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   Table of Contents - Current issue
Coverpage
May-August 2018
Volume 35 | Issue 2
Page Nos. 97-216

Online since Friday, August 17, 2018

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EDITORIAL  

From the editorial board p. 97
AB Ande
DOI:10.4103/TJOG.TJOG_55_18  
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REVIEW ARTICLES Top

Instrumental vaginal deliveries: A review Highly accessed article p. 99
Jacob A Unuigbe, Godwill E Agbon-Ojeme, Robinson A Erhatiemwomon, Kenneth Toby Maduako
DOI:10.4103/TJOG.TJOG_49_18  
In contemporary obstetric practice, safety with caesarean section in developed countries has witnessed its increased application in deliveries and the decreasing use of instrumental deliveries. This trend follows the relative hazards complicating instrumental vaginal deliveries and increasing litigations arising thereof. In developing countries however, caesarean sections are not so readily available to parturients and are relatively unsafe, especially with mothers presenting late in health facilities with complicated (commonly obstructed) labors, not infrequently with fetal death. In these circumstances, instrumental vaginal deliveries serve as suitable options. It is with this background that this review considers the role of instrumental vaginal delivery and gives a critical account of current techniques of operative procedures. Important issues, including case choice, documentation, application and use, avoidance of complications, and the need for medical staff training, are included. To this end, nondestructive instrumental (vacuum and forceps), “corrective” instrumental (symphysiotomy), and destructive instrumental assisted vaginal deliveries are considered and carefully analyzed.
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Contraceptive implants: A review and current perspective in southwest Nigeria Highly accessed article p. 108
Olatokunbo Olayiwola Kolawole, Oluwaseun Oludotun Sowemimo, Opeyemi Olawale Ojo, Olusola Benjamin Fasubaa
DOI:10.4103/TJOG.TJOG_6_18  
Contraceptive implants are highly cost-effective forms of long-acting reversible contraception. They are the most effective reversible contraceptives and are more effective than sterilization. Pregnancies are rare in women using this method of contraception, and those that do occur must be fully investigated. There are very few contraindications to use of implants, and they have an excellent safety profile with very high acceptability and continuation rate. Other benefits include noninterference with intercourse, immediate onset of action, and return to fertility after removal, improvements in dysmenorrhea, ovulatory pain, and endometriosis. Despite the numerous advantages, the uptake of contraceptive implants is still very low in the southwestern part of Nigeria. This may be due to lack of public awareness about their numerous benefits. Efforts should be made to increase awareness via campaigns and health education. Also, there should be easy accessibility to the contraceptive implants and continuous training of family planning providers on the insertion and removal techniques.
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ORIGINAL ARTICLES Top

A decade of instrumental vaginal deliveries in Jos University Teaching Hospital, North Central Nigeria (2007–2016) p. 113
PH Daru, C Egbodo, M Suleiman, IH Shambe, AF Magaji, S Ochejele
DOI:10.4103/TJOG.TJOG_38_18  
Background: Instrumental vaginal deliveries are witnessing a steady decline despite its usefulness in improving obstetric outcomes in resource-limited settings. This decline in instrumental deliveries is enhanced by dearth of information on good outcomes thereby making its use unpopular among younger generations of obstetricians. The study was aimed at determining the rate of instrumental deliveries and associated outcomes in Jos University Teaching Hospital (JUTH). Materials and Methods: This study was a 10-year retrospective hospital-based study carried out between January 2007 and December 2016 in JUTH which compared the use of vacuum extractors and forceps to effect vaginal deliveries and the delivery outcomes encountered following such deliveries. Results: Of the 16,614 deliveries during the study period, 71 were instrumental vaginal deliveries with an incidence of 0.4% for the study period. Vacuum accounted for 97.2% of the deliveries and forceps 2.8%. Prolonged second stage was the indication for instrumental delivery in 85.9% of parturients and there were no significant differences in Apgar scores between babies that had instrumental deliveries and those that did not. Age and parity were not significantly associated with instrumental deliveries. The instrumental delivery rates were, however, significantly lower than earlier reports from this center, and that globally recommended. Conclusion: Instrumental vaginal deliveries are fast declining in JUTH and the few instrumental deliveries carried out showed a faster decline in forceps deliveries. Efforts have to be made to revive the art of instrumental vaginal delivery in the center to save it from extinction.
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A 10-year review of instrumental vaginal delivery at the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria p. 118
Justina O Alegbeleye, Ngozi C Orazulike, Tamunomie K Nyengidiki, Samuel A Uzoigwe
DOI:10.4103/TJOG.TJOG_26_18  
Background: Instrumental vaginal deliveries are conducted for either maternal or fetal indications to shorten the second stage of labour. Global trends show a diminished instrumental delivery rates. Objectives: To determine the prevalence, indications, complications, and the trend of instrumental vaginal deliveries at the University of Port Harcourt Teaching Hospital. Materials and Methods: This was a retrospective study of 164 women who had an instrumental vaginal delivery over a 10-year period at the University of Port Harcourt Teaching Hospital from January 1, 2008, to December 31, 2017. Data obtained from the labour ward registers and case notes of patients were entered into a proforma and analyzed using EPI-info ver. 7. P value of 0.05 was set as significant at 95% confidence interval. Results: The incidence of instrumental vaginal delivery was 0.67% of all deliveries. Vacuum delivery accounted for 0.63% whereas forceps delivery was 0.04%. Delayed second stage of labour (56; 34.15%) and severe pre-eclampsia/eclampsia (42; 25.61%) were the most common indications. Senior resident trainees conducted majority (121; 73.78%) of the deliveries. The most common maternal complications were perineal tears (13; 50%) and primary postpartum haemorrhage (11; 42.31%). These maternal complications significantly occurred more with vacuum delivery (P value = 0.001). About half of the babies (80; 47.62) had birth asphyxia. Conclusion: The instrumental vaginal delivery rate in this study is very low despite being an alternative to caesarean section. Therefore, efforts should be made toward training and retraining of doctors on this skill to reduce maternal and fetal morbidity associated with the procedure, and also reduce the caesarean section rate.
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Instrumental vaginal delivery in Usmanu Danfodiyo University Teaching Hospital, Sokoto: A ten-year review p. 123
JA Garba, AT Burodo, AD Saidu, B Sulaiman, AG Umar, R Ibrahim, AM Nasir
DOI:10.4103/TJOG.TJOG_13_18  
Background: Instrumental vaginal delivery is one of the key elements of essential obstetric care that mimics spontaneous vaginal delivery in order to expedite delivery with minimal maternal and neonatal morbidity. The objectives of the study were to determine the rate of instrumental deliveries, the common indications, and compare outcome and complications between forceps and vacuum deliveries. Materials and Methods: This was a retrospective cross-sectional study on instrumental vaginal deliveries carried out in UDUTH over 10 years from January 2007 to December 2016. The list of cases was obtained, the case files were retrieved and relevant information was obtained. Data analysis was done using SPSS version 21. Level of significance was set at P < 0.05. Results: The instrumental vaginal delivery rate was 2.06%. Vacuum deliveries accounted for 83.3% (n = 524) but forceps deliveries accounted for 16.7% (n = 105). The most common indication for both was delayed second stage of labor due to malposition. There was no statistical difference in the mean APGAR scores at 1st and 5th min between babies delivered by vacuum and those delivered by forceps. Majority had no complication and there was no statistical association between the type of procedure and maternal or fetal complications observed during the procedure (χ2 = 3.18, P = 0.2). Conclusion: The rate of instrumental vaginal delivery is much lower than that reported in some centers in Nigeria and globally. Majority of the cases had no complication and there was no significant difference in complications observed between vacuum and forceps deliveries.
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A 5-year retrospective review of instrumental vaginal deliveries in Uyo, Akwa Ibom State, Nigeria p. 128
Emem A Bassey, Gabriel M Abah
DOI:10.4103/TJOG.TJOG_52_18  
Context: Instrumental vaginal deliveries are deliveries conducted using obstetric forceps or vacuum extractor and are an essential component of basic emergency obstetric care. Objective: To determine the rate of instrumental deliveries and their outcome over a 5-year period (2013–2017) at the University of Uyo Teaching Hospital. Study Design and Methods: A 5-year retrospective review of maternity delivery records. A survey of 16 resident doctors of the department was also done to determine their views on the rate of instrumental deliveries in the hospital. Results: During the study period, there were 6,754 deliveries; of these 109 (1.61%) were instrumental deliveries. Vacuum extractions accounted for 97 (88.99%) of the instrumental deliveries and there were only 12 (11.01%) forceps deliveries. The majority of the instrumental deliveries were carried out on booked women (78; 82.98%), with low parity (Para 1; 73.83%), term mothers (59.4%), and normal birth weight babies. There were only five stillbirths (4.59%), all of which were vacuum extractions and were comparable to 4.5% among spontaneous vertex deliveries and less than 6.2% among caesarean sections and 45.5% among breech deliveries. This was statistically significant, χ2 = 114.03, P < 0.001. Most of the resident doctors cited lack of proper training as responsible for low rate of instrumental deliveries. Conclusion: The rate of instrumental vaginal deliveries in the University of Uyo Teaching Hospital is low with adverse consequences on the training of resident doctors. There is thus need to prioritize training on this life-saving skills.
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Review of instrumental vaginal delivery at the Obafemi Awolowo University teaching hospitals complex p. 133
Oluwaseun Oludotun Sowemimo, Zainab Foyeke Abdur-Rahim, Olatokunbo Olayiwola Kolawole, Ekundayo Oluwole Ayegbusi, Michael Sylvester Archibong, Emeka Philip Igbodike, Olusola Benjamin Fasubaa
DOI:10.4103/TJOG.TJOG_51_18  
Background: Instrumental vaginal delivery (IVD) is one of the signal functions of the basic emergency obstetric and newborn care. Some recent reviews point towards a sustained fall in the performance of this lifesaving procedure. With increasing caesarean section rates, institutional reviews of the practice of IVD are important to improve and sustain this art which is on the path of extinction. Objectives: To determine the IVD rate at the OAUTHC over a 5-year period from January 2013 to December 2017 and to review the maternal and newborn outcomes. Methods: This was a retrospective review. Case records of parturients who had either forceps or vacuum delivery during the study period were retrieved and relevant information were extracted. Data analysis was done with IBM-SPSS version 20. Results: There were 10,286 deliveries and 101 IVDs over the 5-year period giving an IVD rate of 0.98%, with 0.41% for forceps and 0.57% for vacuum delivery. Seventy-one case records were available for review. Mean maternal age was 27.21 ± 5.8 years and 31 (43.7%) of the parturients were primigravidae. Thirty-nine (54.9%) were booked and 66 (93%) of the procedures were performed as emergencies. Senior residents conducted most (94.4%) of the procedures and poor maternal efforts in the second stage of labor was the most common indication (43.8%). All resulted in vaginal delivery with the most common maternal complication being genital tract laceration, most notably first and second-degree perineal tears. Of the 66 livebirths, neonatal ward admission rate was 45.5%. There was an early neonatal death which followed a traumatic vacuum delivery. Conclusion and Recommendations: The IVD rate at OAUTHC is low, with higher preference for vacuum delivery. Appropriate case selection is evident, and poor maternal effort in second stage of labor remained the leading indication. The neonatal admission rate is high. Training and retraining of resident doctors is necessary towards increasing the conduct and ensuring better outcome.
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Qualitative cervicovaginal fluid β-hCG versus cervicovaginal fluid fetal fibronectin assessment in prediction of preterm labor in asymptomatic high risk women p. 137
Mohamed Lotfy Mohamed El-Sayed, Mostafa Abdo Ahmed, Shymma Abdelazim Mansour, Marwa Abdelazim Mansour
DOI:10.4103/TJOG.TJOG_24_18  
Context: Preterm births occur in 11% of all births worldwide, but account for more than 85% of perinatal morbidity and mortality. One of the best predictors to assess the risk of preterm labor (PTL) is by measuring fetal fibronectin (fFN) in cervicovaginal secretions (CVS). In addition, measurement of cervicovaginal fluid fFN is a good negative predictor of spontaneous PTL in both symptomatic and asymptomatic high-risk women after 22 weeks of pregnancy. Aim: We aimed to evaluate the diagnostic accuracy of qualitative cervicovaginal beta-human chorionic gonadotropin (β-hCG) versus qualitative fFN for prediction of PTL in asymptomatic high-risk women during antenatal care. Settings and Design: This prospective observational study was undertaken at Egypt, Zagazig University Hospitals. In all, 220 with singleton pregnancies and having risk factors for spontaneous preterm birth were included in this study. Materials and Methods: Cervicovaginal fluid sampling was undertaken at 24 weeks gestational age for qualitative β-hCG and qualitative fFN assessment. Women were categorized into two arms: women who delivered preterm and women who delivered at term. Statistical Analysis Used: Data were presented as mean, ±standard deviation, number, and percentage. Chi-square test (χ2) was used for comparison between groups with regard to qualitative variables; validity of the test is done using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: As regarding qualitative β-hCG assessment for prediction of PTL, sensitivity, specificity, PPV, and NPV were 72%, 85%, 41%, and 95.5%, respectively. As regarding qualitative fFN assessment for prediction of PTL in the same studied group, sensitivity, specificity, PPV, and NPV were 73%, 87%, 38%, and 96%, respectively. Conclusion: Our study showed that qualitative β-hCG assessment in cervicovaginal fluid can be used as an alternative method to qualitative fFN assessment as it is a valid test, more available, and not expensive in prediction of PTL in asymptomatic high-risk patients.
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Abruptio Placenta: A retrospective analysis in a tertiary hospital, Sagamu, Nigeria p. 142
Adebayo A Akadri, Kehinde M Ogunsowo, Oluseyi I Odelola
DOI:10.4103/TJOG.TJOG_14_18  
Context: Abruptio placenta is an important contributor to perinatal and maternal morbidity and mortality in Nigeria. Although the primary etiology remains unknown, there are many associated risk factors, some of which are preventable or treatable. Aim: To determine the prevalence, sociodemographic characteristics, risk factors, and feto-maternal outcome of abruptio placenta in Olabisi Onabanjo University Teaching Hospital Sagamu. Materials and Methods: This was a retrospective study involving all pregnant women who had abruptio placenta from January 1, 2012, to December 31, 2016. Data on sociodemographic characteristics, risk factors, and fetal and maternal morbidity and mortality were extracted from patients' case notes for analysis. Results: The mean age of the subjects was 33.4 ± 6.3 years. The prevalence of abruptio placenta was 1.03%. Hypertensive disorder was the most important risk factor, seen in 53.1% of the subjects. Birth asphyxia was the major perinatal morbidity and was found in 42.9% of the babies, whereas 46.9% were still births. The caesarean section rate was 63.3%. Forty subjects (81.6%) had blood transfusion, 17 subjects (34.7%) had postpartum hemorrhage, and 40.8% had postpartum anemia. There were two maternal deaths giving a case-specific fatality rate of 4.1%. Conclusion: Abruptio placenta is an important pregnancy complication in Olabisi Onabanjo University Teaching Hospital Sagamu, Nigeria. Good antenatal care services will enable caregivers to identify women at risk who may benefit from targeted management aimed at reducing the adverse outcomes associated with the condition.
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Economic recession and family planning uptake: Review of a Nigerian health institution p. 147
KO Wright, E Ukatu, TA Ottun, MO Oyebode, V Sarma, S Chung
DOI:10.4103/TJOG.TJOG_82_17  
Introduction: Family planning has been considered a “best buy” among health investments in terms of improving healthier and more economically stable societies. Uptake has, however, remained low in sub-Saharan Africa. This study assessed a 5-year trend in contraceptives uptake at the family planning clinic of a Southwest tertiary health institution in Nigeria during an economic recession. Materials and Methods: This was a 5-year retrospective review of 2552 hospital records for family planning clients at the Lagos State University Teaching Hospital from 15 August 2011 to 31 August 2016 compiled from the clinic register quantitatively. Data entry and analysis were conducted using SPSS version 20.0. A test of significance was used to determine association between variables and level of significance set at P < 0.05. Ethical approval was sought from the hospital authorities before commencement of the study. Results: The highest proportion of new acceptors of contraceptives was in the year 2013 (24.8%) followed by a gradual decline. Unemployment rate among the respondents was 8.5%. Despite a distinct preference for some long-acting reversible contraceptives (LARCs), namely, intrauterine contraceptive device (45.0%), followed by implants (43.3%), there was significantly less preference for hormonal LARCs such as implants with increasing age. Conclusion: The study findings are counter-cyclical, in that economic recession seemed to reduce contraceptive usage with a potential of increasing fertility in Lagos, Nigeria, which could result in further increase in population size and its sequelae. Multidimensional efforts are required to improve contraceptive coverage to reduce the already overstrained resources.
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Menstrual hygiene among adolescent school girls in Kano p. 153
Ibrahim Garba, Ayyuba Rabiu, Idris S Abubakar
DOI:10.4103/TJOG.TJOG_81_17  
Background: Adolescent girls often lack knowledge regarding reproductive health including menstruation that could be due to sociocultural barriers in which they grow up. Materials and Methods: The study was a cross-sectional survey conducted among adolescent girls in three secondary schools at Kano, from 1st January to 31st December, 2016. Ethical approval was obtained from Aminu Kano Teaching Hospital Ethics Committee and Kano State Ministry of Health. Consent/assent was obtained from all the participants/guardians. Data obtained were recorded on questionnaires and analyzed using SPSS version 18 Statistical Software. Fishers' exact test was used in this study and P value of ≤0.05 was considered significant. Result: During the study period (from January to December, 2016), 219 adolescent secondary school girls participated in the survey. The mean age (±SD) was 16.1 ± 1.34 years. There was no statistically significant association between the mean age at menarche and the socioeconomic status of their parents (P [Fishers'] = 0.817). Up to 202 (92.2%) adolescent girls had premanarcheal counseling. Most of the information on premenarcheal counseling was provided by the parents/guardians 139 (62.9%) followed by the school teachers 42 (19.0%). Sanitary pads were the most used menstrual absorbent among the adolescents 202 (92.2%). Other menstrual absorbent used by the adolescents were toilet roll 11 (5.0%) and cloth 5 (2.3%). Among the methods of disposal of menstrual absorbent, dustbin 161 (73.9%) was the most used followed by disposal in the toilet 32 (14.7%), and burning 21 (9.6%). Other methods of disposal used by the adolescents were by washing it or road side/farm/over the fence disposal 4 (1.8%). Conclusion: There was good menstrual hygiene among the adolescent school girls. Sanitary pads were the most used menstrual absorbent.
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Association of sociodemographic characteristics with KAP regarding menstrual hygiene among women in an urban area in Delhi p. 158
Palak Goel, Rajesh Kumar, GS Meena, Suneela Garg
DOI:10.4103/TJOG.TJOG_58_17  
Introduction: Menstruation despite being a natural process is linked with several misconceptions and false practices, which sometimes results in adverse health outcomes. The aim of this study was to assess knowledge, attitude, and practices regarding menstrual hygiene and their association with sociodemographic determinants among women in an urban area of Delhi. Materials and Methods: A community-based cross-sectional survey was conducted for a period of 1 year among 350 women age 18–45 years residing in an urban resettlement colony in Delhi. Semi-structured questionnaire containing questions regarding subject's demographic profile, their knowledge, attitude, and practices pertaining to menstrual hygiene was used. It had seven questions regarding knowledge and eight questions each about attitude and practices regarding menstrual hygiene, respectively. A 5-point Likert scale was used to assess women's responses to attitude questions. Practices satisfactory or unsatisfactory were based on UNICEF guidelines. Data were analyzed using SPSS software version 17. Results: The mean age of women was 26.53 ± 0.295 years. More than three-fourths (88.3%) women had good knowledge, whereas only 32.3% of women had a positive attitude regarding menstrual hygiene. More than two-thirds of the women were using sanitary pads as menstrual absorbent. Significant association was seen between knowledge and subject's marital status (P = 0.034) and subject's occupation (P = 0.046). A significant association was observed between attitude and socioeconomic status of the participant (P = 0.001). Conclusion: These findings indicate the need for education about healthy menstrual practices. Health education is an essential requirement to fill the knowledge gap to promote accessibility, availability, and sanitary facilities and products.
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The effects of etonorgestrel implant (ImplanonR) on the lipid profile of Nigerian women p. 165
Roberts A Olumuyiwa, Adekunle O Adeyemi, Fawole O Adeniran, Okunlola A Michael, Arinola G Olatubosun
DOI:10.4103/TJOG.TJOG_43_17  
Background: Provision of contraceptive methods with minimal side effects will enhance uptake of contraception particularly in Nigeria where contraceptive prevalence rate remains low. The safety profile of ImplanonR, a long-acting hormonal subdermal contraceptive containing etonogestrel, has not been adequately evaluated among Nigerian women. Objective: To assess the effects of etonogestrel subdermal implant (ImplanonR) on lipid profile among Nigerian women. Materials and Methods: The study was a longitudinal follow-up of 54 consenting women selected over a 6-month period at the Family Planning Clinic of the University College Hospital, Ibadan. After ImplanonR insertion, each woman was followed-up monthly for a period of 12 months. Fasting venous blood samples were collected for quantification of serum lipids prior to insertion of the implant, then at 1st, 3rd, 6th, 9th, and 12th months of follow-up. Results: The mean age of the women was 34.4 ± 5.6 with a range of 22–47 years. The modal number of children was 2 ranging from 1 to 6. Total cholesterol (TC) levels showed a general tendency toward a rise. The rise was, however, only significant in the 3rd and 12th months of use. Serum triglycerides showed a tendency toward reduced levels, which were only significant at the 6th and 9th months of use. High-density lipoprotein (HDL) levels were consistently and significantly elevated above baseline levels. Beyond the 3rd month, low-density lipoprotein (LDL) levels were lower but not significantly compared with baseline levels. HDL/TC and HDL/LDL ratios were consistently and significantly elevated in comparison with baseline values. Conclusion: Etonogestrel implant seems to cause significant effects on the lipid profile of Nigerian women. The increases were mainly in the HDL fraction, which suggests that the atherogenic and cardiovascular disease risks are reduced. We recommend larger studies to confirm our findings.
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A review of clinical experience with progesterone-only injectable contraceptives at OAUTHC, Ile-Ife p. 170
Adebimpe O Ijarotimi, Boluwatife S Idowu, Oluwaseun O Sowemimo, Adebanjo B Adeyemi, Ernest O Orji
DOI:10.4103/TJOG.TJOG_20_18  
Background: Progestogen-only injectable contraceptives (POICs) remain the most popular contraceptive method in Nigeria. Considering how widely used POICs are worldwide, there is little published evidence of their safety and effectiveness. There is also a paucity of research to determine associations between the influence of age and parity and the preferred choice of POICs in women. Aim: This study was to determine the use prevalence and the influence of age and parity on the preferred choice of POIC, and also the reasons for discontinuation among users of POICs at the family planning clinics of OAUTHC, Ile-Ife. Materials and Methods: A retrospective record of 324 women who chose POICs out of a total of 1,029 clients seen at the family planning units of the hospital was collected for the period between January and December 2015. Information relevant to this study objectives was extracted using a purpose-designed proforma. Data were analyzed with SPSS version 16, and results were presented as frequencies and percentages. Pearson Chi-square test was used as test of significance where applicable and a P value < 0.05 was considered statistically significant. Results: The prevalence of POIC during the study period was 31.49%. Depo-Provera (depot medroxyprogesterone acetate [DMPA]) was the most popular injectable preferred by the women. Age and parity had significant effects on the preferred injectable contraception with P values of 0.032 (CI 0.088-0.099) and 0.002 (CI 0.009-0.013), respectively, as younger clients with lower parity preferred Noristerat while preference for DMPA increased with age and parity. Majority (67%) did not experience any side effect; secondary amenorrhea was the most common side effect experienced by 27% of the clients. Only 34% continued with the method for the duration of study while 66% discontinued for different reasons. Conclusion: POICs are very effective and safe long-acting reversible method of contraception. While DMPA may be the more popular overall choice, norethisterone enanthate (NET-EN) is preferable in younger women of low parity.
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Seroprevalence and clinical correlates of human immunodeficiency virus infection among women with infertility in northwestern Nigeria p. 177
Anisah Yahya, Adebiyi Adesiyun, Fatima Giwa, Abdulhakeem A Olorukooba
DOI:10.4103/TJOG.TJOG_17_18  
Background: Infertility is a major cause of social and psychological problems among couples, especially in our environment where child bearing is regarded as one of the major reasons for marriage. Studies have shown that fertility among human immunodeficiency virus (HIV)-infected women may actually be reduced posing social and psychological disturbance among a group of people that are already burdened with disease. Objective: The aim of the study was to determine the prevalence and clinical correlates of HIV infection among women with infertility attending a gynecology clinic in northwestern Nigeria. Materials and Methods: It was a cross-sectional descriptive study comprising of women attending the gynecology clinic due to infertility that satisfied the inclusion criteria. The sample size was 250. Ethical clearance was obtained from the health research and ethics committee of the study setting. Clients were recruited consecutively as they presented to the infertility clinic from May 2015 to January 2016 and tested for HIV infection. HIV testing was done in the Department of Medical Microbiology after collecting 5 ml of blood from the clients using sterile syringes. Investigations to determine the cause of infertility were also conducted. Obtained data were analyzed using Statistical Package for Social Science version 20.0. Results: A total of 250 clients were recruited for the study. The age range of respondents was- 17 – 47 years with a mean age of 30.3 years. Hausa was the predominant ethnic group in all respondents (61%). Most of the respondents had secondary education (39%). Only 4% had postgraduate education. Out of the 250 respondents, 21 (8.4%) were found to be positive for HIV infection. Chi-square test showed an association between tuboperitoneal infertility and HIV infection. Conclusion: The prevalence of HIV infection in women with infertility attending our clinic was high and an association was seen between HIV infection and tuboperitoneal infertility.
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Hysterectomies pattern at a tertiary healthcare center, northern Nigeria p. 184
Afolabi K Koledade, Adekunle O Oguntayo, Marliya S Zayyan, Solomon Avidime, Modupe O Samaila, Adebiyi G Adesiyun
DOI:10.4103/TJOG.TJOG_16_18  
Background: The uterus is an important female genital organ for menstrual and reproductive functions. However, there are various gynecologic and obstetric indications for carrying out hysterectomy. Objectives: To determine the indications and the patterns of hysterectomies done at Ahmadu Bello University Teaching Hospital, Zaria Nigeria. Materials and Methods: 5-year retrospective descriptive study on patients who had hysterectomy done from 2011 to 2015. Results: The age range of the patients was 2–70 years with a mean of 48.6 ± 8.8 years. Hysterectomies constituted 19.3% of total gynecology surgeries done during the same period. Of these total abdominal hysterectomy 144 (87.8%) was the most common, next was vaginal hysterectomy with pelvic floor repair 13 (7.9%), and then subtotal hysterectomy was 7 (4.3%). The most common indication for total abdominal hysterectomy was multiple uterine fibroids, a benign uterine tumor. Conclusion: Hysterectomy is a common gynecological surgery which may be used to treat benign uterine pathologies, especially when there is no more desire for conception. It could also be lifesaving in uncontrollable postpartum hemorrhage as well as malignant pelvic organ pathologies, especially in early stages.
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Symptomatology of menopause among suburban Nigerian women p. 188
Omotayo A Oloyede, Gbolahan O Obajimi
DOI:10.4103/TJOG.TJOG_71_17  
Background: It is believed that the perception and attitude of women to menopause are strongly influenced by several variables which are largely social, cultural, and economic and may reflect in the differences in the mode of treatment. The objective of this study is to determine the age of attainment of menopause and the perception of the symptomatology of menopause among Nigerian women of different backgrounds. Materials and Methods: Information was obtained with the aid of a structured questionnaire from 543 women who had attained natural menopause. Data were analyzed using SPSS version 21. Data analysis was descriptive and inferential at 95% confidence interval, and P < 0.05 was considered statistically significant. Results: The mean menopausal age was 49.1 ± 4.54 years. The commonest early symptom of menopause was hot flushes (45.8%). The commonest late symptom of menopause was pain in the joints (57%). A majority of the women (82.4%) did not think that any of the symptoms may have been associated with cessation of their menses. However, the better educated the women were, the more knowledgeable they were about the symptoms of menopause P < 0.01. Conclusion: The age at which Nigerian women attain menopause is comparable to that of other populations. The manifestation of menopausal symptoms in our women may constitute a significant health burden and it is imperative that healthcare providers should be knowledgeable about the manner in which these groups of women perceive menopausal symptoms. Education improves perception and may be the link to promoting better health-seeking behavior among menopausal women.
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CASE REPORTS Top

Caesarean section in a primigravida with spina bifida occulta and a spinal cord stimulator: Preconception counselling, antenatal care and anesthetic considerations p. 192
Hadijat O Raji, Zakari A Suleiman, Zainab A Abdulkadir, Aminudeen Abdulrahman
DOI:10.4103/TJOG.TJOG_7_18  
Recent developments in medical and surgical subspecialties have contributed to improved quality of life in patients with spina bifida (SB). Despite the challenges of chronic pain, spinal abnormality, gait abnormalities, loss of urinary, and fecal continence, female patients can become pregnant. Provision of obstetrics and/or surgical care to patients with SB may become more common as more patients survive to adulthood. Preconception counseling, antenatal care, obstetrics, and other specialized care are essential components of optimal management of these patients. We report the obstetric and anesthetic challenges encountered in a primigravida with SB occulta and a spinal cord stimulator who had caesarean delivery. Effective communication between the patient, obstetricians, and anesthetists, as well as planned and coordinated care, ensured a successful feto-maternal outcome.
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Malignant melanoma in pregnancy: Rarity and paucity p. 196
R Manipriya, CD Narayanan, N Palaniappan
DOI:10.4103/TJOG.TJOG_12_18  
Malignancy diagnosed during pregnancy is a rare coincidence and a taxing situation for the health care provider. The diagnosis and therapeutic management become laborious and it involves both the mother and fetus. One of the major cause of death among women of the childbearing age group is malignant melanoma in the western world. The literature vastly suggests that it has an ominous prognosis when diagnosed during pregnancy as it is known to rapidly metastasize to the placenta and fetus. Prompt diagnosis and appropriate treatment can avoid catastrophic events. We report a case of Indian women diagnosed with non- metastatic malignant melanoma in the first trimester of pregnancy with successful outcome.
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Third-trimester ultrasound diagnosis of twin-to-twin transfusion syndrome (TTTS) – A review of two cases p. 199
JA Akinmoladun, GO Obajimi
DOI:10.4103/TJOG.TJOG_2_18  
Twin-to-twin transfusion syndrome (TTTS) is an unbalanced net transfusion of blood between twin fetuses through placental anastomoses. It is a complication of monochorionic diamniotic (MCDA) twin gestation in which one of the twins is the donor while the other twin acts as the recipient. TTTS without treatment is a major cause of increased morbidity and mortality among MCDA twin pregnancies. Ultrasound diagnosis and staging of TTTS are based on Quintero staging which influences the choice of management. We present two cases of ultrasound diagnosed TTTS. A 27-year-old G2P1+0 with twin gestation who had an ultrasound scan at 34 weeks gestation, and a diagnosis of Quintero stage 1 TTTS was made. She had an emergency caesarian operation and was delivered of two live babies. A 24-year-old G1P0+0 with twin gestation who had an ultrasound scan at 35 weeks gestation, with a diagnosis of Quintero stage 5TTTS. The donor twin was alive while the recipient twin had hydrops fetalis with no cardiac activity. An emergency caesarian section was done and the donor twin survived. TTTS is a common complication among MCDA twins and it is a cause of increased morbidity and mortality among them. Early diagnosis through ultrasonography and prompt management will help reduce the morbidity and mortality associated with the syndrome.
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Lower urinary tract symptoms secondary to mass lesion of the brain: A case report p. 204
Roopa Verghese, Jewel J Jacob
DOI:10.4103/TJOG.TJOG_19_18  
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Ovarian leiomyoma and the relevance of the size of ovarian mass to clinical management p. 207
MO Odubanjo, OA Oguntunde, F Iketubosin, NW Okoh, A A F Banjo
DOI:10.4103/TJOG.TJOG_77_17  
This article describes a 45 year old woman with a 13cm right ovarian leiomyoma (OL) coexisting with multiple uterine fibroids. Ovarian leiomyoma is rare, there are only few reports from Africa but it is likely that the incidence from Africa is under-reported. There was no associated abdominal pain in spite of the size of the mass and multiple adhesions from a previous myomectomy done 12 years prior to this presentation. We discuss the relevance of the size of an ovarian mass to clinical management and the other factors guiding the choice of the appropriate management options in patients with ovarian masses, such as the age of the patient, the clinical symptoms, the risk of malignancy, the desire for future fertility and the proximity to menopause. The clinical (including ultrasonographic features), histopathologic, immunohistochemical and molecular features of the disease are also discussed.
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Aggressive angiomyxoma of the uterine corpus: A rare presentation p. 213
Amina Gambo Umar, Adulhadi Diyo Saidu, Abdullahi Umar Adoke, Nuraddeen Muhammed, Mairo Hassan, Yakubu Ahmed, Umar Ibrahim Augie, Bilal Sulaiman, Boysungni Zaro, Kabiru Rabi'u
DOI:10.4103/TJOG.TJOG_4_18  
Aggressive angiomyxoma (AA) is a rare benign soft tissue tumor usually affecting the female pelvis and perineum. A 16-year-old girl presented on June 23, 2016, with vaginal protrusion of 1-year duration. Examination revealed protrusion through the introitus; it was hyperemic with necrosis. Investigation revealed urinalysis that revealed blood (+), leucocytes (+), and others normal; Swab (taken from purulent discharge on the protruded mass) microscopy revealed numerous pus cells; and culture yielded no growth. Abdominopelvic ultrasound (USS) showed left-sided pelvic soft tissue mass with no features of metastasis. Other investigations were normal. She had polypectomy with subtotal abdominal hysterectomy. Histology revealed benign AA. A rare tumor of the genital tract had been presented with a diagnostic dilemma. However, confirmation of diagnosis was easy with histology.
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