The Role of Ultrasonography in In-vitro Fertilization And Embryo Transfer (IVF-ET)

BACKGROUND: Although ultrasonography was introduced into Obstetrics and Gynaecology by a British Gynaecologist over five decades ago, the requirement for formal training in its use by gynecologists in Nigeriais just beginning to catch on, despite its indispensible role in various aspects of our clinical practice.OBJECTIVE: To describe the role of ultrasonography in in-vitro fertilization and the indispensability of the instrument to reproductive medicine.METHOD: A review of literature written in English language on the use and application of ultrasonography in in-vitro fertilization was done. The review covered articles published between 1980-2012.RESULTS: Ultrasound is the most versatile method for pre-treatment assessment in IVF being the dominant instrument for assessing ovarian reserve, pelvic pathologies and for assessing the uterine cavity. Theability of ultrasonography to measure endometrial thickness in addition to detecting uterine masses gives it an edge over laparoscopy/hysteroscopy as a diagnostic procedure in uterine cavity assessment, although hysteroscopy has the advantage of therapeutic potential. Similarly, ultrasonography is superior to biochemical methods for follicular monitoring because of its ability to demonstrate the number and sizes of follicles, and guide preparations for oocyte retrieval. The relative easeof ultrasound guided oocyte retrieval; its less technical demands and the possibility of conducting the procedure under local anaesthesia have made ultrasound guided oocyte retrieval more popular across the world.Randomized controlled trials show that ultrasoundguided transfer techniques have better outcomes than the clinical touch technique in terms of on-going pregnancies and clinical pregnancies. Ultrasonographyis now the key instrument for diagnosing and monitoring pregnancy following embryo transfer, biochemical methods being complimentary.CONCLUSION: Ultrasonography is now the single most important  instrument in in-vitro fertilization programmes and gynaecologists with interest in reproductive medicine need necessarily to obtain a formal training in its use.KEY WORDS: ultrasonography, in-vitro fertilization, infertility, assisted reproduction technolog

Risks associated with subsequent pregnancy after one caesarean section: A prospective cohort study in a Nigerian obstetric population

Context: Aversion for cesarean delivery is common in our practice and risks associated with caesarean section may contribute to this phenomenon.Objective: The objective of this study was to estimate the risks associated with subsequent pregnancies in women with one previous cesarean section in a low resource setting.Setting and Design: A prospective cohort study carried out at two major tertiary maternity centers in Enugu.Materials and Methods: Maternal and perinatal outcomes were compared between women with one previous caesarean and women who had only previous vaginal deliveries.Statistical Analysis Used: Analysis was performed with SPSS statistical software version 17.0 for windows (IBM Incorporated, Armonk, NY, USA) using descriptive and inferential statistics at 95% of the confidence level confidence.Results: A total of 870 women were studied. These were divided into 435 cases and 435 controls. The absolute risk of cesarean section in a  subsequent pregnancy in women with one previous cesarean was 75.8% (95% confidence interval [CI]: 72.0, 80.0). Cesarean section was  significantly commoner in women with one previous cesarean comparedwith those who had previous vaginal delivery (Relative risk [RR] =3.78; 95% CI: 1.8, 6.2). Placenta praevia (RR = 5.0; 95% CI: 2.6, 7.2.), labor dystocia (RR = 6.4, 95% CI: 3.2, 11.2) intrapartum hemorrhage (RR = 5.0, 95% CI: 2.1, 9.3) primary postpartum hemorrhage (RR = 5.0, 95% CI: 1.5, 4.3.), blood transfusion (RR = 6.0, 95% CI: 3.4, 10.6) and Newborn special care admission (RR = 2.5; 95% CI: 1.1, 4.9) were significantly more common in women with one previous cesarean compared with those with previous vaginal deliveries. The absolute risk of failed trial of vaginal birth after a cesarean was 45% (95% CI: 38.5, 51.5).Conclusion: Women who have one previous C.section face a markedly  increased risk of repeat caesarean sections and feto.maternal  complications in subsequent pregnancies. There is a need for doctors in Nigeria to be mindful of these risks while offering primary cesarean section in this low resource setting.Key words: Absolute risks, pregnancy after caesarean, primary cesarean sectio

Current approaches for assessment and treatment of women with early miscarriage or ectopic pregnancy in Nigeria: A case for dedicated early pregnancy services

Context: It has been suggested that women with early miscarriage or ectopic pregnancy are best cared for in dedicated units which offer rapid and definitive ultrasonographic and biochemical assessment at the initial review of the patient.Aims: To describe the current protocols for the assessment and treatment of women with early miscarriage or ectopic pregnancy as reported by  Nigerian Gynecologists, and determine if dedicated early pregnancy  services such as Early Pregnancy Assessment Units could be introduced to improve care.Settings and Design: A cross.sectional survey of Nigerian Gynecologists  attending the 46th Annual Scientific Conference of the Society of  Gynaecology and Obstetrics of Nigeria.Materials and Methods: This was a questionnaire.based study.Statistical Analysis: Data analysis was by descriptive statistics using Statistical Package for the Social Sciences software, version 17.0 for Windows (IBM Corporation, Armonk, NY, USA).Results: A total of 232 gynecologists working in 52 different secondary and tertiary health facilities participated in the survey. The mean age of the respondents was 42.6 } 9.1 years (range 28-70 years). The proportion of gynecologists reporting that women with early miscarriage or ectopic  pregnancy were first managed within the hospital general emergency room was 92%. The mean reported interval between arrival in hospital and first ultrasound scan was 4.9 } 1.4 hours (range .-8 hours). Transvaginal scan was stated as the routine initial imaging investigation by only 17.2% of respondents. Approximately 94.8% of respondents felt that dedicated early pregnancy services were feasible and should be introduced to improve the care of women with early miscarriage and ectopic pregnancy.Conclusions: Reported protocols for managing early miscarriage or ectopic pregnancy in many health facilities in Nigeria appear to engender  unnecessary delays and avoidable costs, and dedicated early pregnancy services could be both useful and feasible in addressing these  shortcomings in the way women with such conditions are currently  managed.Key words: Early pregnancy assessment units, ectopic pregnancy,  gynaecological ultrasonography, miscarriage,ultrasonograph

The Society of Gynaecology and Obstetrics of Nigeria (SOGON) Plan for Sustainable Reduction in Maternal Mortality: A Review

In the year 2000, SOGON formulated a strategic plan on women’s health based on the reproductive health approach with the aim of reducing maternal mortality by 50% by the year 2010. In 2005, the Nigerian Road Map for accelerating the attainment of Millennium Development Goals 4 and 5 was launched. One of the key guiding principles of the Road Map was promoting partnerships and joint programming among stakeholders including professional associations. In response, SOGON decided to align her strategic plan with the Road Map by refocusing the plan to the key objectives of the Road Map. The new SOGON Plan involves interventions with a focal objective of reducing the case-fatality of emergency obstetric conditions. The plan is anchored on interventions where SOGON has comparative advantage such as providing human resources and promoting capacity building for emergency obstetric care and skilled attendance at delivery, and advocacy and  information dissemination on maternal health (Afr. J. Reprod. Health 2010; 14[2]: 139-147).KEYWORDS: SOGON, Maternal mortality Reduction, Road Map, Partnerships, MDGs

Blood transfusion trends in obstetrics at the Federal Teaching Hospital in Abakaliki, South-East Nigeria

Osaheni L Lawani,1 Chukwuemeka A Iyoke,2 Azubuike K Onyebuchi1 1Department of Obstetrics and Gynecology, Federal Teaching Hospital, Ebonyi State, Nigeria; 2Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu State, Nigeria Background: Obstetric hemorrhage has been repeatedly implicated as a leading cause of maternal mortality in Nigeria, yet there are very few studies that evaluate the practice of blood transfusion in obstetrics as a life saving measure. Objectives: The aim of this study was to evaluate the practice of obstetric blood transfusion, the mean decision-transfusion interval, and the outcome in parturients who had blood transfusions. Methods: This was a prospective descriptive study conducted at the Federal Teaching Hospital, Abakaliki, South-East Nigeria, between 1st January, 2012 and 31st December, 2012. Statistical analysis was done using SPSS version 15.0 for Windows. Results: Out of 151 parturients who received blood transfusion, 141/151 (97.4%) were knowledgeable about blood transfusion, while only 10/151 (2.6%) had no knowledge of it. The hospital was the source of information for 120/151 (80.8%) of the participants. Blood transfusion rate was 7.04% of all parturients. The mean decision-transfusion interval was 12.0 ± 4.3 hours. All participants were transfused with either whole blood or sedimented cells. The mean number of blood units transfused was 1.77 ± 0.93 units. The indications for transfusion were: anemia, 109/151 (72.2%); shock, 13/151 (8.6%); postpartum hemorrhage, 23/151 (15.2%); antepartum hemorrhage, 6 (4%). Six (4%) women died; mortality was due to renal failure in 3/6 (50%) and disseminated intravascular coagulopathy in 3/6 (50%). These deaths were due to delays and difficulty in securing blood for transfusion, while those who got transfused on time were salvaged with minimal morbidity, 21/151 (14%), or with no morbidity, 130/151 (86%). Conclusion: Excessive blood loss and anemia still complicate most pregnancies in our practice and the mean decision-transfusion interval is unacceptably long with debilitating maternal morbidity and mortality that can be improved with safe and effective blood transfusion with minimal or no risk. Keywords: blood, hemorrhage, obstetrics, transfusion, tren

Prevalence and Correlates of Maternal Morbidity in Enugu, South-East Nigeria

The objective of the study was to determine the prevalence and correlates of maternal morbidity following childbirth in Enugu, South East Nigeria. A questionnaire-based cross-sectional study of women with recent deliveries in Enugu was done. Respondent were 8 times more likely to report a symptom than not (OR 8.14 95% C.I. 5.48, 12.68). Puerperal sepsis, perineal pain, dyspareunia, postpartum haemorrhage, gestational (postpartum) hypertension and utero-vaginal prolapse were the commonest obstetric/gynaecological morbidities. Multivariate analysis showed that the main predictors of specific morbidities were high parity category, abdominal delivery and delivery by unskilled birth attendant. It is concluded that the prevalence of morbidity following childbirth in the population sampled was high due mainly to obstetric factors and that reportage of morbidity had little to do with the demographic characteristics of respondents. A population based study is recommended to determine the actual prevalence and predictors of morbidity following childbirth in the population (Afr. J. Reprod. Health 2010; 14[3]: 121-129).Key words: Prevalence, correlates, maternal morbidity, childbirth, Nigeria

The Impact of Health Education on the Awareness and Acceptability of Strategies for Preventing Mother to Child Transmission of HIV in Enugu, Nigeria

BACKGROUND:  Majority of Paediatric HIV/AIDS are from infected mothers and adequate prevention of mother to child transmission (PMTCT) of HIV is a critical factor in the control of paediatric HIV/AIDS. Success of PMTCT strategies will require a high level of acceptability of these strategies by pregnant women.METHODS: A cross sectional descriptive study of the impact of health education on the awareness of strategies for PMTCT was undertaken using interviewer administered questionnaire on antenatal women recruited from three health institutions in Enugu.RESULTS:  A total of 150 antenatal clients were studied.  Their mean age was 29.9 + 4.0.  Ninety four point seven percent (94.7%) were married and 60% of them had post secondary education.  There was high level of awareness and acceptability of PMTCT measures amongst the respondents.  Out of the 150 respondents, 123 (82.0%) identified correctly the meaning of HIV, 140 (93.3%) were aware it can affect the newborn, 105 (75%) knew how it is transmitted and 135 (90.0%) had awareness that we can prevent mother to child transmission of HIV.  130 (86.6%) of the respondents would accept some measures for PMTCT.  Awareness that HIV can affect new born increased from 140 (93.3%) to 145 (96.7%) following health education while those who would accept PMTCT measures increased from 130(86.6%) to 146 (97.3%).  These increases were statistically significant (P<0.05).CONCLUSION:  Health education has a positive and significant impact on the awareness and acceptability of Prevention of Mother to Child transmission of HIV amongst antenatal clients in Enugu.KEYWORDS:  Health education, mother to child transmission, HIV, Enugu

Clients’ knowledge, perception and satisfaction with quality of maternal health care services at the primary health care level in Nnewi, Nigeria

Background: Clientsf knowledge, perception of and satisfaction with the quality of maternal health services (QMHS) enables maternal health programs to assess the impact of their services from the clients'  perspective.Objective: The objective of this study is to assess the knowledge,  perception of and clients' satisfaction with the QMHS at the primary health care (PHC) level in Nnewi, Nigeria.Materials and Methods: This was a cross.sectional survey. Using multistage sampling technique, 280 women utilizing maternal health services from randomly selected PHC facilities in Nnewi, Nigeria were selected for the study. Data were collected using a mix of quantitative and qualitative methods. Quantitative data were analyzed using Statistical Package for Social Sciences version 16, while qualitative data were reported verbatim, analyzed thematically and necessary quotes presented.Results: A total of 280 women were studied. The mean age of the  respondents was 29.2±5.9 years. 231 (82.5%) were married. 89 (31.8%) did not report any knowledge about QMHS. Level of satisfaction was not different among women of different socioeconomic groups (P > 0.05). Sociodemographic characteristics of clients were not found to be associated to the perception of waiting time: (P > 0.05). The attitude of health care providers toward the clients was reported as good.Conclusions: Despite the poor quality of services provided, this study  showed that client's knowledge of quality of services was good. Furthermore cost, local language used, staff attitude and interaction with clients was acceptable and may be the reason for high level of satisfaction reported.Key words: Clients' knowledge, clientsf perception, clients' satisfaction, primary health care level, quality of maternal health service

Maternal and perinatal outcomes of delivery after a previous Cesarean section in Enugu, Southeast Nigeria: a prospective observational study

George O Ugwu,1 Chukwuemeka A Iyoke,1 Hyacinth E Onah,1 Vincent E Egwuatu,2 Frank O Ezugwu2 1Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu, Nigeria; 2Department of Obstetrics and Gynaecology, Enugu State University Teaching Hospital (ESUTH), Parklane, Enugu, Nigeria Background: Obstetricians in developing countries appear generally reluctant to conduct vaginal delivery in women with a previous Cesarean because of lack of adequate facilities for optimal fetomaternal monitoring. Objective: To describe delivery outcomes among women with one previous Cesarean section at a tertiary hospital in Southeast Nigeria. Methods: This was a prospective observational study to determine maternal and perinatal outcomes of attempted vaginal birth after Cesarean sections (VBAC) following one previous Cesarean section. Analysis was done with SPSS statistical software version 17.0 for Windows using descriptive and inferential statistics at 95% level of confidence. Results: Two thousand six hundred and ten women delivered in the center during the study period, of whom 395 had one previous Cesarean section. A total of 370 women with one previous Cesarean section had nonrecurrent indications, of whom 355 consenting pregnant women with one previous Cesarean section were studied. A majority of the women (320/355, 90.1%) preferred to have vaginal delivery despite the one previous Cesarean section. However, only approximately 54% (190/355) were found suitable for trial of VBAC, out of whom 50% (95/190 had successful VBAC. Ninety-five women (50.0%) had failed attempt at VBAC and were delivered by emergency Cesarean section while 35 women (9.8%) had emergency Cesarean section for other obstetric indications (apart from failed VBAC). There was no case of uterine rupture or neonatal and maternal deaths recorded in any group. Apgar scores of less than 7 in the first minute were significantly more frequent amongst women who had vaginal delivery when compared to those who had elective repeat Cesarean section (P=0.03). Conclusion: Most women who had one previous Cesarean delivery chose to undergo trial of VBAC, although only about half were considered suitable for VBAC. The maternal and fetal outcomes of trial of VBAC in selected women with one previous Cesarean delivery for nonrecurrent indications were good. Obstetricians in this area should do more to allow VBAC in women with one previous Cesarean section for nonrecurrent indications. Keywords: previous Cesarean section, vaginal birth, pregnancy, VBA

Perception and Care-Seeking Behaviour for Post Partum Morbidity among Mothers in Enugu South East, Nigeria

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