Ruptured uterus: Fetomaternal outcome among unbooked mothers and antenatal care defaulters at the University of Portharcourt teaching hospital.

BACKGROUND: Unbooked emergencies are major reasons for the high maternal and perinatal mortality and morbidity in Nigeria. Rupture of the gravid uterus in women without antenatal care usually present late to hospital as unbooked emergencies with high perinatal deaths and very poor maternal outcome. AIM: To determine the factors implicated in the poor feto-maternal outcome with ruptured uterus amongst the unbooked mothers at the University of Port Harcourt Teaching Hospital(UPTH).METHOD: A retrospective analysis of case records of 82 consecutive patients without antenatal care who had ruptured uterus between January 2008 and December 2012.RESULT: There were 2133 deliveries among unbooked mothers at the University of Port Harcourt Teaching Hospital over this 5-year period. The incidence of ruptured uterus for the period under review was 3.8%. The mean age was 28.1years and the modal parity was 2. Abdominal massage and prolonged obstructed labor were the commonest predisposing factors, occurring in 43.9% and 34.1% of these women respectively. There were 80 perinatal deaths contributing to 12.2% of the perinatal mortality rate. There were 6 maternal deaths from ruptured uterus which was 10.9% of the maternal mortality ratio of 2578.5 per 100,000 live birth during the study period.CONCLUSION: Perinatal and maternal mortality rates from ruptured uterus were high. The major causes of uterine rupture are abdominal massage and prolonged obstructed labor, which are both preventable. Public enlightenment and condemnation of practices that promote these factors is advocated.KEYWORDS: ruptured uterus, feto-maternal outcome, unbooked, Port Harcourt

Obstetric dating and growth scans in a tertiary health facility in Nigeria; are we doing it correctly?

The study was prompted by the observed heterogeneity in performing dating and growth scans in Nigeria. The primary aim of the study was to determine whether the conduct of dating and growth scans in Nigeria conform to international norms. The secondary goal was to assess the implication of the scans for maternal and foetal care. The study was of mixed design – observational and cross-sectional with audit component, carried out at the Rivers State University Teaching Hospital (RSUTH), Nigeria from November, 2020 to February 2021. A literature search was carried out on the subject and standards were deduced from the review. 417 consecutive patients were recruited from the antenatal clinic and data on their history and the conduct of the scans were collected. The content of the individual scan report was compared with the international standards. Data were analysed using Epi. Info 2018 software. The results showed that there were no guidelines nor uniformity in the conduct of dating and growth scans at the RSUTH. Out of the total 744 scans that were done, 175 (25.36%) and 569 (74.64%) took place inside and outside the RSUTH respectively. The gestational ages at the first and the second scans were 8-41 weeks but 24-42 weeks for all the third scans. Appropriate biometric parameters were used in 115 (28.19%), 33 (14.10%) and 3 (2.94%) out of the 408 first, 234 second and 102 third scans respectively while in the rest, inappropriate or incomplete parameters were used. During subsequent scans after the first one, different EDD were assigned to pregnancies in 210 (93.59%) out of the 234 second scans, and 100 (98.04%) out of the 102 third scans, the differences ranging from 27 days earlier to 26 days later in both scans. The deficiencies in dating and growth scans would likely lead to wrong dating and inaccurate growth assessment with associated adverse maternal and foetal outcomes, including failure to diagnose important obstetric problem like SGA/FGR, LGA babies and wrong timing for obstetric interventions. The findings underscore the urgent need for formulating national guidelines on the subject, effective referral cascade for scans and adoption of practical approach to training in maternal and foetal medicine

Emergency inevitable caesarean myomectomy, challenge to obstetrician/ gynaecologist: a case report

BACKGROUND Caesarean myomectomy is not routinely done by Obstetricians/Gynaecologists due to associated complications and increased risk of maternal morbidity/mortality. The incidence of fibroid in pregnancy varies from 1.6% to 10.7% globally.AIM To present an uncommon management modality.CASE REPORT Mrs BD is a 34-year-old unbooked G1 Para 0+0 at 38 weeks’ gestation who presented on self-referral from a maternity with complaints of increasing abdominal pain and breathlessness of 1day duration.  Examination at presentation revealed fundal height of 44cm, intra-abdominal mass consistent with huge uterine fibroid extending from the fundus to the lower segment, oblique-lying foetus with normal heart tones. Obstetric ultrasound done on admission were in keeping with above clinical findings with uterine fibroid measuring 22cm by 20cm. She was billed for elective caesarean section but went into labour which necessitated an emergency caesarean section with delivery of a live male baby, birth weight 3.2kg and myomectomy for uterine fibroid at the lower uterine. The estimated blood loss was 800mls, She had a unit of blood intra-operatively.  Her post-operative period was uneventful. She was counselled on the extent of the surgery including her future fertility and family planning. She was discharged home on her 7th post-operative day in satisfactory clinical condition. CONCLUSION Caesarean myomectomy may be a hazardous surgical procedure to the attending Obstetrician/Gynaecologist. However, adequate pre-operative preparation, the skill and speed of the surgeon may help improve maternal /perinatal outcome.Key Words: caesarean myomectomy, obstetrician/ gynaecologist, maternal morbidity/mortality

Ruptured uterus: fetomaternal outcome among unbooked mothers and antenatal care defaulters at the University of Port Harcourt Teaching Hospital

Unbooked emergencies are major reasons for the high maternal and perinatal mortality and morbidity in Nigeria. Rupture of the gravid uterus in women without antenatal care usually present late to the hospital as unbooked emergencies with high perinatal deaths and very poor maternal outcome. To determine the factors implicated in the poor feto-maternal outcome with ruptured uterus amongst the unbooked mothers at the University of Port Harcourt Teaching Hospital (UPTH). A retrospective analysis of case records of 82 consecutive patients without antenatal care who had ruptured uterus between January 2008 and December 2012. There were 2133 deliveries among unbooked mothers at the University of Port Harcourt Teaching Hospital over this 5-year period. The incidence of ruptured uterus for the period under review was 3.8%. The mean age was 28.1 years and the modal parity was 2. Abdominal massage and prolonged obstructed labor were the commonest predisposing factors, occurring in 43.9% and 34.1% of these women respectively. There were 80 perinatal deaths contributing to 12.2% of the perinatal mortality rate. There were 6 maternal deaths from ruptured uterus which was 10.9% of the maternal mortality ratio of 2578.5 per 100,000 live birth during the study period. Perinatal and maternal mortality rates from ruptured uterus were high. The major causes of uterine rupture are abdominal massage and prolonged obstructed labor, which are both preventable. Public enlightenment and condemnation of practices that promote these factors is advocated.Keywords: ruptured uterus, feto-maternal outcome, unbooked, Port Harcour

Practical Approach to Sub-specialty Training in Maternal Foetal Medicine (MFM) in Nigeria

The heavy burden of maternal and perinatal morbidities and mortalities in Nigeria, most of which are MFM-related has stimulated the introduction of subspecialty training in MFM. Unfortunately in the available curriculum, less attention was paid to the ultrasound-related aspect of the training and also there was less clarity on the order of navigation through the various modules of the training. The objective of the present study therefore was to design a sub-specialty training curriculum in MFM with practical approach to its execution, taking into consideration the Nigerian ethno- cultural peculiarities, its disease topography and the level of its economic development. It was of mixed design study, with both observational and review components. A literature search and telephone communication with MFM specialists in tertiary health institutions in Nigeria on the subject were carried out. There was no structured training program in MFM in Nigeria. A competency-based modular training framework whereby acquisition of ultrasound-based competencies intertwined with the maternal medicine components of the training was proposed. The ultrasound modules to be covered were as following: first trimester scan at 11+0 to 13+6 weeks, the 20 + 0 to 23 + 6 weeks scan, growth and doppler ultrasound, cervical assessment, foetal echocardiography, application of ultrasound in the management of labour, screening for and diagnosis of placenta accrete spectrum and invasive procedures. Successful completion of the training modules, including rural posting, rotation in allied disciplines will earn the trainee an exemption from the dissertation component of the part II fellowship examination and award of fellowship or diploma in MFM, depending on whether the trainee completed the invasive module or not