Neonatal thrombocytopenic purpura: report of two cases and review of literature

Severe neonatal thrombocytopenia is a hematological emergency that can be due to increased platelet destruction(such as immune-mediated and peripheral platelet consumption) or congenital failure of platelet production. The definitive diagnosis of the underlying cause of neonatal thrombocytopenic purpurais based on both clinical and laboratory findings.Case report; We present two infants with persistent severe thrombocytopenia of distinct aetiologies: neonatal alloimmune thrombocytopenic purpura and hepatitis B virus exposure. Their clinical course, haematological profile and treatments are discussed.Conclusion: This reportreiterates the need to think laterally while considering the differential diagnoses of neonatal thrombocytopenic purpura. Moreover, ithighlightsits treatment challenges in peripheral health facilities, especially in resource-limited settings

Decompressive Craniotomy in the Management of Entrapment of after Coming Head of Breech with Intrapartum Fetal Death in a Rural Centre: A Case Report

Background: Several studies have demonstrated a high prevalence of strong aversion for caesarean section among Nigerian women; hence, interventions of proven efficacy in reducing caesarean section rate are crucial. Although controversial in modern day obstetric practice, destructive operation is still of importance in reducing caesarean section rates in Nigeria, especially in the rural setting.Case: A case of breech delivery complicated with intra-partum fetal death and entrapment of the aftercoming head is presented. The patient  presented with a fresh stillbirth dangling in the introitus in breech presentation with the head entrapped in the pelvis. A de-compressive craniotomy was performed with subsequent delivery of the entrapped after-coming head.Results: There were no post-procedure complications.Conclusion: Training of medical personnel in the skills of destructive  operation is recommended, as it still has a role in reducing caesarean section in rural settings

Premature rupture of membranes at term: immediate induction of labor versus expectant management

Objective: To compare the maternal outcomes of immediate induction of labor with expectant management in women presenting with premature rupture of membranes (PROM) at term.Methods: One hundred and fifty two women with PROM at term were randomized into either immediate induction of labor with oxytocin or expectant management for a period of 12 hours. The primary outcome measure was the incidence of clinical endometritis in each group. Secondary outcomes were the mode of delivery, the neonatal outcome and the proportion of women in the expectant management group that progressed to spontaneous labor.Results: The immediate induction arm had a lower caesarean section rate, (7.9% vs 28.9%, P=0.001), higher spontaneous vaginal delivery rate (92.1% vs 71.1%; P=0.001) and lower incidence of clinical endometritis (0% vs 5.3%, P=0.006), when compared with the expectant management arm. The estimated duration of labor was shorter in the expectant management arm (8.9±2.17hours vs 10.6±2.35hours; P=<0.001). Neonatal morbidity rates were comparable in both groups.Conclusion: Immediate induction of labor in women with PROM at term resulted in significantly lower rate of infectious morbidity without increasing the risk of operative delivery. It is therefore recommended as the management option of choice.Keywords: Premature rupture of membranes, induction of labor, endometriti

Maternal death and obstetric care audits in Nigeria: A systematic review of barriers and enabling factors in the provision of emergency care.

Acknowledgements We would like to thank Yutaka Osakabe for co-ordinating the retrieval of full text articles. The John D. and Catherine T. MacArthur Foundation supported this study, grant number 12-100074-000-INPPeer reviewedPublisher PD

Is menarche really occurring earlier? A study of secondary school girls in Ile-Ife, Nigeria

Context: A secular trend of progressively earlier attainment of menarche has been described in various populations. The existence of this trend in Ile-Ife, Nigeria, has not been documented. Aim: To determine the current age of menarche and its trend in comparison with previous studies among secondary school girls in Ile-Ife, Nigeria. Settings and Design: School-based cross-sectional analytical study. Materials and Methods: Three-hundred secondary school girls in the lower four classes (JSS 1--SSS 1) were studied. Sociodemographic and menstrual data such as cycle length, duration of menstrual flow, and presence of dysmenorrhoea were obtained using a structured self-administered questionnaire. The mean age at menarche was compared with figures from previous local studies to determine the trend in Ile-Ife. Menstrual characteristics were also analyzed. Statistical Analysis: Data was analyzed with SPSS version 20. Means and standard deviations were generated for continuous variables, while frequencies and proportions were determined for categorical variables. Results: Out of the 300 subjects studied, a total of 198 (66%) had attained menarche at the time of this study. Their reported ages at menarche ranged from 11 to 17 years with a mean of 13.08 ± 1.61 years. This was lower than the 13.98 ± 1.30 and 13.94 ± 1.31 years reported in Ile-Ife in 1992 and 1997, respectively. These three figures show a trend of progressive decline in the mean age at menarche. The subjects' mean duration of menstrual flow was 4.26 ± 0.87 days, with 97.5% of them reporting flow of ≤5 days. Only 22 (11.1%) of the respondents had a cycle length of 28 days. Dysmenorrhoea was reported by 75% of the respondents and 24% reported loss of concentration during periods. Conclusion: Similar to the widely reported secular trend, menarche indeed appears to be occurring progressively earlier in Ile-Ife, Nigeria

Total laparoscopic hysterectomy: A case report from ILE‑IFE, Nigeria

Total laparoscopic hysterectomy (TLH) is an advanced gynecological laparoscopic procedure that is widely performed in the developed world. However, its feasibility in resource‑poor settings is hampered by obvious lack of equipments and/or skilled personnel. Indeed, TLH has never been reported from any Nigerian hospital. We present a 50‑year‑old multipara scheduled for hysterectomy on account of pre‑malignant disease of the cervix, who had TLH with bilateral salpingo‑oophorectomy in the Obafemi Awolowo University Teaching Hospitals Complex, Ile‑Ife, southwestern Nigeria and was discharged home on the first post‑operative day. She was seen in the gynecology clinic a week later in stable condition and she was highly pleased with the outcome of her surgery. This case is presented to highlight the attainability of operative gynecological laparoscopy, including advanced procedures like TLH in a resource‑constrained setting, through the employment of adequate local adaptation and clever improvisation.Keywords: Laparoscopy, endoscopy, hysterectomy, NigeriaNigerian Medical Journal | Vol. 53 | Issue 4 | October-December | 201

THE BURDEN OF VESICO-VAGINAL FISTULA IN ILE-IFE, SOUTH WESTERN NIGERIA

Background: Vesicovaginal fistula is a major cause of severe morbidity and potential mortality, which can result in marital disruption, rejection, and eventual destitution. Methodology: A retrospective study of all cases of vesicovaginal fistula managed over a 30 year period between 1st January 1984 and 31st December 2013 at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. Relevant data were obtained from the case notes and analyzed for the demographics, clinical features, management and outcome using SPSS version 20. Result: There were 213 patients with vesicovaginal fistula over the period of the study with aprevalence of 3.9 per 1000 deliveries. The age range was 15-45 years with a mean age of 24.8 years. Most of them were primiparous, (52.1%) and of the low social class (84.5%). Obstetric fistula accounted for 93.9%. The majority of them (64.8%) did not have antenatal care during the antecedent pregnancy. Labor was attended by unskilled attendants in about 90% of them while 92% labored for at least 24hours. The juxta-cervical fistula was the most common anatomical type (47.0%). The overall success rate at repair was 76.4%. Stillbirth rate in the antecedent pregnancy was 67.5%. Other associated morbidities included chronic vulva excoriation, obstetric palsy, and secondary amenorrhea. Conclusion:Vesicovaginal fistula (VVF) is a major public health problem in developing countries with too many calamities as shown in this study. Improving the educational and economic status of women in Nigeria will go a long way in empowering them to access quality antenatal care. This will also enhance hospital delivery thereby preventing prolonged obstructed labor which is a strong etiological factor for VVF. Decentralization of treatment centers and training of specialists in fistula surgery is very important to improving treatment outcomes

Upright or dorsal? childbirth positions among antenatal clinic attendees in Southwestern Nigeria

Background: Upright childbirth positions are associated with better delivery outcomes. These positions such as kneeling and squatting were the norm for childbirth in indigenous Nigerian custom. However, westernization has largely replaced them with supine positions. Objective: This study was conducted to compare the knowledge, attitude and experience regarding childbirth positions between antenatal clinic attendees in southwest and northwest Nigeria. Materials and Methods: A mixed methods design was employed. Quantitative data were obtained using a structured questionnaire in Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife (n = 201) and Federal Medical Centre, Katsina (n = 104). Knowledge was graded as poor, fair or good whereas attitude toward each position was graded as favoured, indifferent or against. The resulting proportions were compared using Chi-square. Qualitative data were obtained through key-informant interviews. Results: Knowledge of childbirth positions was generally poor. Overall, only to women (0.6%) had good knowledge, whereas 60 (19.7%) had fair knowledge and the rest (79.7%) had poor knowledge. More women in Katsina than Ile-Ife knew the squatting position (32.7% vs. 16.4%; P < 0.001) and favoured it (25.0% vs. 7.5%; P < 0.001), whereas more Ile-Ife women knew the lithotomy position (42.3% vs. 26.9%; P = 0.01). Attitudes towards the remaining positions were comparable between them. Key-informant interviews of the midwives revealed that they were trained to conduct delivery exclusively in the supine positions. They were, however, interested in learning the use of upright positions. Conclusion: Knowledge about childbirth positions was very poor. Women in northwestern Nigeria were more aware and favorably disposed to childbirth in their customary squatting position. Training of Nigerian midwives on upright childbirth positions is recommended

Diagnostic performances of the fluorescent spot test for G6PD deficiency in newborns along the Thailand-Myanmar border: A cohort study

Background: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited enzymatic disorder associated with severe neonatal hyperbilirubinemia and acute haemolysis after exposure to certain drugs or infections. The disorder can be diagnosed phenotypically with a fluorescent spot test (FST), which is a simple test that requires training and basic laboratory equipment. This study aimed to assess the diagnostic performances of the FST used on umbilical cord blood by locally-trained staff and to compare test results of the neonates at birth with the results after one month of age. Methods: We conducted a cohort study on newborns at the Shoklo Malaria Research Unit, along the Thai-Myanmar border between January 2015 and May 2016. The FST was performed at birth on the umbilical cord blood by locally-trained staff and quality controlled by specialised technicians at the central laboratory. The FST was repeated after one month of age. Genotyping for common local G6PD mutations was carried out for all discrepant results. Results: FST was performed on 1521 umbilical cord blood samples. Quality control and genotyping revealed 10 misdiagnoses. After quality control, 10.7% of the males (84/786) and 1.2% of the females (9/735) were phenotypically G6PD deficient at birth. The FST repeated at one month of age or later diagnosed 8 additional G6PD deficient infants who were phenotypically normal at birth. Conclusions: This study shows the short-comings of the G6PD FST in neonatal routine screening and highlights the importance of training and quality control. A more conservative interpretation of the FST in male newborns could increase the diagnostic performances. Quantitative point-of-care tests might show higher sensitivity and specificity for diagnosis of G6PD deficiency on umbilical cord blood and should be investigated