approach is encouraged in managing cases of severe burns in pregnancy.

A longitudinal study of amniotic fluid index in normal pregnancy in Nigerian women.

OBJECTIVE: To establish normal reference values of amniotic fluid index by week of gestation for normal pregnancies in our population. METHOD: A longitudinal prospective assessment of amniotic fluid index in healthy pregnant women carrying singleton pregnancies. The subjects were recruited at 20 or 22 weeks of gestation and concluded at 40 or 42 weeks of gestation. The numeral data were analyzed on an IBM Personal System 2 computer with statistical and graphical packages. RESULT: from a mean of 17.18 cm at 20 weeks gestation, the amniotic fluid index rose progressively to a peak of 20.39 cm at 26 weeks gestation. It then gradually declined to a mean of 8.37 cm at 42 weeks gestation. CONCLUSION: Gestational age specific values of amniotic fluid index should be used and the 5th and 95th percentiles taken as lower and upper limits of normal, respectively.

Normal fetal growth pattern in a Nigerian population.

The objective of this study was to establish normal reference range values for gestational age-specific fetal weights for normal pregnancies in our population. A longitudinal prospective assessment of fetal weight in healthy pregnant women was carried out. The subjects were recruited at 20 or 22 weeks' gestation and concluded at 40 or 42 weeks' respectively. The numerical data were analysed on an IBM personal systems 2 computer with statistical and graphical packages. From a mean of 407.27 g at 20 week gestation, the fetal weight progressively increased to 3630.00 g at 42 weeks' gestation. There were two growth spurs; 2830 weeks' and 3436 weeks' gestation, respectively. Gestational age-specific reference range values of fetal weight has been derived for our population. The 5th and 95th centiles should be taken as the lower and upper limits of normal, respectively.

Transvaginal ultrasound scan versus laparoscopy in the diagnosis of suspected ectopic pregnancy.

This is a prospective study comparing the performance of transvaginal ultrasound scan with laparoscopy as the last diagnostic tool in a clinically suspected ectopic pregnancy. Both diagnostic methods have the same sensitivity of 100%. Transvaginal ultrasound scan had a specificity of 73.7% and a positive predictive value of 89.8%. Laparoscopy had a specificity of 84.8% and a positive predictive value of 94.6%. The use of laparoscopy could avoid laparotomy in only 3.4% of patients. Since transvaginal ultrasound scan is easier, safer and cheaper than laparoscopy, more emphasis should be laid on its use in our environment than laparoscopy.

Caesarean morbidity and mortality at Maiduguri, Nigeria.

A total of 2456 deliveries took place at the University of Maiduguri Teaching Hospital, Maiduguri, between January 1995 and December 1996 inclusive. Two hundred and five women were delivered by caesarean giving a caesarean section rate of 8.3%. One hundred and ninety-eight (96.6%) case records were retrieved for analysis. Eighty-eight patients (44.4%) had one or more intra- and/or postoperative complications. Sepsis was the commonest complication involving 62 (70.4%) women. All were cases of emergency caesarean section. The incidence of other complications were anaemia, 59 (67%); hemorrhage, 38 (43.2%); and wound dehiscence, 11 (12.5%). There were two maternal deaths (2.3%) due to an anaesthetic accident and septicaemia respectively. The factors resulting in complications of the caesarean deliveries were prolonged obstructed labour, prolonged rupture of fetal membranes, previous caesarean sections, antepartum haemorrhage and severe pre-eclampsia and eclampsia. A review of the use of prophylactic antibiotics in selected cases, early recourse to operation in cases with cephalo-pelvic disproportion, and the acquisition of trained anaesthetists are advocated.

Maternal mortality in Maiduguri, Nigeria.

Maternal mortality is an index of the standard of antenatal care in a given environment. In developed countries the level of antenatal care has risen to an extent that maternal mortality has virtually disappeared (Nylander and Adekunle, 1990). This is in sharp contrast with the situation in developing countries like Nigeria where maternal mortality is still deplorably high. According to the World Health Organization, only 29-36% of deliveries in Africa are attended to by trained health personnel (World Health Organization, 1985). Therefore the mortality rates reported from most developing countries may be just the tip of the iceberg. Another disturbing dimension to the problem of maternal deaths in developing countries is the fact that most of the deaths are due to causes that can be prevented by the provision of essential obstetric care. Nearly a decade after the launching of the international safe motherhood initiative the tragedy of maternal deaths remains unmitigated in most developing countries such as Nigeria. The purpose of this study is to evaluate the causes of maternal deaths in two tertiary level hospitals in Maiduguri, north-eastern Nigeria and to identify ways of reversing the trend.