Previous Second Trimester Abortion: A risk factor for third trimester uterine rupture in three subsequent pregnancies. Report of three cases

The authors report on three cases of uterine rupture. The first two cases occurred spontaneously and the third occurred in labour. All the patients refused voluntary termination of pregnancy before surgery. The true story was only re-constituted after surgery. Literature on spontaneous rupture of the uterus is scanty but cases occurring after hysteroscopic metroplasty,resectroscopy for Asherman´s syndrome, hysteroscopic fundal perforation, and voluntary termination of pregnancy and in a primiparous woman are reported. Spontaneous uterine rupture though rare should always be considered in the differential diagnosis of a woman who presents with severe pain in the later half of pregnancy, with foetal loss, anaemia, with a stable orunstable hemodynamic status and a past history of unsafe termination of a second trimester pregnancy. Though rare, this possibility should be considered in the differential diagnosis of a prolonged third stage of labour. Thorough clinical history and physical examination of patients remains the cornerstone for accurate diagnosis of uterine rupture

A survey of knowledge, attitudes and practice of emergency contraception among university students in Cameroon

<p>Abstract</p> <p>Background</p> <p>Unsafe abortion is a major public health problem in low-and-middle income countries. Young and unmarried women constitute a high risk group for unsafe abortions. It has been estimated that widespread use of emergency contraception may significantly reduce the number of abortion-related morbidity and mortality. The purpose of this study was to evaluate the knowledge, attitudes and experiences on emergency contraceptive pills by the university students in Cameroon in order to develop and refine a national health programme for reducing unwanted pregnancies and their associated morbidity and mortality.</p> <p>Methods</p> <p>A convenient sample of 700 students of the University of Buea (Cameroon) was selected for the study. Data was collected by a self-administered, anonymous and pre-tested questionnaire.</p> <p>Results</p> <p>The response rate was 94.9% (664/700). General level of awareness of emergency contraceptive pills was 63.0% (418/664). However, knowledge of the general features of emergency contraceptive pills was low and misinformation was high among these students. Knowledge differed according to the source of information: informal source was associated with misinformation, while medical and informational sources were associated with better knowledge. Although the students generally had positive attitudes regarding emergency contraceptive pills, up to 65.0% (465/664) believed that emergency contraceptive pills were unsafe. Those with adequate knowledge generally showed favourable attitudes with regards to emergency contraceptive pills (Mann-Whitney U = 2592.5, p = 0.000). Forty-nine students (7.4%) had used emergency contraceptive pills themselves or had a partner who had used them.</p> <p>Conclusion</p> <p>Awareness of emergency contraception pills by Cameroonian students is low and the method is still underused. Strategies to promote use of emergency contraception should be focused on spreading accurate information through medical and informational sources, which have been found to be reliable and associated with good knowledge on emergency contraceptive pills.</p

Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial

Aims  The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results  Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) were adjudicated as Type 1, 386 (20.8%) as Type 2, and 244 (13.1%) as Type 4. Few events were Type 3 (n = 2) or Type 5 (n = 5). Alirocumab reduced first MIs [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77–0.95; P = 0.003], with reductions in both Type 1 (HR 0.87, 95% CI 0.77–0.99; P = 0.032) and Type 2 (0.77, 0.61–0.97; P = 0.025), but not Type 4 MI. Conclusion  After ACS, alirocumab added to intensive statin therapy favourably impacted on Type 1 and 2 MIs. The data indicate for the first time that a lipid-lowering therapy can attenuate the risk of Type 2 MI. Low-density lipoprotein cholesterol reduction below levels achievable with statins is an effective preventive strategy for both MI types.For complete list of authors see http://dx.doi.org/10.1093/eurheartj/ehz299</p

Effect of alirocumab on mortality after acute coronary syndromes. An analysis of the ODYSSEY OUTCOMES randomized clinical trial

Background: Previous trials of PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitors demonstrated reductions in major adverse cardiovascular events, but not death. We assessed the effects of alirocumab on death after index acute coronary syndrome. Methods: ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) was a double-blind, randomized comparison of alirocumab or placebo in 18 924 patients who had an ACS 1 to 12 months previously and elevated atherogenic lipoproteins despite intensive statin therapy. Alirocumab dose was blindly titrated to target achieved low-density lipoprotein cholesterol (LDL-C) between 25 and 50 mg/dL. We examined the effects of treatment on all-cause death and its components, cardiovascular and noncardiovascular death, with log-rank testing. Joint semiparametric models tested associations between nonfatal cardiovascular events and cardiovascular or noncardiovascular death. Results: Median follow-up was 2.8 years. Death occurred in 334 (3.5%) and 392 (4.1%) patients, respectively, in the alirocumab and placebo groups (hazard ratio [HR], 0.85; 95% CI, 0.73 to 0.98; P=0.03, nominal P value). This resulted from nonsignificantly fewer cardiovascular (240 [2.5%] vs 271 [2.9%]; HR, 0.88; 95% CI, 0.74 to 1.05; P=0.15) and noncardiovascular (94 [1.0%] vs 121 [1.3%]; HR, 0.77; 95% CI, 0.59 to 1.01; P=0.06) deaths with alirocumab. In a prespecified analysis of 8242 patients eligible for ≥3 years follow-up, alirocumab reduced death (HR, 0.78; 95% CI, 0.65 to 0.94; P=0.01). Patients with nonfatal cardiovascular events were at increased risk for cardiovascular and noncardiovascular deaths (P<0.0001 for the associations). Alirocumab reduced total nonfatal cardiovascular events (P<0.001) and thereby may have attenuated the number of cardiovascular and noncardiovascular deaths. A post hoc analysis found that, compared to patients with lower LDL-C, patients with baseline LDL-C ≥100 mg/dL (2.59 mmol/L) had a greater absolute risk of death and a larger mortality benefit from alirocumab (HR, 0.71; 95% CI, 0.56 to 0.90; Pinteraction=0.007). In the alirocumab group, all-cause death declined wit h achieved LDL-C at 4 months of treatment, to a level of approximately 30 mg/dL (adjusted P=0.017 for linear trend). Conclusions: Alirocumab added to intensive statin therapy has the potential to reduce death after acute coronary syndrome, particularly if treatment is maintained for ≥3 years, if baseline LDL-C is ≥100 mg/dL, or if achieved LDL-C is low. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01663402

Materno-foetal outcome of labour in obese women in Yaounde, Cameroon.

Overweight, obesity or morbid obesity has been shown to have a deleterious effect on the mother and the foetus. Among the various complications are macrosomic babies, increased caesarean section rate, postpartum haemorrhage, foetal distress and foetal death. The objectives of the study were to determine the socio-demographic characteristics of pregnant women with obesity and morbid obesity determine the mean birth weight, foetal length and Apgar score of the babies as well as associated maternal complications. This was a descriptive cross sectional prospective study carried out between the 1st of January and the31st July 2006. Recruitment was carried out in the maternity service of the main teaching hospitals in Yaoundé. All pregnant women in labour or in the immediate postpartum with body mass index greater or equal to 30 were fit for the study. About half of the women were married (46.5%), multi-parous (49%), attained the level of secondary education (59:3%). Most of the women were of low socio-economic status (82%) with the male partners slightly more financially fit than the women (57.1%). The 25-29years age group was most represented (32.6%), with the morbid obesity being preponderant (90.8%). Maternal complications were seen in 64% of the patients. The complications were more frequent in the morbid obesity than in the obesity group. Only uterine atony and placenta retention were seen in the obesity group. Placenta retention and caesarean section (20.5%) was commoner in the morbid obesity group. Stillbirths, small-for-dates, poor Apgar score and foetal macrosomia were reported inthe morbid obesity group. The babies were longer and weighed more with means of 51.3 cm and 3348 g respectively. Obesity and morbid obesity constitute a high risk factor in pregnancy. Pregnancy in these women must therefore be monitored closely in the ante-partum, intra-partum and immediate post-partum periods. Early detection of complications and treatment is paramount if we have to improve on the materno-foetal morbidity and mortality among obese pregnant women

A four-year retrospective review of postabortal surgical complications at the central maternity Yaounde, Cameroon

In Cameroon as in most African countries, the law on abortion is restrictive. Consequently most unwanted pregnancies are terminated clandestinely with the known associated high morbidity and mortality rates. We therefore decided to carry-out a retrospective cross-sectional descriptive study in order to determine the proportion of women operated for complication of induced abortions, describe the operative findings and associated morbidity, and the different treatment modalities and finally evaluate the outcome. The most affected groups were adolescents 15-19 years (30%) and single women and widows (30%). The mean gravidity and parity in the sample population were 3 and 1.7 respectively. Purulent collection in the peritoneum was observed in 78% of the patients. The volume of collection varied between 20 and 6000 ml with a mean of 1206ml. A rent or perforation was found on the uterus in 27(54%) of the patients. Perforation occurred mostly in the fundus, followed by the posterior, the anterior and lateral walls of the uterus. Associated lesions were found on the small bowel (10%), sigmoid (4%), bladder (2%) and omentum (4%). The corpus of the uterus was gangrenous in 12% of the patients. Inflammatory changes usually accompanied the infectious process. A frozen pelvis was found in 12% of the patients. An occlusive and/or pseudo-occlusive process was noted in 6% of the patients. All the patients had peritoneal washing with at least three litres of saline and drains left in the pouch of Douglas and/ or the paracolic gutter. The uterine perforation was repaired in 18 patients; 5 patients had subtotal hysterectomy; one patient had a total hysterectomy and three were left to heal by granulation. Only 4% of the patients were discharged within 10 days of hospitalisation. The maternal mortality rate in this study was 1400/100000. From this study it is evident that unsafe abortion is associated with an increased maternal morbidity and mortality. The issue of abortion is a delicate one in our country and most developing countries, presenting a complex moral and ethical dilemma. Most abortion laws in the developing countries, inherited from the former colonial powers, have remained stagnant for the past four decades, despite the fact that social values regarding sex and pregnancy have greatly changed. Although the legalisation on abortion in some developing countries have not positively influenced the incidence, reviewing the current law and policy on abortion to ensure that safe abortion services are made available to all women in our environment must be considered. The training of abortion providers may also help reduce the risk of unsafe abortions in our environment. Clinics in Mother and Child Health Vol. 2(2) 2005: 359-36

Purulent pelvic collections in HIV infected female patients: bacterial flora and antibiotic sensitivity

Purulent pelvic collections are common pathologies observed in contemporary gynaecological practice. They may originate from chronic pelvic inflammatory disease, from abortions or following normal deliveries. This study was designed to compare the bacterial flora in purulent pelvic collections obtained from HIV infected and noninfected female patients treated over a period of two years. Samples of pus were collected from both groups during laparotomy that was carried out by the same trained surgeon and sent for culture and sensitivity tests at the “Centre Pasteur” laboratory in Yaounde, Cameroon. There were 2016 admissions into the gynaecological wards during the study period and 113 (5.60%) were patients with purulent pelvic collections of whom 39 (34.50%) were tested positive for HIV. The collections in HIV positive patients were mainly chronic (tubo-ovarian abscesses, 53.83% and pyosalpinges, 2.207%). On the other hand acute pelvic collections (post partum 32.43%, post-abortum 46.65%) were predominant in women who were tested negative. Bacteroides spp and Staphylococcus aureus were the dominant bacteria isolated from HIV infected samples as against Escherichia coli and Streptococcus spp found in HIV noninfected samples. All the bacteria isolated were sensitive to chloramphenicol. HIV infected group of patients had longer periods of hospitalization. Routine counseling and testing of patients with purulent pelvic collections should be incorporated in their work-up packages before surgery and short courses of chloramphenicol therapy should be administered. Clinics in Mother and Child Health Vol. 2(2) 2005: 375-37

Variation of plasma plasmodium density among women receiving sulfadoxine – pyrimethamine for intermittent preventive treatment of malaria during pregnancy

Malaria prophylaxis during pregnancy is gradually being replaced with intermittent preventive treatment (IPT) using sulfadoxine - pyrimethamine (SP). This change in approach has been deemed necessary because of the high resistance to chloroquine by Plasmodium falciparum observed in malaria endemic zones. Chloroquine has been widely used for malaria prophylaxis. The objectives of this study was to evaluate the changes in plasmodium density among women receiving SP for IPT. The second objective was to determine the proportion of women who develop clinical malaria despite IPT. It was a descriptive analytic study that lasted two years (2003 – 2004 inclusive) at the Yaounde Central Maternity and at the University Biotechnological Centre in Nkolbison, Yaounde. 210 pregnant women who accepted freely to participate in the study were recruited between the 18th and 20th week of gestation. Parasite densities were determined initially (To) before the first dose of SP and two weeks after at T1, also at T2 (before the second dose of SP) and at T3 (two weeks after the second dose). The final parasite density estimations were at birth (T4). The women were followed up closely for evidence of clinical malaria. Ten out of 210 pregnant women recruited defaulted. Consequently only 200 women were followed up to term and received two doses of SP. 35.5% of them were infected at To with an average parasite density of 1415.9+155/mm3. At T1, the proportion of infected women and the average parasite density decreased to 6% and 755.62 + 205/mm 3 respectively. The proportion of infected women rose to 10.0% at T2 but the parasite density dropped to 385.44+ 331/mm3. At T3, only 1.4% of the women were infected and the average parasite density was 100/mm 3. At T4, no woman had a positive blood smear. 6.25% of the women developed clinical malaria. Clinics in Mother and Child Health Vol. 2(2) 2005: 351-35