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   Table of Contents - Current issue
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September-December 2019
Volume 36 | Issue 3
Page Nos. 319-477

Online since Wednesday, January 22, 2020

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REVIEW ARTICLES  

Challenges and practical steps to optimizing the utilization of electronic fetal monitoring in low and medium income countries: The UBTH experience Highly accessed article p. 319
E Enabudoso, A B A Ande, N Enaruna, C E M Okoror, S Igbarumah
DOI:10.4103/TJOG.TJOG_76_19  
Electronic fetal monitoring with special emphasis on cardiotocography (CTG) has become indispensable in the management of pregnancy and labor, especially in the high-risk parturient. While this is an essential part of the practice in high-income countries, many low- and medium-income countries (LMICs) lack the facilities and skill to deploy the technology in their centers. The reasons for this stem from various issues including lack of knowledge on the significance of the tool, lack of training in the acquisition and interpretation of the trace, inordinate fear of the presumed increase in Caesarean section rate, equipment cost and maintenance, among others. In this commentary, the lessons learnt from the 10-year experience of the implementation of CTG monitoring at the Maternal and Fetal Unit of the Department of Obstetrics and Gynecology of the University of Benin Teaching Hospital, Benin City are shared. The basic steps necessary to commence the service are proposed. The issue of training and retraining is emphasized while also highlighting the necessity of preventive maintenance of the equipment. The challenges of the program and limitations of the report are also brought to the fore. Despite these drawbacks, in the spirit of the peer review system for the introduction and sustenance of contemporary medical technology in LMICs, it is believed that sharing these experiences will help build an enduring system capable of improving service delivery and practice in these regions.
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Measurement of maternal mortality p. 325
VO Otoide
DOI:10.4103/TJOG.TJOG_59_19  
Context: Accurate measurement of maternal mortality is an imperative for policy and planning on maternal health care. Objective: The objective of this review is to focus attention on the various methods of measuring maternal mortality, advantages, and drawbacks. Source of materials for this article are from learned journals and reports on the subject. Conclusion: The measurement of maternal mortality poses unique challenges in resource-poor settings in developing countries. In these settings, though various methods may be employed, a census, cumbersome as it may be, offers the best possible source of data.
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Role of blood transfusion in obstetrics p. 330
L Reshma, S Sreelatha
DOI:10.4103/TJOG.TJOG_68_19  
Blood transfusion in obstetrics should be administered to save the patient's life. Severe blood loss could lead to hypovolemic shock which requires an immediate blood transfusion to prevent organ failure and death. Transfusion of blood and blood components must be approached like the use of medicines. They must be used only after weighing the benefits against the risks as well as in the right dose, right indication, and schedule. This review article deals with preparation, indications, administration of blood components, and its complications in obstetrics.
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ORIGINAL ARTICLES Top

Evaluation of psychometric properties of the Uterine Fibroids Symptoms and Health-related Quality of Life (UFSQOL) questionnaire: The translated Bengali version Highly accessed article p. 338
Jasleen Luthra, Pritha Halder, Laijun Nahar, Najne Sultana, Aniruddha Banerjee, Ashutosha Kumar, Manjari Rai, Ompriya Mishra, Abhijit Chattopadhyay, Sangita Saha, Amila Modak, Anamika Basu, Sk Swaif Ali, Juniper Banerjee, Munmun Koley, Subhranil Saha
DOI:10.4103/TJOG.TJOG_37_19  
Background: The Uterine Fibroids Symptom and Health-related Quality of Life (UFSQOL) is a validated questionnaire assessing symptom severity and Health-Related Quality of Life (HRQL) in patients with uterine fibroids. The English version contains 37 items measuring 7 components—symptom severity, concern, activities, energy/mood, control, self-consciousness, and sexual function. To date, no validated Bengali version of the questionnaire is available. We aimed to translate the UFSQOL into Bengali and validate the same. Methods: The UFSQOL-Bengali version (UFSQOL-B) was produced by standardized forward-backward translations. A cross-sectional, multi-center, observational study was conducted to gather responses by convenience sampling. Reliability was tested using internal consistency and test-retest reliability analyses, while construct validity by exploratory factor analysis (EFA; n = 120) using principal component analysis (PCA; varimax rotation). Subsequently, confirmatory factor analysis (CFA; n = 120) was performed to verify the a priori scales by the goodness-of-fit model. Results: Both the internal consistency (Cronbach's α) and the intra-class correlation (ICC) coefficient were 0.92. All the items loaded above the pre-specified value of 0.4. The factor analyses using varimax identified 10 components (activities, energy and control, concern about clothing, mood, sexual function, self-consciousness, associated symptoms, heavy bleeding, cycle disturbance, and concern about flooding); explaining 70.2% of the variation. The Kaiser-Meyer-Olkin (KMO) was 0.801 and Bartlett's test of sphericity was P < 0.001. The goodness-of-fit of CFA model was mediocre. Therefore, the final version consisted of 37 items, framed within 10 components. Conclusion: The UFSQOL-B was a valid and reliable questionnaire but measured different dimensions from the English version.
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Patient safety in maternity: The Nigerian context p. 348
OO Badejoko
DOI:10.4103/TJOG.TJOG_102_19  
Background: The death of Folake Oduyoye at the Lagos University Teaching Hospital (LUTH), Nigeria on 13th December 2014 triggered a protest march against the hospital, by a coalition of civil society organizations and human rights activists, and a legal suit was instituted against the government. Although a Federal High Court ruled in 2018 to overturn Oduyoye's case on a technicality, this ruling is currently being appealed. Objective: To perform a sociological analysis of the Oduyoye/LUTH case and another managed in OAUTHC Ile-Ife; as a means of providing insight into the current state of patient safety in maternity, in Nigeria. Methodology: This sociological analysis was conducted using secondary data, sourced from a combination of detailed online searches of published literature, news items, and social media posts; along with personal observations and reviews of patient's records. Results: Patient safety issues in maternity are prevalent in Nigeria. Responsible macrosociological factors include lack of clarity regarding the political economy of healthcare in Nigeria, dubious justiciability of citizens' right to healthcare, poor resource allocation to healthcare, and dismal coverage of national health insurance, along with poor regulation of health services, and nonintegration of healthcare with partner social institutions. At the mesosociological and microsociological levels are lack of public confidence in Nigerian healthcare, gross infrastructural decay from chronic neglect, understaffing and inadequate training of personnel, lack of institutional risk management and clinical governance. Conclusion: The state of patient safety in maternity in Nigeria is quite worrisome. Various sociological factors were identified and viable solutions proffered.
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Pregnancy outcome among parturients living in and outside Sagamu: A cement factory town p. 356
AO Sule-Odu, OE Jaiyesimi, AO Adejumo, AK Akiseku, OI Odelola
DOI:10.4103/TJOG.TJOG_80_19  
Cement Dust and Pregnancy Outcome: Cement factory poses major health challenge to human health especially those living around the vicinity. The inhaled particulate matters are deposited in most organs in the body. Some of the pollutants migrate through the placenta which could adversely affect the growing fetus. Aims: To compare the fetal and maternal outcomes of pregnant women living within to those living outside Sagamu. Settings and Design: A retrospective study conducted among booked deliveries in Olabisi Onabanjo university teaching hospital in Sagamu from 1st of January 2017 and 31st December 2018. Subjects and Methods: Case notes were retrieved from central medical records. A total of 848 women were living within Sagamu, whereas 236 women were those living outside Sagamu. Statistical Analysis Used: Information retrieved was entered into SPSS version 21 and analyzed. Results: The mean age in years for the study and control group respectively were 29.1 ± 4.9 years and 30.2 ± 5.0 years and the difference was statistically significant (t = 2.723; P < 0.007). The rate of preterm delivery among the study group was significantly higher than the control (x2 = 5.29; P = 0.021). The mean gestational age at delivery for preterm babies was 29.6 ± 7.5 weeks (study) and 31.2 ± 6.0 weeks (control) and there was no significant difference (t-0.843; P < 0.401). The mean packed cell volume of the study and control at booking was 31.7 ± 8.1% and 31.4 ± 4.1% and the difference did not achieve significant level (t-0.538; P < 0.591). The mean birth weight was 3.2 ± 1.6 kg and 3.3 ± 2.1 kg for the study and control groups respectively and there was no significant difference between the two populations (t-0.885; P < 0.376). Conclusions: Pregnant women residing within Sagamu had significant increase risk of preterm deliveries than those living outside Sagamu.
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Feto-maternal outcome of ICU and non-ICU admitted eclampsia at LAUTECH Teaching Hospital: A 10-year review p. 363
Daniel A Adekanle, Adegboyega S Afolabi, Adeniyi O Fasanu, Bolanle S Bola-Oyebamiji
DOI:10.4103/TJOG.TJOG_14_19  
Introduction: Eclampsia has been one of the major causes of maternal mortality worldwide and its impacts are more felt in sub-Saharan Africa, including Nigeria. There is an urgent need to reduce its adverse effects on maternal health. The aim of this study is to reappraise our management protocol, identify gaps, and suggest ways of improvement. Methods and Materials: It is retrospective 10-year study of cases of eclampsia and assessing feto-maternal outcomes. Statistical Analysis: Categorical variables were summarized using frequency while continuous variables were summarized using mean and standard deviation. Measures of association were carried out using student t-test, F-test for continuous variables, and Chi-square test for categorical variables where appropriate. P value set at 0.05%. Results: 130 cases were identified. A comparative analysis was done on cases admitted to ICU and those managed without admission to ICU. Feto-maternal adverse effects were found more in cases admitted to ICU and were majorly unbooked cases. Conclusion: Despite ICU care, which should improve feto-maternal outcomes, the case in this study was opposite, suggesting suboptimal antenatal care, inefficient referral system, poor infrastructure, and inadequate manpower in our health sector. Sensitization will impact positively to reduce the burden of the disease.
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Five-year review of cases of miscarriage in a tertiary hospital in Abakaliki, South East, Nigeria p. 367
CC Anikwe, CC Ikeoha, JA Obuna, BC Okorochukwu, UU Nnadozie
DOI:10.4103/TJOG.TJOG_38_19  
Background: Abortion complication is a major contributor to maternal morbidity and mortality. Objective: To review the profile of cases of abortion in Federal Teaching Hospital, Abakaliki (FETHA). Materials and Methods: This was a retrospective review of all cases of abortion managed in the Department of Obstetrics and Gynecology of FETHA between January 1st, 2013 and 31st, December 2017. Results: During the period, 3528 gynecological emergencies were recorded. Abortion represented 45.5% (1604) of all gynecological admission. The mean age of the women was 28.4 ± 6.4 years. All the pregnancies were unbooked and majority of abortion occurred between the gestational age of 8–12 weeks. More than half (58.8%) of the women had secondary education. Unsafe induced abortions were 547 (34.1%). Bleeding per vaginam (741, 46.2%) was the commonest symptom at presentation; majority had incomplete abortion. Interventions offered include manual vacuum aspiration (1319, 82.2%) and dilatation and curettage (157, 9.8%). Less than ten percent had laparotomy for pelvic abscess. Infectious morbidities were seen in 145 patients. Abortion complication constituted 11.5% of all maternal death during this period. Conclusion: The study shows that abortion is one of the common gynecological emergencies recorded in the hospital. Provision and use of contraceptives by sexually active women will help to reduce the rate of unsafe abortions seen in our study. The morbidity and mortality associated with abortion can also be reduced by early presentation of the patients to the hospital with accurate diagnosis and prompt management.
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Low uptake of human papillomavirus vaccination and cervical cancer screening among female undergraduates of a Nigerian University p. 373
EK Afolabi, OO Ogunsanwo, SO Oyebamiji, OB Ani
DOI:10.4103/TJOG.TJOG_96_19  
Background: Cervical cancer is a public health problem affecting women all over the world. Persistent infection with high-risk types of human papillomavirus (HPV) is a key risk factor for the development of cervical cancer. Besides, HPV vaccines and cervical cancer screening have been established as the primary and secondary preventive measures, respectively, yet studies have documented low uptake of these preventive measures. This study was designed to identify factors associated with uptake of HPV vaccination and cervical cancer screening among female undergraduates in Obafemi Awolowo University, Ile-Ife, Nigeria. Methods: This is a cross-sectional descriptive study employing a semi-structured, self-administered questionnaire to elicit information from 240 female undergraduates on sociodemographics and factors associated with uptake of HPV vaccines and screening for prevention of cervical cancer. The data collected was analyzed using the statistical package for social sciences (SPSS) version 20.0. Descriptive statistics were used to present data in tables and frequencies. Results: Findings from the study revealed that 80% of the respondents have heard of cervical cancer; however, only 48.3% and 41.7% have information about HPV vaccination and cervical cancer screening, respectively. The key factors identified for low uptake of HPV vaccination and cervical cancer screening were inadequate information about HPV vaccines (96.7%) and lack of detailed information about cervical cancer screening (94.6%), respectively. However, the least identified factors for low uptake of the primary and secondary preventive measures were some of the respondents considered their age too young to receive HPV vaccines (15%) and lack of time (42.1%) for the uptake of cervical cancer screening. Conclusion: There is a high level of knowledge about cervical cancer, but does not translate to high uptake of the prevention services. Thus, there is a great need to put in place measures to improve the uptake of HPV vaccination and cervical cancer screening services among the target population.
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Microbial isolates and antibiotic sensitivity pattern among women with early preterm spontaneous prelabor rupture of fetal membranes in a Nigerian teaching hospital p. 378
RU Habib, A Rabiu, Z Muhammad, OO Abiodun
DOI:10.4103/TJOG.TJOG_41_19  
Background: Preterm prelabor rupture of membranes (PPROM) is a significant risk factor for prematurity, maternal, and early-onset neonatal sepsis. A study of the microbial isolates and antibiotic sensitivity pattern is needed in a resource poor country. Objectives: To identify the microbial isolates and antibiotic sensitivity pattern of patients with early PPROM. Materials and Methods: It was a comparative study between 60 pregnant women who had PPROM and 60 matched controls without PPROM. Study variables of interest were sociodemographic characteristics and gestational age at recruitment, microbial isolates, and antibiotic sensitivity pattern. Data obtained were presented in tabular forms and recorded as frequencies and percentages. x2 and students' t – tests were used to compare qualitative and quantitative variables, respectively. Statistical significance was considered at P value < 0.05. Results: Sociodemographic characteristics did not show any significant association between the two groups except for social class (x2 = 11.659, P = 0.003) and booking status (x2 = 53.494, P < 0.001). Positive culture rate of 51 (85.0%) and 9 (15.0%) were found in the PPROM and non-PPROM groups, respectively. Escherichia coli 18 (30.0%) was the most frequently isolated organism in the PPROM group. Chlamydia trachomatis antigen was detected in six cases (10.0%) among the PPROM group. Antibiotics that had excellent sensitivity to the isolated organisms were meropenem, ceftazidime, and piperacillin. Conclusion: Genital tract infection was significantly related to the occurrence of PPROM and E. coli was the commonest microbial organism isolated. Intravenous ceftriaxone followed by oral cefixime met national institute of child health and human development, maternal-fetal medicine units (NICHD-MFMU) criteria for selection as prophylactic antibiotic in PPROM.
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Analysis of vaginal and rectal sampling methods for maternal group B streptococcal isolation p. 387
V Sharmila, T Arun Babu
DOI:10.4103/TJOG.TJOG_36_19  
Background: Group B streptococci (GBS) is considered as an important cause of neonatal morbidity and mortality. The Centers for Disease Control and Prevention (CDC) recommends recto-vaginal sampling of pregnant women and the use of selective broth medium for GBS isolation. This study was done to evaluate the GBS yield from only vaginal, only rectal, and both rectal and vaginal swabs collected. In addition, the drawbacks of using the selective broth mediums for GBS isolation were also analyzed. Methodology: This was a prospective study that was done to screen 300 pregnant women for vaginal and rectal GBS colonization. Vaginal and rectal swabs were inoculated separately in Todd Hewitt Broth and later subcultured on blood agar for GBS isolation. Results: The GBS detection rates from both vaginal and rectal swabs were 42.9%, indicating heavy colonization in these women. In addition, our study noted certain drawbacks with the use of selective Todd Hewitt Broth medium used for GBS isolation. Conclusion: GBS isolation rate was higher when both rectal and vaginal swabs were collected. Our study also concluded that there was a need to develop alternative culture media for GBS isolation in view of the drawbacks encountered with the selective Todd Hewitt Broth medium.
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Suicidality among Nigerian postpartum women: Prevalence and correlates p. 391
T Opakunle, O Aloba, O Opakunle
DOI:10.4103/TJOG.TJOG_43_19  
Background: Postpartum suicidality is a major public health concern that has been identified as one of the major contributors to the global mortality burden. It poses a profound risk to women in the postpartum and the community in general. Aim: To determine the prevalence and correlates of suicidality among Nigerian postpartum women. Subjects and Methods: This is a cross-sectional descriptive study involving 347 Nigerian women recruited during the postpartum period. They completed a study-specific sociodemographic and pregnancy-related questionnaire, the Edinburgh Postpartum Depression Scale, Suicidal Behaviors Questionnaire-Revised, and the Brief version of the World Health Organization Quality of Life Questionnaire. Results: The prevalence of lifetime suicidal ideation, plans, and attempts was 10.4%, 2.9%, and 1.7% respectively. In addition, 5.2% of the respondents reported suicidal ideation in the past year, while 4.0% of the respondents indicated the likelihood of suicide attempts in the future. Depression, lower quality of life, preterm delivery, complications during pregnancy, poor support from the husband and the in-laws, stressful infant care, and baby's hospitalization were significantly associated with suicidality. Conclusion: Suicidality is relatively common among Nigerian postpartum women. Therefore, postpartum women should be routinely screened for suicidal behaviors.
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A novel daily fetal movement monitoring chart to detect the fetus at risk for IUD- A case–control study p. 398
SR Hemmanur, B Koteswaramma, V Nagashree
DOI:10.4103/TJOG.TJOG_65_19  
Background: Fetal movement (FM) monitoring by the expectant mother is a noninvasive and inexpensive method to detect a fetus at risk. In spite of using available methods, stillbirths continue to occur; hence, there is a need for newer methods. Methods: In this prospective case–control study, 500 booked uncomplicated singleton antenatal mothers were introduced to a specially designed daily FM count (DFMC) chart at 24 weeks of gestation. The ultrasonography (USG) evaluation for all the women was conducted before the beginning of the study. Women were advised to record FMs for an hour after breakfast, after lunch, and after dinner. If the FMs felt were less than five in the first hour, they were advised to continue recording the movements in the subsequent hours. Women were advised to consider “FM diminished” and report to the doctor when they persistently perceived less than five movements/hour for 6 h. Five hundred similarly booked antenatal mothers, who were not given DFMC charts, formed the control group. The number of mothers who reported diminished FM, number of intrauterine fetal deaths (IUFDs), and the number of meconium-stained liquor at delivery in the subgroups of women with abnormal cardiotocography (CTG) and biophysical profile (BPP) were recorded in both groups and compared. Results: The number of mothers who reported diminished FM in cases was 39 (7.8%) and in controls was 15 (3%). The number of IUFDs in cases were 2 (0.4%) and in controls were 9 (1.8%). The number of fetuses with abnormal CTG and BPP in cases was 15 (3%) and in controls was 3 (0.6%). The number of fetuses with meconium-stained liquor in subgroup of women with abnormal CTG and BPP in cases was 11 (73%) and in controls was 3 (100%). Statistically significant differences were observed between cases and controls with P < 0.005, favoring the use of new DFMC charts. Conclusion: Fetal monitoring with the new DFMC charts by every mother from 24 weeks onward improves maternal awareness about FMs and helps detect fetuses at risk for IUD, leading to reduction in stillbirths.
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Correlation of abnormal umbilical artery Doppler Indices and mode of delivery in intrauterine growth restriction p. 403
S Ganju, B Dhiman, N Sood
DOI:10.4103/TJOG.TJOG_79_19  
Background: Elevated impedance to blood flow in the placenta is reflected by abnormal umbilical artery (UA) indices as seen in intrauterine growth restriction (IUGR). Aims: To correlate abnormal UA Doppler velocimetry parameters with birth weight and mode of delivery in IUGR. Material and Methods: A prospective study was conducted in Department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child, IGMC Shimla HP, over a period of one year from August 2017 to July 2018. The study included a total of 120 consecutive clinically suspected cases of singleton IUGR pregnancies, at 34–40 weeks of gestation. Umbilical artery (UA) Doppler indices including systolic/diastolic (S/D) ratio, pulsatility index (PI), and resistive index (RI) were measured. The decision regarding mode delivery was based on absent or reversal of diastolic flow, abnormal fetal heart tracing, and other maternal and fetal conditions, e.g., preeclampsia or abnormal biophysical profile. The birth weight, mode of delivery, and the reasons for emergency cesarean section were noted. Statistical analysis was performed using Statistical Package for Social Sciences, version 16.0 and a P value <0.05 was considered statistically significant. Results: Abnormal UA PI (>1.42) was seen in 24 fetuses. Among these, 69% (n = 16) underwent a cesarean delivery, and 91% (n = 22) had a birth weight less than 2.5 kg. Statistically significant association was noted with abnormal UA PI (P-value: <0.01), abnormal UA RI (P-value: <0.001), and abnormal UA S/D (P-value: <0.001) and cesarean delivery. The main indication for cesarean section was fetal distress. Conclusion: Abnormal UA Doppler indices are significantly associated with cesarean deliveries and low birth weight babies.
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Ovarian seromucinous tumor: A case series of WHO newly introduced entity p. 408
E Dwivedi, N Dhameja, M Lader, AG Kar
DOI:10.4103/TJOG.TJOG_30_19  
Introduction: Ovarian epithelial tumors account for the majority of female ovarian neoplasms but seromucinous tumors are rare and not adequately described in the literature. The recent World Health Organization (WHO) 2014 classification of tumors of female reproductive organs introduced this new category of ovarian neoplasm as “seromucinous tumors. Materials and Method: Sectioning of tissue followed by staining and immunohistochemistry. Results: Four of our cases which were diagnosed as cystic lesion clinically and radiologically , on histopathological examination two of them reported as seromucinous cystadenoma and rest two as seromucinous borderline tumors (SMBT). One of the case of SMBT also showed microinvasion along with focal areas of intraepithelial carcinoma high grade and clear cell component. Conclusion: Proper histopathological diagnosis is very important for better treatment and to reduce the use of aggressive therapies.
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An appraisal of anaesthetic technique for caesarean delivery in a tertiary Institution North Central Nigeria p. 412
MB Adegboye, CI Oyewopo, KA Adegboye, J Josiah, EO Ibegbula
DOI:10.4103/TJOG.TJOG_63_19  
Background: The rate of caesarean delivery is on the rise globally and our institution is not left out. Therefore we set out to assess the trends, indications and anaesthetic techniques for caesarean delivery in our environment. Methods: This was a retrospective review of all caesarean deliveries between 1st January 2015 and 31st December 2017 from the anaesthetic chart, anaesthetic theatre records and labour ward record of the University of Ilorin Teaching Hospital (UITH). Patient's demographic data, indication for caesarean section, nature of caesarean section, ASA physical status, anaesthetic technique used, cadre of anaesthetist and the total number of deliveries were recorded. Data were analysed and presented as frequencies and percentages using statistical package for social sciences (SPSS software version 22). Results: During the study period a total of 7940 patients delivered and 1822 patients had undergone caesarean delivery. The caesarean section rate at the institution is around 22.9%. The commonest indication for caesarean delivery was previous caesarean section (31.6%) followed by hypertensive disorder in pregnancy(14.7%). Most of the caesarean section was performed as emergency (80%). Regional anaesthesia was the most frequently used for both emergency(91.3%) and elective (98.7%) caesarean section, and spinal anaesthesia(88.9%) was the commonest regional anaesthetic technique used. Conclusion: The rate of caesarean section is high in our institution, with majority being performed under spinal anaesthesia. We need to improve on other regional anaesthetic technique so that our parturients can have the best and safest option.
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Severe preeclampsia and eclampsia: A 6-year review at the Federal Teaching Hospital, Abakaliki, Southeast Nigeria p. 418
RC Onoh, JE Mamah, CD Umeokonkwo, EO Onwe, PO Ezeonu, L Okafor
DOI:10.4103/TJOG.TJOG_45_19  
Introduction: Severe preeclampsia and eclampsia are pregnancy-specific diseases associated with increased maternal and perinatal morbidity and mortality. Objective: To evaluate the prevalence and outcomes of pregnancies complicated by severe preeclampsia and eclampsia in the Federal Teaching Hospital Abakaliki (FETHA). Materials and Methods: This was a retrospective study of patients managed for severe preeclampsia/eclampsia from 1st January 2012 to 31st December 2017. Registers were reviewed, and the patient's case files were retrieved. Sociodemographic data, risk factors, and fetomaternal outcomes were extracted using a pro forma. The data were collated, imputed, and analyzed using Epi Info (Atlanta, USA) version 7. The proportion and outcomes of pregnancies complicated by preeclampsia and eclampsia within the period were estimated. A Chi-squared test was used to compare the relationship between the severe disease and sociodemographic characteristics and fetomaternal outcome at 5% level of significance. Ethical clearance was obtained from the research and ethics committee of FETHA. Results: The overall prevalence of severe preeclampsia/eclampsia was 4.0% with severe preeclampsia accounting for 3.4% and eclampsia 0.6%. The peak prevalence was in 2017, 5.2%. The majority of the patients were between 20 and 34 years, mean age was 27.3 ± 5.2 years. The majority of the patients were rural dwellers 130 (51.4%). About 107 (51.4%) attained secondary level of education. Only 93 (36.6%) were booked in FETHA. Primigravidity was the commonest risk factor 76 (29.9%). More women had cesarean section 124 (48.8%). The mean gestational age was 35 weeks and mean birth weight was 2.4 ± 0.8 kg. Maternal and perinatal deaths were recorded in 0.8% and 29.1% of the parturient, respectively. Conclusion: The prevalence of preeclampsia and eclampsia was high in this study and there was increased maternal and perinatal morbidity and mortality. There is an urgent need for wider antenatal coverage, timely diagnosis, and prompt intervention to reverse this trend.
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Fetal distress, options of anesthesia, and immediate postdelivery outcome at state specialist hospital Akure p. 424
RS Omotayo, OR Akinsowon, EO Bello, O Akadiri, AL Akintan, SE Omotayo
DOI:10.4103/TJOG.TJOG_66_19  
Background: When abnormalities of the fetal heart rate are recognized promptly and dealt with, asphyxia and therefore perinatal morbidity and mortality can be reduced. The objective of fetal monitoring during labor is the prediction and diagnosis of fetal asphyxia before fetal/newborn morbidity with particular reference to brain damage occurs. Fetal distress is one of the conditions in which the obstetrician is required to hasten the process of delivery. This urgency is also usually transferred to the anesthetists, whereas the burden of adverse fetal outcome falls squarely on the pediatrician. Objective: This study found out the form of anesthesia mostly used for caesarean sections (CS) in cases of fetal distress, its appropriateness in terms of achieving management goals, and advantages over the other form of anesthesia. Study Design: This study is a retrospective descriptive cross-sectional study. Materials and Methods: Records of patients that had caesarean section for suspected fetal distress over a period of 5 years were reviewed. The fetal status at the point of making diagnosis, type of anesthesia used, suite-arrival-incision-interval, and the baby's condition after surgery were retrieved from the case notes. Data were analyzed with the Statistical Package for Social Sciences (SPSS) version 20.0. Frequencies and proportions of data from the type-of-anesthesia groups were compared. Variables were compared for significance using Chi-square. Results: Most of the surgeries for fetal distress were done under spinal anesthesia in 90% of the patients. Suite arrival-to-incision interval which is largely affected by type of anesthesia was within 1 h 30 min in 91.6% of those that had spinal anesthesia compared to 100% for those that had general anesthesia (GA). P value = 0.000. APGAR score of <4 was more in neonates delivered with GA (61.1%) than those delivered with spinal anesthesia (14.5%). Percentage of neonatal admission into special care baby unit (SCBU) was more in those that had GA (85%) than those that had spinal anesthesia (14%). Conclusion: The predominant type of anesthesia used for caesarean section for fetal distress from this study was spinal anesthesia which had better neonatal outcome.
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Comparison of performance of shock index and conventional vital sign parameters for prediction of adverse maternal outcomes following major postpartum hemorrhage in Abakaliki, Southeast Nigeria p. 431
JI Nwafor, VO Obi, BI Onwe, D P C Ugojis, VU Onuchukwu, CN Obi, CC Ibo
DOI:10.4103/TJOG.TJOG_60_19  
Background: Despite advances in care, postpartum hemorrhage has continued to contribute disproportionately to maternal morbidity and mortality in developing countries due to delayed and/or substandard care in the diagnosis and management of hypovolemic shock. Aim: To compare the performance of the shock index with conventional vital signs for prediction of maternal outcome following postpartum hemorrhage and to establish alert thresholds for use in low-resource settings. Materials and Method: This is a 7-year retrospective cohort study of 289 women treated for primary postpartum hemorrhage at the Alex Ekwueme Federal University Teaching Hospital, Abakaliki. The data for systolic and diastolic blood pressure, mean arterial pressure, pulse pressure, heart rate, and shock index measured at the time of diagnosis of postpartum hemorrhage were analyzed. Adverse maternal outcomes such as intensive care unit admission, blood transfusion ≥5 units, hemoglobin level <7 g/dL, surgical interventions, end-organ failure, and death were reviewed. The area under the receiver operating characteristic curve (AUROC) for each vital sign was used to predict adverse maternal outcomes. Sensitivity, specificity, and negative and positive predictive values were calculated to determine the thresholds of the best predictor. Results: Shock index had the highest AUROC to predict invasive surgical procedures (0.70 for SI [95% CI 0.66–0.80] compared with 0.69 [95% CI 0.61–0.76] for pulse rate). Shock index was a consistent superior predictor for other outcomes. Shock index (SI) ≥0.9 had 100% sensitivity (95% CI 74.6–100) and 46.7% specificity (95% CI 34.9–56.5) for prediction of intensive care admission, and SI ≥1.7 had 46.9% sensitivity (95% CI 19.8–62.8) and 98.9% specificity (CI 91.1–100) for prediction of maternal death. Conclusion: Shock index is a consistent superior predictor of adverse maternal outcomes following postpartum hemorrhage when compared with conventional vital signs. SI <0.9 provides reassurance, whereas SI ≥1.7 indicates a need for urgent intervention to prevent maternal mortality.
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Knowledge and perception of postmenopausal symptoms among postmenopausal women presented at the gynecological clinic of a tertiary health institution in Abakaliki p. 437
CC Ibo, LO Ajah, JI Nwafor, KE Ekwuazi, OS Okoro, CN Obi, JE Mamah
DOI:10.4103/TJOG.TJOG_61_19  
Introduction: As life expectancy increases, most women spend a larger part of their lives in the postmenopausal state. This period is associated with other medical comorbidities which affect the quality of life. Knowledge and perception of postmenopausal symptoms could help them cope with such a situation. Aim: To determine the knowledge and perception of postmenopausal symptoms among postmenopausal women presented to the gynecological clinic of Alex Ekwueme Federal University Teaching Hospital, Abakaliki. Materials and Methods: This was a cross-sectional study carried out at the Gynecological clinic of Alex Ekwueme Federal University Teaching Hospital, Abakaliki. Around 408 women were administered structured questionnaires. The information obtained was analyzed using SPSS version 20. Results: Majority (50%) of the respondents were 50–54 years age group and the least (6.9%) were 55–59 years. The commonest menopausal symptom reported was hot flushes by 300 (73.5%) respondents. Tiredness and vaginal dryness were reported by 188 (46.1%) and 180 (44.1%) respondents, respectively. The knowledge of hormone replacement therapy was low (7.8%). The study showed that 356 (87.3%) women have no knowledge of hormone replacement therapy. Conclusion: There is a need for educating women in the clinics regarding menopause and hormone replacement therapy which would further enable women to make informed choices about their health postmenopause.
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Birth and sorrow: The medico-social consequences of obstetric fistula in Ilesha, Nigeria p. 442
AO Fehintola, FO Fehintola, AO Adetoye, EO Ayegbusi, OA Alaba, AD Ajiboye, OO Badejoko, BA Adeyemi
DOI:10.4103/TJOG.TJOG_32_19  
Background: Obstetric fistula is an abnormal communication between the epithelium of female genital tract and the bladder and (or) the rectum. It is not just “a hole”; it affects every aspect of the life of the sufferers. Objective: This study examined the etiology, psychosocial and medical consequences of obstetric fistula on the patients. Methodology: It was a cross-sectional study with quantitative and qualitative data collection methods employed. Quantitative data collection was done by the aid of a structured interviewer-administered questionnaire while qualitative data collection was by focus group discussions (FGDs) and in-depth interviews (IDIs). The sample consists of eligible and consenting patients with obstetric fistula admitted for repair at the Wesley Guild Hospital, Ilesha between July 2017 and August 2018. Purposive sampling technique was used to select 86 patients. Results: The mean age of patients was 28.7 years ± 7.5 (SD) with a divorce rate of 40%. Only 10% of them had their first marriage between ages 15 and 20 years. Prolong obstructed labor accounted for 55.8% of all the obstetric fistula in this study. The remaining were either following hysterectomy or cesarean section. Reported medical problems were dermatitis (60%), dyspareunia (25%), recurrent urinary tract infection (UTI) (10%), infertility (5%), and amenorrhea (5%). Socially, 45% felt ostracized, and 50% were economically impoverished by job loss. Some 56.6% respondents suggested that hospital delivery was a preventive measure, while 8% felt that avoidance of early marriage would prevent obstetric fistula. Conclusion: Obstetric fistula is still a major reproductive health problem. Most of these patients understand the role of unsupervised childbirth in its development.
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Accuracy of qualitative maternal cervicovaginal fetal fibronectin test in predicting spontaneous preterm birth in symptomatic pregnant women p. 448
EO Alajiki, OB Fasubaa, EO Babalola, M Ajayi, AA Sule, CC Umelo, A Magaji, E Orji, KO Ajenifuja
DOI:10.4103/TJOG.TJOG_93_19  
Background: The incidence of preterm birth is increasing worldwide. Preterm birth is a common cause of neonatal morbidity and mortality commonly associated with low-birth weight and deficiency of lung surfactants in the newborn. Children who were born preterm have higher rates of cerebral palsy, neurodevelopmental anomalies, learning disabilities, and respiratory illnesses compared with children born at term with attendant psychosocial and financial burden on the parents or carers. These problems may be minimized via the use of a preterm birth prediction test such as the maternal cervicovaginal fetal fibronectin test (FFT) to determine those women in genuine preterm labor and at a higher risk for preterm birth. Effective treatment can then be focused on this group of women to reduce the incidence of preterm birth. However, the FFT in preterm birth prediction is underutilized in Nigeria. Aim: To determine the role of cervicovaginal fetal fibronectin testing as a predictor of spontaneous preterm birth in symptomatic pregnant women in a local setting. Setting: This study was conducted at the obstetrics unit of the Department of Obstetrics and Gynaecology at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun state, Nigeria. The OAUTHC comprises two obstetrics units – Ife Hospital Unit (IHU) and Wesley Guild Hospital Unit at Ilesha (WGH). Design: Cross-sectional, descriptive study. Methods: In this study, 182 booked and unbooked singleton antenatal mothers between 28 weeks and 36 weeks 6 days gestation who had symptoms suggestive of preterm labor were recruited. An interviewer administered questionnaire was filled for each subject and a sterile speculum vaginal examination was then performed to obtain a specimen of the subject's cervicovaginal secretion using a sterile cotton swab. A qualitative FFT was done on each sample collected, then recruited mothers were monitored till delivery and further data obtained. Outcome Measures: The main outcome measures were the sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of FFT in predicting spontaneous preterm birth in symptomatic pregnant women. Results: A total of 182 women presenting with symptoms suggestive of preterm labor were recruited: 171 (93.96%) women delivered at term, whereas 11 (6.04%) women had preterm birth with a calculated preterm birth rate of 7.33 per 1000 deliveries during the study period. Also, 7 (3.85%) women had a positive FFT, while 175 (96.15%) women had a negative test. FFT had a sensitivity, specificity, PPV, and NPV of 9.09%, 96.49%, 14.29%, and 94.29%, respectively; a LR+ and LR- of 2.59 (95% confidence interval, CI, 0.34–19.68) and 0.94 (95% CI, 0.78–1.14) respectively; a relative risk of 2.59 (95% CI, 0.341–19.675); a calculated accuracy of 91.21% (95% CI, 86.12%–94.89%); and an area under the receiver operating characteristic curve of 0.60. Conclusion: The high NPV of fetal fibronectin sampling in a population of pregnant women with symptoms supports less intervention for patients with negative results.
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Does genital Chlamydia trachomatis cause spontaneous miscarriage in black women? p. 455
RM Aliyu, AG Adesiyun, S Aliyu
DOI:10.4103/TJOG.TJOG_75_19  
Background: Chlamydia trachomatis (Ct) is the commonest bacterial sexually transmitted disease worldwide and is now being considered as an emerging “obstetric pathogen”. It is an enemy to the human reproductive system causing infertility, adverse pregnancy and perinatal outcomes but its role in causing spontaneous miscarriage is still unclear. Objective: To assess the association between genital Chlamydia trachomatis and spontaneous miscarriage in black women. Materials and Methods: Eighty three women with spontaneous miscarriage (case group) were compared with 83 women with on-going pregnancy beyond 28 weeks' gestation (control group). Sera of both groups were tested for the presence of Chlamydia trachomatis Immunoglobulin G (IgG) antibody using ELISA. Results: Seroprevalence of IgG to Ct was 8.4% and 3.6% among women with spontaneous miscarriage and on-going pregnancy, respectively. Ct IgG seropositivity was not significantly different between the two groups (P = 0.192; OR = 0.41, CI 0.10 – 1.63). Conclusion: Chlamydia trachomatis IgG seropositivity is not associated with spontaneous miscarriage in this study. However, multicentre study with larger sample size and using polymerase chain reaction as a diagnostic technique is recommended.
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Awareness, knowledge, and perception about Sayana press® contraceptive technology in Nigeria p. 459
F Eremutha, VC Gabriel
DOI:10.4103/TJOG.TJOG_81_19  
Background: Access to modern contraception can save lives. Sayana Press® is a 3-month injectable contraceptive that has a small needle and comes in a prefilled syringe, which makes it easy to use and less painful. Subjects and Methods: A mix method cross-sectional study was carried out in the Federal Capital Territory (FCT) and 3 states chosen across Nigeria: Nassarawa, Benue, and Oyo states. Quantitative data were collected using an interviewer-administered questionnaire while the qualitative data were collected using focus group discussions with selected youths, teachers, family planning service providers (caregivers), and parents. Results: Despite its years of introduction into the family planning market, Sayana Press® awareness was low, with 37.7% (43) of the 114 respondents in the quantitative study being aware of its existence as a new family planning method. The qualitative data also reinforced the crucial role of contraceptive knowledge (benefits and side effects) and cost on the uptake of Sayana Press®. Conclusion: Government and donor support for centralizing the procurement and distribution of contraceptives is a key determinant of Sayana Press® awareness and uptake.
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CASE REPORTS Top

Cervical ectopic pregnancy patient treated with intramuscular methotrexate who subsequently had live birth: A case report and literature review p. 465
M Bukar, HA Usman, SM Ibrahim, AI Numan
DOI:10.4103/TJOG.TJOG_46_19  
Cervical ectopic pregnancy (CP) is a rare form of ectopic gestation. It is associated with high morbidity and mortality if not properly managed. Transabdominal ultrasonography (TAS) alone without transvaginal ultrasonography (TVS) could create diagnostic dilemmas. Minimally invasive treatment with local or systemic methotrexate is effective and has no effect on subsequent reproductive carrier. We present a 39-year-old G5P2+2 woman who presented with pregnancy of unknown location following TAS. The TVS confirmed CP. She had a successful medical treatment with a single dose of intramuscular methotrexate and subsequently got pregnant and delivered a live-born infant 11 months after treatment.
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Deep tongue laceration following eclampsia, Cesarean section, repair and blood transfusion- A case report p. 468
HM Abdullahi, M Yusuf, AL Dayyabu, AM Miko
DOI:10.4103/TJOG.TJOG_95_18  
Eclampsia still remains an issue of serious concern in Sub Saharan Africa. Preeclampsia is the precursor to eclampsia, in which hypertension and proteinuria are present, with or without oedema1-2. This is a case of Mrs SK, a 21year old Primigravida who was unsure of her last menstrual period, but she was said to be 9 months pregnant; she developed generalized tonic clonic convulsions with each episode lasting about 30 seconds. She sustained a V-shaped laceration affecting lower one third of the tongue with clots of blood on the affected area. A diagnosis of antepartum eclampsia was made. She was admitted into the eclamptic ward and resuscitated. Intravenous infusion and Magnesium sulphate were commenced using Zuspan Regimen. She had an emergency caesarean section and was delivered of a fresh still birth female baby who weighed 3.0kg. The lacerated tongue was repaired by maxillofacial surgeon and she was transfused with 2 pints of blood. Eclampsia is the leading cause of maternal mortality in developing countries. Recognizing the features of preeclampsia and instituting appropriate measures is mandatory in order to prevent the progression of the disease to eclampsia with its associated complications.
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Once treated, twice harmed: A case report of acquired gynatresia following vaginal insertion of herbs p. 472
Olubukola O Allen, Olusegun O Badejoko
DOI:10.4103/TJOG.TJOG_101_19  
Gynatresia is the narrowing or complete occlusion of the vagina, which may be congenital or acquired. In Nigeria, acquired gynatresia is more common, usually resulting from the use of herbal pessaries. Its mere occurrence is indeed one social calamity to many. We present a case of a 37-year-old P0+1 with acquired gynatresia following insertion of herbal pessaries at a trado medical center. This was in an attempt to treat cryptomenorrhea which had developed following an abortion complicated by uterine perforation at a private hospital 20 years prior. Poor quality of medical care may push women to seek unsafe alternatives, resulting in even more harm.
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Medical termination of pregnancy in bicornuate uterus with twin gestation p. 474
Krishnan Geetanjali, Sowmya Raghavan, Dina G Selvi
DOI:10.4103/TJOG.TJOG_48_19  
The incidence of uterine anomalies in general population is about 3-5 %.abnormalities of fusion of mullerian duct during embryogenesis results in varied congenital abnormalities like arcuate, septate, uni-cornuate, bi-cornuate uterus. Majority of them are asymptomatic. The suspicion of uterine abnormalities is always considered when there is a history of recurrent abortions, intrauterine growth restrictions, preterm labour, mal-presentations. We are presenting a 31 year old pregnant women who came with history of urine pregnancy test positive at 56 days of amenorrhea and requested medical termination of pregnancy. On ultrasound examination a bi-cornuate uterus with pregnancy in both horns of the uterus was imaged. Her first pregnancy was a normal full term delivery one year ago. She was not diagnosed with bi-cornuate uterus in her previous pregnancy. She was given a combination of mifepristone and misoprostol for termination of pregnancy, which ended in a successful medical termination of pregnancy, confirmed by transvaginal ultrasound done two weeks later.
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LETTER TO EDITOR Top

A case report of vulvar schwannoma and literature review p. 477
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/TJOG.TJOG_31_19  
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