Improving maternal health in the face of tuberculosis: the burden and challenges in Ile-Ife, Nigeria.

Context: The super-imposition of tuberculosis on the demands of pregnancy confers a grim prognosis.Objectives: To determine the prevalence, pattern of presentation, management and outcome of tuberculosis among pregnant women in Ile-Ife during the first 10 years of the Millennium Development Goal-driven intervention.Study Design: A retrospective analysis of 29 women managed for tuberculosis during pregnancy and the puerperium at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife between 2001 and 2010 was done using SPSS version 16.0. Prevalence was determined using the total deliveries over the same period. Social class was determined using the Olusanya et al classification and assessment for congenital tuberculosis was done with Cantwell's diagnostic criteria.Results: There were 29 women with tuberculosis in pregnancy and puerperium, with 15,194 deliveries during the review period; giving a prevalence of 191 cases/100,000 deliveries. Cough and weight loss were the commonest complaints, and 53% of screened subjects were retroviral positive. Only 24% of these women were successfully treated using Directly Observed Treatment Short course; strike action and financial constraints being the hindering factors in 36% of them. The mean weight and EGA at birth were 1.87±0.69kg and 35.1±4.0 weeks respectively. Maternal and fetal case-fatality rates were 16.6% and 31.6% respectively.Conclusion: The high prevalence of tuberculosis in pregnancy in Ile-Ife is comparable to the national figures. The associated high feto-maternal morbidity and mortality rates also contribute to the unhealthy statistics of the country. Prevention of HIV infection and consistent health service delivery are advocated to reduce this scourge figures. The associated high feto-maternalmorbidity and mortality rates also contribute to the unhealthy statistics of the country. Prevention ofHIV infection and consistent health service delivery are advocated to reduce this scourge

Where there is no anaesthetist: the role of obstetrician - administered spinal anaesthesia for emergency caesarean section

Context: Shortage of anaesthetic manpower is a stark reality in developing countries like Nigeria where “waiting for the anaesthetist” has been repeatedly identified as a cause of phase 3 delays. This has led to widespread abuse of ketamine anaesthesia for emergency caesarean section in private hospital settings.Objectives: To determine the effect of single handed obstetrician-anesthetist administered spinal anesthesia for caesarean section on Decision-Delivery Interval (DDI), postoperative hospital stay, fetal and maternal outcome.Materials and Methods: A prospective analytical study comparing caesarean DDI between 42 consecutive emergency caesarean sections (CS) under Obstetrician-administered Spinal anesthesia (OASA) versus 42 women who had locum anesthetist administered spinal anesthesia (LAASA) and an equal number who had ketamine anesthesia.Results: The DDI was about 2.5 fold shorter in the OASA (59.67 ± 9.40 minutes) compared with the LAASA (144.54 ± 28.00 minutes) group (pConclusion: Obstetrician-administered Spinal Anesthesia for emergency caesarean section reduces Decision-Delivery Interval and postoperative hospital stay. It is therefore judicious where there is no anesthetist. Moreover, it is superior to ketamine anesthesia for caesarean section.Keywords: Obstetric anaesthesia, Spinal anaesthesia, Caesarean section, Bupivacaine, KetamineTrop J Obstet Gynaecol, 30 (1), April 201

Fertility-preserving Management of Cervical Ectopic Pregnancy in a Nigerian Teaching Hospital

Cervical Ectopic Pregnancies (CEPs) are commonly associated with adverse outcomes due to diagnostic and treatment challenges. This report describes the successful management of an initially misdiagnosed CEP. A 30-year-old G4P2+1(Alive 2) presented to the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, with vaginal bleeding following 11 weeks amenorrhea. The patient was haemodynamically stable, with minimal bleeding per vaginam, and ultrasonography had previously diagnosed complete miscarriage. However, transvaginal ultrasonography demonstrated classical hour-glass uterus. The ballooned cervix contained a gestational sac and foetal node without cardiac activity. The patient was managed with a single dose of intramuscular methotrexate injection. Her serum B-HCG concentration declined from 460.8mIU/ml at presentation to <5mIU/ml on the 10th day post-methotrexate injection, with a complete clinical and ultrasonographic resolution of the features. A high index of suspicion and appropriate ultrasonographic skills are necessary for prompt diagnosis of a CEP. Medical management could minimise the risk of intractable haemorrhage and hysterectomy

Hepatorenal Syndrome In Nigeria: A Review of Pathophysiology, Clinical Features and Management

Hepatorenal syndrome (HRS), a functional renal failure in patients with advanced chronic liver disease (CLD), cirrhosis or fulminant hepatic failure, in the absence of clinical or laboratory evidence of intrinsic renal disease is a common cause of admission into the intensive care unit. Despite the preponderance of CLD in our environment, HRS is rarely reported with sparse (if any) literature in our setting. In this review we discussed the definition, suggested aetiopathogenesis, clinical features and management. We reviewed cases of HRS managed in our centre and found that type 1, which is the more severe is common mainly because of late presentation and that majority of the patients did not benefit from renal replacement therapy because of haemodynamic instability. The review espoused the horrendous mortality associated with HRS particularly in the absence of liver transplantation and calls for urgent steps to set up liver transplantation units in our country as well as manpower training which will assist in arresting the mortality on a short term. On a long term however, there is the need for community prevention of CLD through mass vaccination against Hepatitis B and C as well as health education on deleterious socio-cultural practices. IFEMED Journal Vol. 14 (1) 2008: pp. 29-3

Criteria Based Audit of the Management of Severe Preeclampsia/ Eclampsia in a Nigerian Teaching Hospital

Background: This study discusses the usage of criteria –based audit in a Nigerian teaching hospital to evaluate the quality of care among patients with severe pre-eclampsia/eclampsia (SPE-E) against set standards and proffers possible interventions in order to improve the quality of care.Methods: The study was a prospective, descriptive hospital based study carried out from 1st of March to 31st of December, 2012. We conducted an 18 criterion-based audit on 52 consecutive cases of severe preeclampsia/eclampsia during the study period at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria.Results: There were 34 cases of severe pre-eclampsia and 18 eclamptic patients. The case fatality rate for SPE-E was 5.8 % and 13.5 % perinatal deaths among 59 infants delivered (multiple pregnancies inclusive). From the pre-determined standard of care based on 18 criteria, the performance score ranged from 17.3 to 100% (average 69.1%). Standard of care was optimal (100%) in taking detailed history and documentation, administering magnesium sulfate, initiating drug treatment for severe hypertension, respiratory rate monitoring and steroid treatment for fetal lung maturity and very sub-optimal for various laboratory investigations and initial consultant obstetrician input in the management of patients.Conclusion: For improvements in maternal and perinatal outcomes for patients with SPE-E, there should be strengthening of hospital facilities and avoidance of Phase 3 treatment delays in carrying out the comprehensive emergency obstetric and neonatal care needed. Hospital leaders should also be trained in hospital management for qualitative care.Keywords: Severe pre-eclampsia, eclampsia, criteria-based audit

Decision-to-Delivery Interval and Obstetric Outcomes of Emergency Caesarean Sections in a Nigerian Teaching Hospital

Background: Prolonged Decision-to-Delivery interval (DDI) is associated with adverse maternal-foetal outcomes following emergency Caesarean section (EmCS). Objectives: To determine the DDI, predictive factors, and the foeto-maternal outcomes of patients that had EmCS in a Nigerian Teaching Hospital. Methods: A descriptive study of all EmCS performed at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, from 1st June 2020 to 31st May 2021, was conducted. Relevant data were extracted from the documentations of doctors, nurses and anaesthetists using a designed proforma. The data obtained were analysed using the IBM SPSS Statistics for Windows, version 25. Results: The median (IQR) DDI was 297 (175-434) minutes. Only one patient was delivered within the recommended DDI of 30 minutes. The most common cause of prolonged DDI was delay in procuring materials for CS by patients’ relatives(s)/caregiver(s) (264, 85.2%). Repeat CS (AOR = 4.923, 95% CI 1.09-22.36; p = 0.039), prolonged decision-to-operating room time (AOR = 8.22, 95% CI 1.87-8.66; p 150 minutes was significantly associated with maternal morbidity (p = 0.001), stillbirth (p = 0.008) and early neonatal death (p = 0.049). Conclusion: The recommended DDI of 30 minutes for CS is challenging in the setting studied. To improve foeto-maternal outcomes, efforts to reduce the DDI should be pursued vigorously, using the recommended 30 minutes as a benchmark

The World Health Organization ACTION-I (Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns) Trial: a multi-country, multi-centre, two-arm, parallel, double-blind, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at risk of imminent birth in the early preterm period in hospitals in low-resource countries

BACKGROUND: Antenatal corticosteroids (ACS) have long been regarded as a cornerstone intervention in mitigating the adverse effects of a preterm birth. However, the safety and efficacy of ACS in hospitals in low-resource countries has not been established in an efficacy trial despite their widespread use. Findings of a large cluster-randomized trial in six low- and middle-income countries showed that efforts to scale up ACS use in low-resource settings can lead to harm. There is equipoise regarding the benefits and harms of ACS use in hospitals in low-resource countries. This randomized controlled trial aims to determine whether ACS are safe and efficacious when given to women at risk of imminent birth in the early preterm period, in hospitals in low-resource countries. METHODS/DESIGN: The trial design is a parallel, two-arm, double-blind, individually randomized, placebo-controlled trial of ACS (dexamethasone) for women at risk of imminent preterm birth. The trial will recruit 6018 women in participating hospitals across five low-resource countries (Bangladesh, India, Kenya, Nigeria and Pakistan). The primary objectives are to compare the efficacy of dexamethasone with placebo on survival of the baby and maternal infectious morbidity. The primary outcomes are: 1) neonatal death (to 28 completed days of life); 2) any baby death (any stillbirth postrandomization or neonatal death); and 3) a composite outcome to assess possible maternal bacterial infections. The trial will recruit eligible, consenting pregnant women from 26 weeks 0 days to 33 weeks 6 days gestation with confirmed live fetuses, in whom birth is planned or expected within 48 h. The intervention comprises a regimen of intramuscular dexamethasone sodium phosphate. The comparison is an identical placebo regimen (normal saline). A total of 6018 women will be recruited to detect a reduction of 15% or more in neonatal deaths in a two-sided 5% significance test with 90% power (including 10% loss to follow-up). DISCUSSION: Findings of this trial will guide clinicians, programme managers and policymakers on the safety and efficacy of ACS in hospitals in low-resource countries. The trial findings will inform updating of the World Health Organization's global recommendations on ACS use. TRIAL REGISTRATION: ACTRN12617000476336 . Registered on 31 March 2017