Use of modern contraceptive implants the: Lagos island maternity Hospital experience

Backround: Implants are an effective and reversible long term method of fertillty regulation, particularily advantageous to women who wish an extended period of contraception protection. The development of contraceptive implants was made possible by the discovery of silicone and its bio-compatibility in the human body. Silastic tubes with sealed ends and filled with steroids provided a sustained release of the steroids in vitro over months; these models were the precursors of today's contraceptive implants. This technology resulted in the development and patent of Norplant' and Norplant-2 by the Population Council. Over the years the popularity and use of Norplant has waned due to difficulties in insertion and removal. Lagos Island Maternity Hospital (LIM H) introduced Jadelle and Implanon- the newer forms of Implants in the year 2007 with the improvement made on these newer forms, we review the use of modern contraceptive Implant in LIMH.Objectives: The objectives of this study are to demonstrate the socio-demographic and clinical variables influencing acceptors of modern contraceptive implants; to describe observed side effects associated with the use of contraceptive implants and to ascertain acceptance of contraceptive implants through determination of continuation rate.Methodology: This involved a review of clients who were counseled and accepted subdermal contraceptive implants. The contraceptive implants were inserted by sub-dermal insertion of either Jadelle consisting of 2 rods. into the medial boarder of the upper arm or insertion of Implanon single rod in a similar anatomic location Data was extracted using an established family planning proforma. Data obtained included sociodemographic features, past obstetric/gynecological history of the respondents and side effects of the implants. Extraction of data was done over a period of one year.(July 31st 2011 to June 30th 2012)Results: A total of 622 clients made use of various methods of contraception during the study period. The proportion of clients who made use of modern Implants is 11.41 % (n= 71). The average age of the respondents is 32years, with a range of 17.49years.The commonest side effect seen is amenorrhea, occurring in 12.7% of respondents (n = 9).lntermenstrual bleeding occurred in 4.2% of respondents (n =3). More of the respondents had insertion of Jadelle (69.0%: n= 49). The other respondents had insertion of Implanon (31%: n= 22). The proportion of clients who had no plan for further child bearing is 29.6% (n= 21). The majority of clients are desirous of further child bearing (70.4%: n=50).First time users constituted 52.1 % of clients (n= 37). Continuation rate was 90.1 % (0.9% discontinuation due to side effects). Some of the clients had used the cupper TIUD(19.7%: n= 14).Conclusion: Contraceptive Implants have been shown by this study to be an acceptable form of contraception. Majority of the women maintained the use of the contraceptive implants, In women who experienced side effects, amenorrhea is the commonest side effect experienced. The relatively high continuation rate of these implants is a testament of its acceptability. Scaling up its uptake and availability will be useful in reducing the unmet needs for contraception

Incidence and risk factors for caesarean wound infection in Lagos Nigeria

<p>Abstract</p> <p>Background</p> <p>Post caesarean wound infection is not only a leading cause of prolonged hospital stay but a major cause of the widespread aversion to caesarean delivery in developing countries. In order to control and prevent post caesarean wound infection in our environment there is the need to access the relative contribution of each aetiologic factor. Though some studies in our environment have identified factors associated with post caesarean wound infection, none was specifically designed to address these issues prospectively or assess the relative contribution of each of the risk factors.</p> <p>Findings</p> <p>Prospective multicentre study over a period of 56 months in Lagos Nigeria. All consecutive and consenting women scheduled for caesarean section and meeting the inclusion criteria were enrolled into the study. Cases were all subjects with post caesarean wound infection. Those without wound infection served as controls. Data entry and analysis were performed using EPI-Info programme version 6 and SPSS for windows version 10.0.</p> <p>Eight hundred and seventeen women were enrolled into the study. Seventy six (9.3%) of these cases were complicated with wound infection. The proportion of subjects with body mass index greater than 25 was significantly higher among the subjects with wound infection (51.3%) than in the subjects without wound infection (33.9%) p = 0.011. There were also significantly higher proportions of subjects with prolonged rupture of membrane (p = 0.02), prolonged operation time (p = 0.001), anaemia (p = 0.031) and multiple vaginal examinations during labour (0.021) among the women that had wound infection compared to the women that did not have wound infection. After adjustment for confounders only prolonged rupture of membrane (OR = 4.45), prolonged operation time (OR = 2.87) and body max index > 25 (2.34) retained their association with post caesarean wound infection.</p> <p>Conclusion</p> <p>Effort should be geared towards the prevention of prolonged rupture of fetal membrane and the reduction of prolonged operation time by the use of potent antibiotics, early intervention and use of good surgical technique. In obese women improved surgical technique and use of non absorbable sutures may suffice.</p

Incidence of and socio-biologic risk factors for spontaneous preterm birth in HIV positive Nigerian women

BACKGROUND: Recent studies have identified HIV as a leading contributor to preterm delivery and its associated morbidity and mortality. However little or no information exists in our sub-region on this subject. Identifying the factors associated with preterm delivery in HIV positive women in our country and sub-region will not only prevent mother to child transmission of HIV virus but will also reduce the morbidity and mortality associated with prematurity and low birth weight. This study was designed to determine the incidence and risk factors for preterm delivery in HIV positive Nigerians. METHOD: The required data for this retrospective study was extracted from the data base of a cohort study of the outcome of prevention of mother to child transmission at the Nigerian Institute of Medical Research, Lagos. Only data of women that met the eligibility of spontaneous delivery after 20 weeks of gestation were included. Ethical approval was obtained from the Institution’s Ethical Review Board. RESULTS: 181 women out of the 1626 eligible for inclusion into the study had spontaneous preterm delivery (11.1%). The mean birth weight was 3.1 ± 0.4 kg, with 10.3% having LBW. Spontaneous preterm delivery was found to be significantly associated with unmarried status (cOR: 1.7;1.52-2.57), baseline CD4 count <200 cells/mm(3)(cOR: 1.8; 1.16-2.99), presence of opportunistic infection at delivery (cOR: 2.2;1.23-3.57), multiple pregnancy (cOR 10.4; 4.24 – 26.17), use of PI based triple ARV therapy (eOR 10.2; 5.52 – 18.8) in the first trimester (cOR 2.5; 1.77 – 3.52) on univariate analysis. However after multivariate analysis controlling for potential confounding variables including low birth weight, only multiple pregnancy (aOR: 8.6; CI: 6.73 – 12.9), presence of opportunistic infection at delivery (aOR: 1.9; CI: 1.1 – 5.7), and 1st trimester exposure to PI based triple therapy (aOR: 5.4; CI: 3.4 – 7.8) retained their significant association with preterm delivery. CONCLUSION: The spontaneous preterm delivery rate among our cohort was 11.1%. HIV positive women with multiple pregnancies, symptomatic HIV infection at delivery and first trimester fetal exposure to PI based triple therapy were found to be at risk of spontaneous preterm delivery. Early booking and non-use of PI based triple therapy in the first trimester will significantly reduce the risk of preterm delivery

Foetal loss and enhanced fertility observed in mice treated with Zidovudine or Nevirapine.

Health concerns for HIV-infected persons on antiretroviral therapy (ART) have moved from morbidity to the challenges of long-term ART. We investigated the effect of Zidovudine or Nevirapine on reproductive capacity across two mouse generations.A prospective mouse study with drugs administered through one spermatogenic cycle. Mouse groups (16 males and 10 females) were given Zidovudine or Nevirapine for 56 days. Males were mated to untreated virgin females to determine dominant lethal effects. Twenty females (10 treated and 10 untreated) mated with the treated males per dose and gave birth to the F1 generation. Parental mice were withdrawn from drugs for one spermatogenic cycle and mated to the same dams to ascertain if effects are reversible. The F1 generation were exposed for another 56 days and mated to produce the F2 generation.Foetal loss was indicated in the dominant lethal assay as early as four weeks into drug administration to the males. At the first mating of the parental generation to produce the F1 generation, births from 10 dams/dose when the 'father-only' was exposed to Zidovudine (10, 100 and 250 mg/kg) was 3, 2 and 1 while it was 7, 1 and 4 respectively when 'both-parents' were exposed. Similarly births from the parental generation first mating when the 'father-only' was exposed to Nevirapine (5, 50 and 150 mg/kg) was 2, 2 and 0 while it was 6, 5 and 9 respectively when 'both-parents' were exposed. However, fertility was not significantly different neither by dose nor by the parental exposure. The F1 mice mated to produce the F2 generation recorded only one birth.The dominant lethal analysis showed foetal loss occurred when the "fathers-only" were treated while fertility was enhanced when "both-parents" were on therapy at the time of mating

Proportion of surviving pups and their sex ratios in relation to dose and parental treatment.

<p>Proportion of surviving pups was determined while weaning the pups at age 4 weeks.</p><p>ZDV = Zidovudine; NVP = Nevirapine.</p>a<p>Four males from each dose mated five females each to give a total of twenty dams per dose. Ten of these dams were untreated (“father-only” treated groups) while the other ten had received the same dose as the males (“both-parents” treated groups) for 56 days before mating. Harem mating was done by co-housing one male and five females for 10 days without checking for vaginal plugs.</p>b<p>We compared the survival proportion of the treatment groups to that of the untreated control group (70.8%) using the binomial test. The proportions of surviving pups were significantly different for most treatment groups except for that of the ZDV 100 mg/kg at both first and repeat mating; for NVP 50 mg/kg at first mating and for NVP 150 mg/kg at repeat mating.</p><p>Proportion of surviving pups and their sex ratios in relation to dose and parental treatment.</p

Dominant lethal assay (DLA) after males were treated with Zidovudine or Nevirapine for eight weeks.

<p>DLA simulates when the “father-only” is ARV treated.</p><p>EMS = Ethylmethylsulfonate (one-time dose); ZDV = Zidovudine; NVP = Nevirapine.</p>a<p>Number of pregnancies observed after 1∶1 mating.</p>b<p>Number of pregnancies before/after adding dams with heavy arterial linings to the pregnancy count. Dams with heavy arterial lining of the uterus and/or uterine fluids indicate fertile mating had occurred but was aborted early.</p>c<p>Number of implants per pregnant dam or the average from all pregnant dams in the group.</p><p>Differences in number of aborted pregnancies at week 4 versus week 8 was not significant.</p><p>Dominant lethal assay (DLA) after males were treated with Zidovudine or Nevirapine for eight weeks.</p

Gestation period in relation to dose and the parental mouse treatment.

<p>Four males per dose mated five females each to give a total of twenty dams per dose. Ten of these dams were untreated (“father-only” treated groups) while the other ten had received the same dose as the males (“both-parents” treated groups) for 56 days before mating. Harem mating was done by co-housing one male and five females for 10 days without checking for vaginal plugs. ZDV = Zidovudine; NVP = Nevirapine; EMS = Ethylmethylsulfonate (one-time dose); SD = Standard Deviation.</p>a<p>Average gestation period obtained for dams mated to males on therapy at the time of mating.</p>b<p>Average gestation period obtained for dams mated to males previously treated but have not received ARVs for another spermatogenic cycle (56 days) to check if effects could resolve. Thus only the females were still on therapy at the repeat mating.</p>c<p>Both parents had been on therapy but at repeat mating, only the dams were currently on therapy as the males had been withdrawn for one full spermatogenic cycle.</p>†<p>Single birth recorded, thus SD could not be calculated.</p><p>Using ANOVA, significantly shorter gestation periods was observed only for the NVP “both-parents” treated groups at first mating and for the ZVP “father-only” treated groups at repeat mating when the treatment groups were compared to the untreated control.</p><p>Gestation period in relation to dose and the parental mouse treatment.</p

Diagrammatic representation of the study design.

<p>Diagrammatic representation of the study design.</p

Dominant lethal assay (DLA) after males were treated with Zidovudine or Nevirapine for four weeks.

<p>DLA simulates when the “father-only” is ARV treated.</p><p>EMS = Ethylmethylsulfonate (one-time dose); ZDV = Zidovudine; NVP = Nevirapine.</p>a<p>Number of pregnancies observed after 1∶1 mating.</p>b<p>Number of pregnancies before/after adding dams with heavy arterial linings to the pregnancy count. Dams with heavy arterial lining of the uterus and/or uterine fluids indicate fertile mating had occurred but was aborted early.</p>c<p>Number of implants per pregnant dam or the average from all pregnant dams in the group.</p><p>Statistical analysis could not be performed because of several missing values.</p><p>Dominant lethal assay (DLA) after males were treated with Zidovudine or Nevirapine for four weeks.</p