Pregnancy, obstetric and neonatal outcomes in HIV positive Nigerian women

While the effect of HIV infection on some maternal outcomes is well established, for some others there is conflicting information on possible association with HIV. In this study we investigated pregnancy and neonatal outcome of HIV positive women in large HIV treatment centre over a period of 84 months. They were managed according to the Nigerian PMTCT protocol. Adverse obstetric and neonatal outcome were observed in 48.3% HIV positives compared 30.3% to the negatives (OR: 2.08; CI: 1.84-2.34). Low birth weight ( OR:2.95; CI:1.95-3.1), preterm delivery (OR:2.05; CI:1.3-3.1), perinatal death (OR:1.9;CI:1.3-3.2), and spontaneous abortion (OR:1.37; CI:1.1-2.3) were factors found to be independently associated with HIV. Low CD4 count (OR: 2.45; CI: 1.34- 4.56) and opportunistic infections (OR: 2.11; CI: 1.56-3.45) were to be associated with adverse obstetric and neonatal outcome. This study confirms the association of HIV, severe immunosuppression and opportunistic infection and adverse obstetric and neonatal outcome.

The burden of anaemia and associated factors in HIV positive Nigerian women

BACKGROUND

Anaemia is the most common complication of pregnancy and a predictor of poor maternal and foetal outcomes. HIV infection is now recognized as one of the major contributors to anaemia in pregnancy. It is therefore important to determine the burden and risk factors of anaemia in maternal HIV infection in others to plan effective prevention strategies as well as optimize management outcomes.

OBJECTIVE

To determine the prevalence and risk factors of anaemia in pregnant HIV positive Nigerians.

METHODS

The prevalence and possible risk factors of anaemia were investigated in HIV positive pregnant Nigerian women at a large HIV treatment clinic in southwestern Nigeria using a cross-sectional design between January 2006 and December 2011.

RESULTS

Nine hundred and eighty-five (42.5 %) women of 2,318 HIV positive pregnant women seen during the period were anaemic by WHO standard defined by haemoglobin <11 g/dl. Majority were of mild to moderate severity (97.9 %). Short inter birth interval (p = 0.002), presence of opportunistic infections (OIs), (p = 0.001), use of zidovudine containing regimen (p = 0.0005) and CD4 cell count <200 cells/mm(3) (p = 0.001) were found to be independently associated with anaemia in HIV positive pregnant women after controlling for confounding variables.

CONCLUSION

Anaemia was found to be high at 42.5 % among the HIV positive women studied and was found to be independently associated with short inter birth interval, presence of OIs, advanced HIV disease and use of zidovudine containing HAART regimen.

Experience with Norplant at a Nigerian teaching hospital

OBJECTIVES

To determine the acceptance of Norplant implants while it was in use and share our experience with other Norplant providers.

DESIGN

Retrospective descriptive study.

SETTING

The family planning clinic of the Jos University Teaching Hospital, Jos, Nigeria.

RESULTS

During the 21-year period, January 1985 to December 2005, a total of eighteen thousand, two hundred and ninety one (18,291) new clients accepted various modern contraceptive methods in the family planning clinic of Jos University Teaching Hospital, Nigeria. Norplant was accepted by 1,333 clients (4.9%) as against the intrauterine devices (IUDs) 25.4%, and Oral Contraceptive Pills (OCP) 22.9%. Female sterilisation was a contraceptive method of choice in 21.2%, the injectables in 13.9%, and the male condom in 9.3%. Failure rate was 0.37% and continuity rate was high among users. The Norplant contraceptive implant was accepted by women of mean age of 29.6 years and women of all parity. The acceptance pattern demonstrated a multi-nodal pattern from the time of introduction in 1985 to December 2005 when supply came to an abrupt stop. The greatest barriers to Norplant use were non- availability and high cost of the commodity.

CONCLUSION

Norplantimplants provided contraceptive protection with high reliability, safety, independence from user compliance, rapid return of pre-existing fertility after removal, good tolerability, and relatively simple and quick insertion and removal. The capsules will definitely be used as a reference for similar contraceptive products in the contraceptive market.

Subclinical vitamin B12 deficiency in pregnant women attending an antenatal clinic in Nigeria

SUMMARY

Inadequate vitamin B12 status in a pregnant woman increases the risk for adverse maternal and fetal outcomes. The use of serum vitamin B12 concentration alone to assess vitamin B12 status in pregnant women is unreliable because of the decrease in serum vitamin B12 levels in normal pregnancy. The combination of serum vitamin B12 and methylmalonic acid (MMA) concentrations may provide a better estimate of vitamin B12 status. We obtained blood samples from 98 pregnant women in the third trimester at an antenatal clinic in Jos, Nigeria. All subjects were taking iron and folate supplements. Twelve of the subjects had a serum vitamin B12 concentration <148 pmol/l and 18 subjects had a serum MMA level >271 nmol/l. Using a combination of low serum vitamin B12 and elevated MMA concentrations, eight subjects were classified as having subclinical vitamin B12 deficiency. Because of the potential harmful consequences of vitamin B12 deficiency in pregnant women, it would be advisable to add vitamin B12 supplements to the existing regimen of folate and iron supplements currently provided to pregnant women in Nigeria.

Review of maternal deaths from unsafe abortion in Jos, Nigeria

BACKGROUND

Unsafe Abortion assumes one of the lead causes of maternal deaths so long as contraceptive services remain low or unavailable and abortion laws remain restrictive. This study seeks to highlight abortion mortality, the practice of contraception amongst these women and complications arising from unsafe abortion.

METHOD

This is a retrospective review of abortion related deaths in Jos University Teaching Hospital over a five year period (1st December 1989 to 30th November 2004). Patients files were retrieved from the hospital records and were reviewed in relation to socio demographic profile, clinical features and cause of death.

RESULTS

Fourteen cases of abortion related deaths out of a total number of 188 induced abortion cases. The case fatality rate was 7.4% with abortion mortality of 74.4/100,000 deliveries. It constituted 12.8% of maternal deaths during the period. Seventy eight point six percent (78.6%) were below 24 years, while 85.7% of the patients were nulliparous. Ninety two point nine percent (92.9%) and 57.1% were single and dependent respectively. Fifty seven point one percent had never practiced contraception and 35.7% had previous pregnancy terminated. In 64.3%, the index pregnancy was terminated at 9 weeks and above because the pregnancies were unwanted in all (100%) cases. In 78.6% of cases the pregnancies were terminated by quacks. Forty two point nine percent (42.9%) presented after a week of termination. The causes of death were septicemia (71.4%), and hypovolaemic shock (28.6%). The average duration of hospital stay before demise was 5.6 days.

CONCLUSION

Unsafe abortion is a public health problem in Jos and policy makers should promote contraception and review existing abortion laws.

Ectopic pregnancy in Jos Northern Nigeria: prevalence and impact on subsequent fertility

BACKGROUND

Ectopic pregnancy remains a major gynaecological problem in contemporary gynaecological practice. Not only do women die from this disease, but also of greater clinical importance is the indirect morbidity of poor fertility prognosis and adverse outcome in subsequent pregnancies. We were interested in documenting the prevalence of ectopic pregnancy and its impact on subsequent fertility.

METHODOLOGY

This retrospective descriptive study was done at the Jos University Teaching Hospital. The case notes of all patients who had tubal ectopic pregnancy managed in JUTH between January 1997 and December 2000 were retrieved. Subsequent fertility and reproductive outcome were assessed among women who reported back for follow up fora minimum period of twelve months post surgery. The data was analyzed using frequencies.

RESULTS

During the study period, January 1997 and December 2000 a total of 168 ectopic pregnancies were managed and 9,638 deliveries occurred during the same period. This gives a prevalence rate of 1.74%. Of the 168 cases of ectopics, 130 case records containing relevant information were retrieved (77.4%) and this constituted the sample population for the study. Majority (53.8%) of the women were between 20 and 29 years. Majority of the women were either nulliparous or primiparous (23.8% and 20.0% respectively). Tubal rupture occurred in 86.9% of the women at the time of laparotomy. Total salpingectomy was the surgical modality in 77.7% of the cases. The right fallopian tube was affected in 66.2% and the left 33.8% of the cases. The contralateral fallopian tube was grossly normal in 73.1% of cases. Of the 64 women who were followed up for a minimum of 12 months, 40.6% achieved viable intra uterine pregnancies, 6.3% had a repeat ectopic pregnancy in the contra lateral tube and 53.1% were unable to achieve pregnancy.

CONCLUSION

Ectopic pregnancy is prevalent in our environment affecting mainly young women of low parity who desire future pregnancies. The subsequent impact on future fertility of these women could be improved if efforts are focused on early diagnosis to prevent tubal rupture. Early diagnosis prior to rupture offers opportunity for medical management and conservative surgical procedures that are proven to improve future fertility prognosis.

A review of bilateral tubal ligation at caesarean section in Jos, Nigeria

CONTEXT

The advent of minilaparotomy under local anaesthesia has revolutionalised the performance of bilateral tubal ligation for permanent contraception in Jos. Female sterilisation has however continued to be performed during caesarean section mainly for obstetric or surgical reasons.

OBJECTIVE

To determine the incidence of bilateral tubal ligation during caesarean section, and the trend over the years in Jos, Nigeria.

METHODOLOGY

This was a retrospective analysis of the register of all bilateral tubal ligations including those performed at caesarean section, between January 1985 and December 2000 (16 years).

RESULTS

A total of 3,585 female sterilisations were performed, and 533 (14.9%) were at caesarean section. The rest were through minilaparotomy under local anaesthesia (84.3%) and laparoscopy (0.7). The yearly rate of tubal ligation at caesarean section declined from 33.8% in 1985 to 16.3% in 2000. The commonest indication for the tubal ligation during caesarean section was repeat caesarean section, and accounted for 55.5%. The mean age and parity of the women were 32.1 years and 5.0 respectively. The mean of the number of children of the women at the time of the caesarean section was 4.5. There was a significant difference in age, parity and number of living children of the women compared with those that had bilateral tubal ligation at times other than during caesarean section. There was no complication specific to the tubal ligation at caesarean section.

CONCLUSION

About 15% of all female sterilisations were performed at caesarean section. The trend demonstrated a decline, probably influenced by the advent of minilaparotomy under local anaesthesia in Jos, Nigeria.

Anaesthetic experience in female sterilisation at Jos University Teaching Hospital, Nigeria

OBJECTIVE

To present the trend of anaesthetics used for interval and post-partum female sterilisation.

DESIGN

A retrospective descriptive study.

SETTING

Jos University Teaching Hospital, Jos, Nigeria from 1985 to 2004.

SUBJECTS

All cases of female sterilisation in Jos University Teaching Hospital within the study period.

INTERVENTIONS

Clients were allowed free choice of the method of anaesthesia after appropriate counseling. Written consent by the patient and her husband was obtained.

RESULTS

During the period, 4,313 female sterilisations were performed. The mean (+/-SD) age and parity of the clients were 36.8 +/- 4.8 years, and 7.6 +/- 2.4 respectively. Local anaesthesia alone was the most commonly used (75.0%), followed by general anaesthesia (15.8%) and local anaesthesia with sedation (9.2%). The use of local anaesthesia alone for minilaparotomy under local anaesthesia for female sterilisation rose from 0.0% in 1985 to 83.0% in 2004. Majority (79.1%) of the cases were performed as interval procedures, 15.1% performed at Caesarean section and 5.8% as postpartum procedures. There were no serious morbidity and/or mortality associated with the types of anaesthesia used.

CONCLUSION

Minilaparotomy under local anaesthesia for sterilisation has been found to be feasible, and now acceptable in our institution.

Indications for removal of intrauterine contraceptive devices in Jos, north-central Nigeria

CONTEXT

Intrauterine contraceptive devices (IUDs) are commonly used reversible methods of contraception. The CuT 380A is recommended for use for 10 years but common observation has shown that they are removed much earlier than the recommended duration ofuse.

METHODOLOGY

A retrospective study of all clients presenting at the family planning clinic of Jos University Teaching Hospital, between 1st January 1999 and 31st December 2004, for removal of their IUDs. MAJOR OUTCOMES/RESULTS: The mean (+/- SD) age of the clients was 32.9 +/- 6.9 years and mean parity was 4.0 +/- 2.2. All the women were married. The CuT 380A IUD was used in 99.3% of the cases. The mean duration of IUD use was 51.5 +/- 51.0 months or 4.3 years only, and the commonest indication for removal was the desire for another pregnancy, which was recorded in 170 (30.7%) of the clients. This was followed by back pain in 70 (12.6%). Husbands' disapproval of the use of the device was recorded in 0.9% of the clients.

CONCLUSION

The duration of IUD use by clients in our centre was very short. The commonest indication for removal of the device was to restore fertility. Shorter lasting IUDs may need to be revisited if these will cost less for clients wishing to use the method only to postpone pregnancies. More effective counselling may be appropriate for alternative contraceptive methods for this category of clients instead of the IUDs currently being used.

Maternal mortality among adolescent women in Jos, north-central, Nigeria

The adolescent maternal mortality ratio is high in Jos, north-central Nigeria. The main causes of maternal deaths among the adolescents were unsafe abortion, eclampsia and sepsis. The Hausa/Fulani ethnic group constituted the largest ethnic group of adolescent maternal deaths in our study. The risk factors for adolescent maternal mortality found in our study were illiteracy, non-utilisation of antenatal services and Hausa/Fulani ethnic group.

Factors contributing to maternal mortality in north-central Nigeria: a seventeen-year review

Maternal mortality ratio in Nigeria is one of the highest in the world. This paper reports a facility based study in north-central Nigeria to determine the magnitude, trends, causes and characteristics of maternal deaths before and after the launch of the Safe Motherhood Initiative in Nigeria, with a view to suggesting strategic interventions to reduce these deaths. The records of all deliveries and case files of all women who died during pregnancy and childbirth between January 1, 1985 and December 31, 2001, in the maternity unit of Jos University Teaching Hospital, Jos, Nigeria, were reviewed. Data collected were analysed for socio-biological variables including age, booking status, educational level, parity, ethnic group, marital status, mode of delivery, duration of hospital stay before death occurred, cause (s) of maternal deaths. There were 38,768 deliveries and 267 maternal deaths during the period under review, giving a maternal mortality ratio (MMR) of 740/ 100,000 total deliveries. The trend fluctuated between 450 in 1990 and 1,010/100.000 deliveries in 1994. The mean age of maternal death was 26.4 (SD 8.1) years. The greatest risk of MMR was among young teenagers (> 15 years) and older women (< 40 years). Parity-specific maternal mortality ratio was highest in the grand multiparous women. Unbooked as well as illiterate women were associated with very high maternal mortality ratio. The Hausa - Fulani ethnic group contributed the largest number (44%) by tribe to maternal mortality in our study. The major direct causes of deaths were haemorrhage (34.6%), sepsis (28.3%), eclampsia (23.6%) and unsafe abortion (9.6%). The most common indirect causes of death were hepatitis (18.6%), anaesthetic death (14.6%), anaemia in pregnancy (14.6%), meningitis (12.0%), HIV/AIDS (10.6%) and acute renal failure (8.0%). Seventy-nine percent of the maternal deaths occurred within 24 hours of admission. Most of the deaths were preventable. A regional-specific programme should be planned to reduce the deplorably high maternal mortality in north-central Nigeria.

Evaluation of menstrual and haematological parameters, after 36 months of Norplant contraception

This ongoing prospective longitudinal study involved 23 women who had complete records, of 37 healthy non-breastfeeding informed volunteers recruited from our family planning clinic since August 1997 to the Norplant training programme. Packed cell volume (PCV), white blood cell (WBC) concentration (total and differential and platelet concentration were analysed at pretreatment and at 12, 24 and 36 months' followup. Statistical analysis was with paired t-tests. The level of significance was set at 5%. Each acceptor received a menstrual calendar to document all events of bleeding. The mean PCV was 40.5 +/- 2.4% at pretreatment. This rose to a statistically significant (P < 0.001) mean value of 44.9 +/- 4.4% at 36 months. The mean WBC concentration at pretreatment was 5552 +/- 1423 per mm3 which declined statistically (P < 0.001) to a mean value of 4400 +/- 1281 per mm3 at 12 months without any further significant changes at 24 months (P > 0.6; 4143 +/- 1301 per mm3 and at 36 months (P > 0.9; 4070 +/- 875 per mm3). At 24 months of study the mean concentration of neutrophils, lymphocytes, monocytes eosinophils and basophils did not change significantly from their respective mean concentrations at 12 months. These insignificant changes were also manifested at 36 months of study in the lymphocytes (P > 0.2), eosinophils (P > 0.5) and basophils (P > 0.2), even though there was a significant decrease in the neutrophils (P < 0.05) with a corresponding significant increase (P < 0.001) in the monocyte concentration. However, there was still a significant decrease (P < 0.001) in the WBC at 36 months of study compared with the mean preinsertion value, which was manifested mainly in the neutrophil concentration (1403 +/- 517 per mm3 (P < 0.001). The mean value of platelet count (136260 +/- 27664 per mm3) at 24 months showed no significant change compared with the 12 months value (126174 +/- 37977 per mm3). The value at 36 months (125391 +/- 18858 per mm3), however, still showed a significant decline over the pretreatment mean concentration (208043 +/- 27250 per mm3). None of the acceptors had thrombocytopenia at 24 and 36 months. At 2 years and 3 years of studies 60.9% and 47.8% of Norplant users reported irregular bleeding patterns, mainly of reduced episodes. The continuation rate at 36 months was 100%. Women using the Norplant implant are at an advantage, because in spite of the variable aberrations in their menstrual pattern, the packed cell volume increased. The changes ob-served in the white cell and the platelet concentrations did not lead to adverse effects.