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

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

Have you seen a rape kit? A snapshot at the quality of care of rape survivors in Nigerian tertiary hospitals

Context: The rape kit has become a fundamental tool in the evaluation of the rape survivor in many countries. Itsavailability and use in Nigeria has however not been documented.Objective: To assess the current availability and usage of the rape kit in Nigerian tertiary hospitals, and evaluate the management of rape survivors.Methodology: Resident Doctors attending the Obstetrics and Gynaecology update course, held in Abuja in March,2009 were interviewed using a self-administered questionnaire assessing experience in rape management, knowledge about the rape kit and its availability, as well as current management of rape survivors.Results: There were 138 respondents from 25 tertiary hospitals, with a male-to-female ratio of 2.8:1 and a meanduration of 3.3 (SD 1.4) years in training. 120 (87%) had personally managed one or more rape survivor(s), but none of the respondents had ever seen a rape kit, and only 29% were aware of it. Although all the respondents indicated availability of emergency contraception, antibiotics and tetanus prophylaxis in their centres, only 32.4% had access to HBV vaccine, and about 8% indicated lack of HIV prophylaxis. Only 28.7% and 45.6% indicated access to clinical psychologists and medical social workers respectively.Conclusion: The rape kit is not available in Nigerian tertiary hospitals. We recommend its provision, and regulartraining of doctors, especially Obstetrics and Gynaecology Residents on rape management, to improve the care ofrape survivors in Nigeria.Key Words: Rape, Rape kit, Rape survivor, Nigeria

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

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

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

The use of magnesium sulphate (MgSO4) for seizure prophylaxis: clinical correlates in a Nigerian tertiary hospital

Background: Magnesium sulphate use in the prevention of seizures resulting from preeclampsia and eclampsia is widely accepted. However, several protocols exist worldwide. Aim: To determine serum magnesium levels and associated clinical outcomes in severe pre-eclamptic and eclamptic women treated with magnesium sulphate. Methods: Women, 28-41 weeks pregnant or in the puerperium with severe pre-eclampsia or eclampsia, participated in this cross sectional study and their serum magnesium levels were measured using the Atomic Absorption Spectrophotometer (AAS) machine. All participants received the standard Pritchard regimen, including monitoring. Results: Seventy five patients participated in the study. They were mostly overweight (mean BMI 26.38 ± 3.40kg/m2). Mean pre-treatment serum magnesium level was 1.96 ± 0.29 mg/dL; eclamptics had significantly lower levels (p<0.001). Mean treatment serum magnesium level attained was 5.41 ± 0.58 mg/dL. No evidence of magnesium toxicity was observed. Therapeutic range of serum magnesium was required to prevent seizures, and was attained ≥4-hours after loading dose in most of the eclamptics (74%). All convulsions occurred in the interval between the loading dose and the first maintenance dose; eclamptics had greater risk of convulsing while on treatment (RR=11.56, 95%CI= 0.62-216.36, P=0.049). Conclusion: Low serum magnesium level before or during treatment with magnesium sulphate is a risk factor for convulsion in OAUTHC. The Pritchard regimen has a low risk for toxicity thus administration of magnesium sulphate at peripheral centres before referral may be beneficial in preventing repeat convulsions. Modifications involving additions to the loading dose in eclamptics and fewer number of maintenance doses may be beneficial.Key words: Pre-eclampsia, eclampsia, magnesium, convulsion, puerperium, Nigeri

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