Placenta percreta causing spontaneous uterine rupture and intrauterine fetal death in an unscared uterus: A case report.

INTRODUCTION: Placenta percreta is a rare; a life-threatening disorder of placentation and one of the components of the placenta accreta spectrum. It can lead to uterine rupture, an obstetric catastrophe that can be associated with increased maternal and fetal morbidity and mortality. PRESENTATION OF CASE: We present an unusual case of spontaneous uterine rupture due to placenta percreta in an unscarred uterus of a multiparous woman leading to spontaneous intrauterine fetal death. She presented with hypovolaemic shock following spontaneous rupture of the uterus and subsequent intra-peritoneal bleeding. DISCUSSION: Uterine rupture occurs commonly in a scarred uterus from some form of trauma or injudicious use of oxytocics. However, uterine rupture occurring in the absence of prior scar or use of oxytocics is a rarity. Placenta percreta is an unusual cause of uterine rupture and subsequent intra-uterine fetal death. Placenta percreta occurs when the uterine wall is invaded by the placenta up to the level of the serosa. A high index of suspicion and thorough review of the patient is required for making this diagnosis. Misdiagnosis is associated with dare consequences of increased maternal morbidity and mortality. CONCLUSION: Placenta percreta is a rare disorder of placentation that can cause uterine rupture which can easily be misdiagnosed. Prompt diagnosis and institution of the appropriate care can help prevent catastrophic outcomes as demonstrated in the case reported.

Patterns of gestational weight gain and its association with birthweight in Nigeria.

BACKGROUND: Despite the increasing global importance of gestational weight gain (GWG) and its impact on birthweight, little is known about the patterns of GWG in African populations. OBJECTIVES: To determine the pattern of GWG and its association with birthweight in Nigeria. METHODS: It was a longitudinal study of 200 pregnant women receiving antenatal care at two tertiary hospitals in Enugu, south eastern Nigeria. The women were consecutively recruited at <14 weeks gestation and their body mass indexes recorded upon recruitment. Thereafter, weight measurements were taken at each visit until 38-39 weeks. RESULTS: Mean total GWG was 10.7 ± 3.4 kg, while mean birthweight was 3.3 ± 0.6 kg. GWG in second trimester had positive correlation with birthweight (r = 0.164, P = 0.02). Obese women gained above the recommended limits by the "institute of medicine" while underweight women gained below the limits. Excessive total GWG was associated with higher risk of macrosomia [8/21 (38.1%) vs. 7/179; RR: 9.74; 95% CI: 3.9-24.2; P < 0.001] while inadequate total GWG was associated with higher risk of low birth weight [7/72 (9.7%) vs. 3/128 (2.3%; RR: 4.15; 95% CI: 1.1-15.4; P = 0.03]. Maternal age of <35 years, high social class, nulliparity, and regular antenatal care were associated with normal GWG while maternal age <35 years and regular antenatal care were associated with normal birthweight (P < 0.05). CONCLUSIONS: Women should be counseled on the factors that influence GWG and birthweight. Interventions to assist women achieve appropriate GWG may need to include components related to improved dietary intake for the underweight and increased physical activity for the obese.

Audit of Childbirth Emergency Referrals by Trained Traditional Birth Attendants in Enugu, Southeast, Nigeria.

BACKGROUND: The essence of training traditional birth attendants (TBAs) is to attend to women in uncomplicated labor and to refer them immediately to hospitals when complications develop. AIM: The aim was to audit childbirth emergency referrals by trained TBAs to a specialist hospital in Enugu, Nigeria. SUBJECTS AND METHODS: A retrospective study of 205 childbirth emergencies referred to Semino Hospital and Maternity (SHM), Enugu by trained TBAs from August 1, 2011 to January 31, 2014. Data analysis was descriptive and inferential at 95% confidence level. RESULTS: Most of the patients (185/205, 90.2%) were married and (100/205, 48.8%) had earlier booked for antenatal care in formal health facilities. There were obstetric danger signs or previous bad obstetric histories (pregnancies with unfavorable outcome) in 110 (110/205, 53.7%) women on admission at SHM. One hundred and fifteen (115/205, 56.1%) women walked into the hospital by themselves while 50 (50/205, 24.39%) could not walk. The fetal heart sounds were normal in 94 (94/205, 45.6%), abnormal in 65 (65/205, 31.8%) and absent in 42 (42/205, 20.4%) of the women on admission. Five healthy babies were delivered by the TBAs before referring their mothers. Delays of more than 12 h had occurred in 155 (155/205, 76.6%) of the women before referrals. Prolonged labor (100/205, 48.8%), obstructed labor (40/205, 19.5%), attempted vaginal birth after previous cesarean delivery (40/205, 19.5%) and malpresentation (30/205, 14.6%) were the common indications for referrals. The maternal mortality and perinatal mortality ratios were 610/100,000 live births and 228/1000 total births respectively. CONCLUSION: Delays at TBA centers are common before referral and most patients are referred in poor clinical state. Further training and re-training of the TBAs with more emphasis on recognition of obstetric danger signs and bad obstetric histories may help in screening high-risk patients for prompt referral to hospitals before complications develop.

Cesarean Delivery for a Life-threatening Preterm Placental Abruption.

Placental abruption is one of the major life-threatening obstetric conditions. The fetomaternal outcome of a severe placental abruption depends largely on prompt maternal resuscitation and delivery. A case of severe preterm placental abruption with intrauterine fetal death. Following a failed induction of labor with a deteriorating maternal condition despite resuscitation, emergency cesarean delivery was offered with good maternal outcome. Cesarean delivery could avert further disease progression and possible maternal death in cases of severe preterm placental abruption where vaginal delivery is not imminent. However, further studies are necessary before this could be recommended for routine clinical practice.

Acceptability of human papilloma virus vaccine and cervical cancer screening among female health-care workers in Enugu, Southeast Nigeria.

BACKGROUND: Cervical cancer, a leading cause of cancer deaths in women in developing countries can be prevented primarily by vaccinating adolescent girls and women against infection by the human papillomavirus (HPV) before their first sexual exposure, and secondarily through screening and treatment of identified precancerous lesions. AIM: To determine the awareness and acceptability of the HPV vaccine and screening for cervical cancer among female health-care workers in Enugu, southeastern Nigeria. MATERIALS AND METHODS: Questionnaires were administered to a cross-section of 177 female health-care workers selected systematically from the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. Statistical analysis was both descriptive and inferential at 95% confidence level using the Statistical Package for Social Sciences (SPSS) computer software version 16. A P value of less than 0.05 was considered statistically significant. RESULTS: The awareness of screening for cervical cancer (91%) was significantly higher than that of the HPV vaccine (62.7%) [odds ratio (OR): 0.17; 95% confidence interval (CI): 0.09-0.30]. However, the acceptability rate of the HPV vaccine (91.0%) was significantly higher than that of cervical screening (71.4%) (OR: 4.04;95% CI: 1.94-8.42)]. Only 25 (14.1%) of the health-care workers had done cervical screening, but 30 (49.2%) of the 61 respondents with adolescent daughters had immunized their daughters with the HPV vaccine. Although no reason was given for the low participation in cervical screening, cost and availability of HPV vaccine was a major deterrent for the latter. CONCLUSION: With more public enlightenment, available and affordable HPV vaccine appears to hold the key for prevention of cervical cancer in developing countries where the burden is high.

Acceptability of Human Papilloma Vrus Vaccine and Cervical Cancer Screening among Female Health-Care Workers in Enugu; Southeast Nigeria

Background: Cervical cancer; a leading cause of cancer deaths in women in developing countries can be prevented primarily by vaccinating adolescent girls and women against infection by the human papillomavirus (HPV) before their first sexual exposure; and secondarily through screening and treatment of identified precancerous lesions. Aim: To determine the awareness and acceptability of the HPV vaccine and screening for cervical cancer among female health-care workers in Enugu; southeastern Nigeria. Materials and Methods: Questionnaires were administered to a cross-section of 177 female health-care workers selected systematically from the University of Nigeria Teaching Hospital (UNTH); Enugu; Nigeria. Statistical analysis was both descriptive and inferential at 95confidence level using the Statistical Package for Social Sciences (SPSS) computer software version 16. A P value of less than 0.05 was considered statistically significant. Results: The awareness of screening for cervical cancer (91) was significantly higher than that of the HPV vaccine (62.7) [odds ratio (OR): 0.17; 95 confidence interval (CI): 0.09-0.30]. However; the acceptability rate of the HPV vaccine (91.0) was significantly higher than that of cervical screening (71.4) (OR: 4.04;95 CI: 1.94-8.42)]. Only 25 (14.1) of the health-care workers had done cervical screening; but 30 (49.2) of the 61respondents with adolescent daughters had immunized their daughters with the HPV vaccine. Although no reason was given for the low participation in cervical screening; cost and availability of HPV vaccine was a major deterrent for the latter. Conclusion: With more public enlightenment; available and affordable HPV vaccine appears to hold the key for prevention of cervical cancer in developing countries where the burden is high

Post-myomectomy intussusception: report of two cases.

BACKGROUND: Post-myomectomy intussusception is a very rare cause of post-operative intestinal obstruction in adult surgical practice. Preoperative diagnosis is usually missed or delayed because the symptoms are usually subacute and nonspecific. METHOD: The case notes of the patients were retrieved and relevant data extracted and summarized. An extensive literature search was done and results reviewed and compared with the present case. RESULTS: The two patients reported developed features of post operative intestinal obstructions which were thought to be due to adhesive bands and initial conservative managements instituted. Exploratory laparotomies later revealed ileo-ileal and jejuno-ileal intussusceptions which were reduced without resection with good outcome. CONCLUSION: Intussusception is a rare but serious complication of myomectomy. High index of suspicion with prompt intervention and early team management optimize outcomes.

Pregnancy after rupture of the pregnant uterus.

Pregnant women managed by us after suture repairs for rupture of the pregnant uterus between 2006 and 2009 in Enugu, South-east Nigeria were reviewed. Five pregnancies were managed during the study period. Four had normal pregnancies. Three booked early in pregnancy and had repeat caesarean deliveries at 36 weeks' gestation. One booked at another private hospital but had emergency caesarean section at 38 weeks' gestation. The fourth woman had repeat rupture at 28 weeks' gestation, suture repair and bilateral tubal ligation. Four healthy babies were discharged home. There was no maternal death. The outcomes of pregnancies after rupture of the pregnant uterus are good. Suture repairs should be the method of choice whenever preservation of future fertility is necessary. The woman and her family must be counselled on the associated risks and the need for hospital delivery by elective caesarean section in the subsequent pregnancies before discharge.

Impact of Free Maternal and Child Healthcare programme on maternal and neonatal healthcare outcome in Enugu State of Nigeria.

BACKGROUND: Unaffordable medical bills is a major barrier to utilization of maternal and child healthcare services. This is associated with very high maternal and perinatal mortality and the inability to attain the MDG4 and MDG5 in many developing countries. This study examined the uptakes of obstetric services following introduction of Free Maternal and Child Health Care (FMCHC) in Enugu State University Teaching Hospital, Southeast Nigeria and its impact on the maternal and neonatal healthcare outcome. METHODS: A retrospective comparative study of the utilizations of maternal and child healthcare services from June to August in 2008 with that of September to November in 2008 after commencement of the FMCHC. Information on all the pregnant women and neonates in their first week of Life that attended clinic within the period under review was collected from the Medical Records department of the hospital. RESULTS: FMCHC caused tremendous increases in the uptakes of antenatal booking (202.2%), and hospital delivery (151.8%). It also resulted in decreased maternal and perinatal mortality by 16.4% and 34% respectively. CONCLUSION: Implementation of FMCHC can make MDG4 and MDG5 attainable in sub-Saharan Africa.

Multiple antenatal bookings among pregnant women in Enugu, Nigeria.

Some pregnant women do book concurrently with multiple antenatal care providers. Structured questionnaires were administered to women attending antenatal clinics in 12 facilities in Enugu, Nigeria. A total of 535 women responded: 372 (69.5%) were booked into more than one facility and 163 (30.5%) were booked into a single facility; 280 (52.3%) booked into the two Teaching Hospitals and 91 (12.5%) booked with a traditional birth attendant. Reasons for multiple bookings included selecting a facility with affordable prices (43.9%); selecting a facility promising vaginal delivery (35.3%); avoiding HIV testing (17.9%); avoiding caesarean section (10.8%); avoiding being regarded as unbooked (10.1%) and booking into a facility where they were not known. Possible disadvantages were confusion in deciding where to deliver (53.1%); default on expert advice (27.5%); mismanagement (18.7%); delays, complications and death (12.5%). Multiple bookings were common in this study. Disadvantages of this practice, including risk of death, were identified by the women.

Maternal mortality in a transitional hospital in Enugu, south east Nigeria.

Nigeria has one of the highest maternal mortality ratios in the world. The study was to determine the trend of maternal mortality ratio in the hospital as it transits from a General through a Specialist to a Teaching hospital. It was a retrospective review of maternal deaths at Enugu State University Teaching Hospital Parklane, over its 5 year transition period (January 2004 to December 2008). There were 7146 live births and 60 maternal deaths giving an overall maternal mortality ratio (MMR) of 840/100,000 livebirths. The MMR rose from 411 to 1137/100,000 live births as a specialist hospital, with a decline to 625/100,000 as a Teaching hospital. Pre-eclampsia/eclampsia was the leading cause (29.63%) of maternal death. MMR was highest as a Specialist hospital due to limited manpower and inadequate facilities to properly manage the rising number of referred obstetric emergencies. Adequate preparations should be made before upgrading a hospital, to enable it cope with the challenges of managing referred obstetric emergencies

Sexual risk behaviour among undergraduate students in Enugu, Nigeria.

This study aims to identify high-risk sexual behaviour among undergraduate students in a developing country and to formulate programmes targeted at reduction of complications of such risky sexual behaviour. This was a questionnaire survey taken of undergraduate students in four institutions of higher learning in Enugu, Nigeria over a 1-month period. The prevalence of sexual activity was 76.8%, with 85.4% of females and 62.3% of males having more than one sexual partner. More female students than their male counterparts (65.7% vs 42.2%) had their first sexual encounter as an adolescent. Sexual risk behaviour that includes having multiple sexual partners, not using a condom, anal and oral sex were more common among the lower social class, adolescents, females and those living off-campus. While economic reasons are a major factor that encourages risky sexual behaviour in the female, the urge to have sex and curiosity, tended to favour such sexual experimentation in the male. Despite a good knowledge of the complications that could follow such risky sex behaviour, the sex lives of the students remained unchanged. Educational and risk reduction programmes targeting a change in belief and behaviour is required to maintain sexual safety among these youth.