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   Table of Contents - Current issue
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January-April 2019
Volume 36 | Issue 1
Page Nos. 1-159

Online since Wednesday, April 17, 2019

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REVIEW ARTICLE  

Fetal imaging and diagnosis services in developing countries – A call to action Highly accessed article p. 1
JA Akinmoladun, D OC Anumba
DOI:10.4103/TJOG.TJOG_59_18  
Fetal congenital anomalies are among the leading causes of perinatal death or survival with disability worldwide. Their accurate antenatal detection employing a range of fetal imaging techniques enables parental choices to be made and for postnatal care of affected babies to be planned. While such prenatal care is well developed in developed countries of the world, it remains poor in many low- and middle-income countries (LMICs). This review article examines the scope of the problem and proffers strategies for service organization and fetal imaging that will improve care in LMIC settings.
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ORIGINAL ARTICLES Top

A 35-year standardized prediction estimates for gynecological lesions in oil and gas exploration and production city in the Niger Delta p. 8
M Onyije Felix, A Ngokere Ajuluchukwu, E Ligha Aloysius, O Mgbere Osaro, O Avwioro Godwin
DOI:10.4103/TJOG.TJOG_64_18  
Background: The impact of constant emission of hydrocarbons and contaminated water level through oil spillage in the oil and gas exploration and production areas of Niger Delta on women's health cannot be underestimated. We developed a 35-year standardized prediction estimates for gynecological lesions using data obtained from an integrated specialist hospital serving the residence of the oil and gas exploration and production City of Port Harcourt and the surrounding areas of Niger Delta, Nigeria. Methods: The study participants comprised of 697 females who received medical care at the Braithwaite Memorial Specialist Hospital (BMSH), Port Harcourt, Rivers State, Nigeria, between 2010 and 2014. Predictive modeling of the diseases was performed using JMP statistical discovery™ software, version 12.0 (SAS Institute, Cary, NC, USA). Results: The distribution of the gynecological lesions (n = 697) differed significantly (P < 0.001) by year of diagnosis, developmental stage, age category, and types of lesion. The mean age of study participants was 39.1 ± 12.8 years, and most of the lesions (61.8%) occurred among females who were 30- to 49-year old. Leiomyoma recorded the highest 5-year standardized prevalence rate of 0.508, and with no intervention, it is estimated that the number of cases diagnosed will rise from 235 in 2015 to 1883 by the year 2050. This was followed by ovarian cyst with a prevalence rate of 0.124 and projected increase from 57 in 2015 to 461 by the year 2050. Similarly, the product of conception is also estimated to increase from 34 to 277 by the year 2050. Conclusion: The over 700% increased prediction of gynecological lesions by 2050 calls for urgent attention by both governmental and private agencies to fund awareness campaigns and screenings for women, especially for those residing in the oil- and gas-producing areas of Niger Delta.
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Maternal and neonatal outcomes in premature rupture of membranes at University of Maiduguri Teaching Hospital, Maiduguri, North-Eastern Nigeria p. 15
A Idrisa, S Pius, M Bukar
DOI:10.4103/TJOG.TJOG_89_18  
Background: Premature rupture of membrane (PROM) is linked to significant adverse events in the prenatal, peripartum and neonatal period. Both, PROM and PPROM are associated with maternal and neonatal morbidities and mortalities. Severe oligohydramnios after PROM is associated with foetal abnormalities, pulmonary hypoplasia, respiratory distress syndromes, intrauterine growth restriction, intrauterine foetal death, foetal/neonatal sepsis, presence of meconium and an Apgar score lower than seven at five minutes. Objective: To determine the factors that influenced maternal and neonatal outcomes following a premature rupture of membranes. Subjects and Methods: This retrospective cross-sectional study was conducted over five years between 1st January 2012 and 31st December 2016 on mother neonate pair delivered at the University of Maiduguri Teaching Hospital Maiduguri. Results: During the period of the study there were 7200 deliveries at the labour ward of (UMTH), out of which 91 (1.3%) had PROM. Seventy three ( 80.2%) of the case files were retrieved and analysed. Thirty six women (49.3%) were delivered by emergency caesarean section (EMCS), while 37 (50.7%) were delivered vaginally (SVD). In the bivariate (crude) analysis, Apgar score < 7 at 5 minutes (P = 0.008, OR 95 % CL: 0.092 (0.011, 0.742), birth weight ≥ 2500g (P = 0.006, 8.944 (1.892, 42.284), and absence of APH (P = 0.007, 4.83 (1.440, 16.196) were factors modifying neonatal outcome. When adjusted regression with only factors with P value < 0.2 in crude analysis were done, only birth weight ≥ 2500 g (P = 0.024, 6.677 [1.286, 34.664]) and absence of APH (P = 0.038, 4.406 [1.085, 17.883]) were independent predictors of neonatal outcome. Thus, neonates with birth weight ≥ 2500 g were about 6.7 times more like to show favourable outcome than those with birth weight < 2500g while those without APH showed 4.4 times more likelihood for a favourable neonatal outcome. Antenatal corticosteroids use also was associated with favourable outcome as it had significantly improved preterm neonatal survival. Conclusion: Intervention with steroids, antibiotics in labour and delivery within 24 hours of PROM will greatly reduce maternal complications and enhances favourable neonatal outcome.
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Disrespect and abuse during facility based childbirth: The experience of mothers in Kano, Northern Nigeria p. 21
TG Amole, MJ Tukur, SL Farouk, AO Ashimi
DOI:10.4103/TJOG.TJOG_77_18  
Context: An important but little understood concept that retards the goal to reduce maternal mortality and increase universal access to reproductive health is disrespect and abuse (D&A) during childbirth. Aim: This study aims to determine the prevalence, pattern, perpetrators, and determinants of D&A during childbirth among recently parturient women in Kano, north western Nigeria. Settings and Design: Using a cross-sectional design, 332 women accessing child immunization and postnatal services at Murtala Muhammad Specialist Hospital, Kano, were selected. Subjects and Methods: Respondents were selected using systematic sampling technique and data collected using an adapted, interviewer administered tool. Statistical Analysis: Data was analysed using IBM SPSS version 21.0 and level of significance set at 0.05. Results: Respondents (n = 306) had a mean age of 27.7 ± 6.3 years and more than half (55.9%; n = 171) had experienced at least one form of D&A during childbirth. Commonest forms of abuse were abandonment and nonconfidential care (84.5%, n = 142; 67.9%, n = 114, respectively). Main perpetrators were nurses/midwives (83.0%, n = 142). The experience during the last childbirth was significantly higher among respondents of non-Hausa/Fulani ethnic group (χ2 = 6.10; P = 0.014), of the Christian faith (χ2 = 8.62; P = 0.003), and with formal education (χ2 = 19.94; P = 0.0001). After controlling for confounders, formal education remained a predictor for experiencing abuse at childbirth (AOR = 2.43; 95% confidence interval = 1.11--5.32). Conclusions: D&A during childbirth is prevalent in our setting. Educating healthcare providers and women about their responsibilities and rights will enhance provision and utilization of quality maternal health services.
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The effect of hyoscine butyl bromide in shortening the duration of first stage of labor: A single-blind randomized control study p. 28
R Ibrahim, EI Nwobodo, KA Tunau, AT Burodo, B Sulaiman, JA Garba, AD Saidu
DOI:10.4103/TJOG.TJOG_57_18  
Background: Active management of labor reduces the number of prolonged labor and the duration of labor without having any adverse effects on the mother and the fetus. Intervention with drugs is among the options used for active management of labor. This includes use of analgesics, oxytocics, prostaglandins derivatives, and smooth muscle relaxants. The objectives of the study were to determine whether hyoscine N butyl bromide (HNBB) shortens the first stage of labor in term pregnancies, to compare the mean duration of labor between primigravidae and multigravidae in HBB group, to compare the maternal and fetal outcome between HBB and control group, and also to determine the side effects of HBB in parturients. Materials and Methods: The study was a single-blind randomized control study carried out in Usmanu Danfodiyo University Teaching Hospital (UDUTH) over 4-month period. A total of 204 pregnant women at term in spontaneous labor who presented in active phase of labor at UDUTH and have met the inclusion criteria were recruited and randomized into 102 women as case group and 102 women as control. The women in the case group received 40 mg (2 mls) of HBB, while those in the control group received 2 mls of normal saline. Data entry and analysis was done with IBM SPSS version 20. The duration and outcome was monitored. Results: The mean duration of labor in the first stage among the case group was 5:44 ± 2:11, while it was 6:52 ± 2:11 among the control group representing a decrease of 16.5%. This was statistically significant (P < 0.05). There was no difference in the duration of the second and third stages of labor among the two groups. There was no difference in the maternal and neonatal outcome among the two groups. Vomiting was the only maternal side effect that was statistically significant among the HBB group. Conclusion: HBB reduced the duration of first stage of labor in both primigravid and multigravid women without adverse maternal and neonatal complications. It is recommended that HBB to be given to women in active phase of labor to reduce the incidence of prolonged labor.
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Awareness and attitude of female undergraduates toward human papillomavirus vaccine in Ibadan p. 33
T AO Oluwasola, OO Bello, AA Odukogbe
DOI:10.4103/TJOG.TJOG_7_19  
Introduction: The human papillomavirus (HPV) has significant public health importance because of its high prevalence, mode of transmission, major causative role in cervical cancer, and having effective vaccines. The main thrust of this study was to ascertain the level of awareness of HPV and its vaccines among students as well as their attitudes toward receiving the vaccines. Materials and Methods: A descriptive cross-sectional survey conducted among female undergraduates of the University of Ibadan using structured self-administered questionnaires. The questionnaires sought to obtain information about their awareness of HPV, their sexual behavior, previous vaccination, and willingness to access HPV vaccination. Results: A total of 489 students, with a mean age of 19.7 ± 3.2 years, satisfactorily responded to the survey. Overall, 411 (84%) had an overall good knowledge about vaccines, 218 (44.6%) recalled that they had been previously vaccinated in childhood, and 147 (30.1%) were aware of HPV. Only 66 (13.5%) were aware of HPV vaccines, and 10 (2%) had ever been vaccinated against HPV. A majority were willing to get vaccinated if the current price is further reduced. Conclusion: There is a low level of awareness of HPV and its vaccines among female undergraduates. When available, uptake is restricted by cost. There is an urgent need to support public health programs that increase awareness through adequate information dissemination on mechanisms of cancer prevention and also to strengthen policy efforts that address the barriers of HPV vaccination.
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Intrauterine adhesions in the University of Uyo Teaching Hospital, Uyo, South-South, Nigeria: A ten year review p. 39
N Utuk, AM Abasiattai, O Asuquo
DOI:10.4103/TJOG.TJOG_42_18  
Background: Asherman's syndrome is a clinical entity that can cause menstrual abnormalities and infertility. Objectives: This study was done to determine the risk factors, and management outcome of intrauterine adhesions in our hospital. Subjects and Methods: We carried out a retrospective study of the patients who were treated for intrauterine adhesions at the University of Uyo Teaching Hospital over a 10 years period-from January 1st 2006 to December 2016. Results: During the study period, a total of 1977 gynecological surgeries were performed of which 83 were for intrauterine adhesions, giving a rate of 4.2%. However, only 52 folders were retrieved, giving a retrieval rate of 62.5%. Analyses, using ratios and percentages, was based on these. Most patients belonged to the 30-34 age group (28.9%) followed by the 20-24 age group (25.0%). The majority of the patients were nulliparous (58.9%), married (65.4%) and had a tertiary education (50.0%). Dilatation and curettage for induced abortion (42.3%), open myomectomy (26.9%), and caesarean section (19.2%) were the common risk factors. Amenorrhoea (65.4%), and hypomenorrhoea (30.8%) were the commonest modes of presentation. All the patients were managed by blind adhesiolysis, done overwhelmingly by the resident doctors, under anaesthesia with a significant percentage (65.3%) showing that there is no change in menstrual condition. Conclusion: Ashermans syndrome is a relatively common condition, and it is necessary to train doctors in the use of, and acquire, a hysteroscope, for the proper management of this condition. Meanwhile, more senior personnel should be involved in the blind adhesiolysis, and Foley catheter that appears superior as a uterine splint to the intrauterine contraceptive device.
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Co morbidities associated with vesico vaginal fistula in patients managed in Maryam Abacha Fistula Hospital Sokoto, Northwestern Nigeria p. 44
M Hassan, S Nasir
DOI:10.4103/TJOG.TJOG_53_18  
Background: Prolong obstructed labor is a preventable obstetric complication in the developing countries with devastating consequences and comorbidities. This study aimed to determine the frequencies of the common comorbidities in patients managed for obstetrics fistula at Maryam Abacha Women and Children Hospital, Sokoto, and also to identify the association of age and parity on the occurrence of some of the comorbidities observed. Materials and Methods: This was a cross-sectional study involving 179 patients with obstetric vesicovaginal fistula seen at Maryam Abacha women and Children VVF center, Sokoto, from January to December 2017. A proforma was used to assess the sociodemograhic features and also to record comorbidities during preoperative evaluation. Results: Foot drop was the commonest comorbidity seen in 106 (59.2%), followed by depression in 104 (58.1%). There was statistically significant association between age, parity, and foot drop P = 0.025. Depression was found to be higher in the primipara P = <0.001.Urinary dermatitis occurred more frequently in the older age group and multipara 62.7% and 80%, respectively. Amenorrhea was commoner among age group 30 years and above 62.7%. Out of 179 patients analyzed, 36 (20.1%) had eclampsia whereas gynaetresia was present in 29 (16.2%). Conclusion: Significant comorbid conditions accompany obstetrics trauma and vesicovaginal fistula. Foot drop had statistically significant association with age. Depression was common in all age groups. There was significant association between depression and parity. Urinary dermatitis occurred more frequently in the older age group and multiparae.
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Effectiveness of mobile phone text message reminder on birth preparedness in a rural community in Kenya p. 49
Cheptum Joyce, Omoni Grace, Mirie Waithira
DOI:10.4103/TJOG.TJOG_84_18  
Background: Birth preparedness is a strategy that has been found effective in preventing obstetric delays. Use of mobile technology can enable access and efficiency of health messages delivered during antenatal care. The mobile technology can be more effective in conveying health messages owing to its accessibility and enables follow up. Materials and Methods: This was a randomized control trial carried out among pregnant women attending public health antenatal clinics in Migori County. Four health facilities were randomized. Two facilities each were randomly picked for the study and control groups respectively. A total of 379 participants were recruited into the study. The study group participants received a verbal message on birth preparedness and a mobile phone text message reminder one month to their expected date of delivery. Follow up was done to both groups through their mobile phone contacts. Data was collected using an interviewer-administered questionnaire and analyzed using Stata version 11. Proportion tests were done to compare the groups. Results: The success rate of the study was 90.5% (n = 343). Most of the participants (73%) were aged between 20 and 34 years. Majority of them were married (79.2%) and most of them had primary level of education. Protestant was the predominant religion (55.2%). Housewives and businesswomen constituted 34.2% and 27%, respectively. The respondents in the study group who were birth prepared were 74.3% (n = 136) while those in the control group were 48.1% (n = 77). Conclusion: The use of mobile phone text message reminder in addition to verbal messages is more effective.
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Can hsCRP be the sole investigation for predicting the severity and outcome in women with pre-eclampsia presenting late in pregnancy? p. 54
N Mishra, K Pradhan, GD Sahoo, M Rohilla, M Meena
DOI:10.4103/TJOG.TJOG_66_18  
Context: Healthcare facilities in developing countries are over burdened and proper triage of patients requiring attention more than others is needed in every sub speciality of medical sciences in them. Patients with pre-eclampsia require attention to prevent any associated complication. Aims: The aim of this study was to evaluate whether hsCRP alone or in combination could be used as an indicator of severity and predictor of outcome in women with PE presenting to a healthcare facility late in the third trimester. Settings and Design: Prospective observational study conducted at a teaching medical college and referral hospital catering primarily to rural, semi urban and tribal population. Methods and Material: 85 women with PE who reported to the hospital after completed 36 weeks of gestation were included. Patients were divided in three groups. hsCRP, biochemical and hematological investigations were performed for each patient. Results were expressed as median. Independent samples Kruskall Wallis one way ANOVA and Mann Whitney U tests were performed and correlation of hsCRP with other parameters and fetal outcome was examined. Statistical Analysis Used: Kruskall Wallis one way ANOVA and Mann Whitney U tests. Results: hsCRP was significantly elevated in severe PE as compared to PE without severe features and normal patients. Higher requirement of labour induction and caesarean section was seen in severe PE patients along with higher still births and low baby weight babies. hsCRP had positive correlation with other markers of severity of PE and negative correlation with still births and fetal weight in severe PE patients. However, although raised in every case of severe PE, a wide variation was noted in hsCRP values. Conclusions: hsCRP alone cannot be recommended as a marker of severity or a predictor of outcome in women presenting late in the third trimester of pregnancy. However, in combination with serum uric acid it can be used for that purpose.
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Sexual dysfunction among women in a Nigerian gynecological outpatients unit p. 61
OO Ogunbode, CO Aimakhu, AM Ogunbode, LA Adebusoye, KM Owonikoko
DOI:10.4103/TJOG.TJOG_78_18  
Background: Sexual dysfunction is an important public-health problem, which is often less reported or explored through opportunistic evaluation during medical consultations. Objective: This study was designed to determine the prevalence and patterns of female sexual dysfunction (FSD) including the sexual quality of life among female patients attending a gynecological outpatients unit in Southwest Nigeria. Materials and Methods: This is a cross-sectional descriptive study of 146 consenting women who attended the gynecological outpatients' clinic of the University College Hospital, Ibadan, Nigeria, during the study period. Participants were selected using multistage sampling technique. The survey instruments were previously validated questionnaires such as Sexual Function Questionnaire (SFQ28), Sexual Quality of Life-Female Questionnaire (SQOL-F), and the Family Adaptation, Partnership, Growth, Affection and Resolve (APGAR) score. The results were analyzed using Statistical Package for Social Sciences version 17 and P value was set at 5%. Results: The mean age was 33.8 ± 5.7 years. Most (85.6%) respondents had at least one form of sexual dysfunction. The commonest dysfunction was arousal-sensation (62.4%) while the least was pain (3.4%). The mean SFQ28 and SQOL-F scores were 58.0 ± 12.57 and 28.0 ± 11.94, respectively. There were no statistically significant differences in the SFQ28 and SQOL-F scores across sociodemographic factors. Women classified as belonging to dysfunctional family on Family APGAR score similarly had poorer scores for sexual dysfunction (100%, P = 0.016). Conclusion: FSD is common among women attending gynecological outpatients clinic. Managing clinicians should be aware of this condition and proffer appropriate care in addition to the main presenting complaint.
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Pattern and determinants of mortality among eclamptic women that presented in the Federal Teaching Hospital Abakaliki, Southeast, Nigeria p. 67
JI Nwafor
DOI:10.4103/TJOG.TJOG_63_18  
Background: Eclampsia is a life-threatening obstetric emergency and one of the major causes of preventable maternal and perinatal mortality worldwide. Some women suffered eclampsia and died, while some live to tell their stories; what determines who dies? Aims: To determine the pattern and determinants of mortality among eclamptic women in our institution. Materials and Methods: This was a 5-year retrospective study of eclampsia managed between 1st January 2012 and 31st December 2016. Results: From this study, the incidence of eclampsia was 13.3 per 1000 deliveries and it contributes 21.1% of the maternal death and fetal case fatality rate of 30.2%. Women between the age range of 20–24 years accounted for majority (33.3%) of cases of eclampsia. The modal parity was Para 0 (50%) and most (89.6%) were unbooked. Antepartum eclampsia (53.1%) was the commonest form of eclampsia. Vaginal delivery was the commonest route of delivery. The determinants of maternal death were late presentation (>24 hours) (x2 = 15.37, P < 0.001), unconsciousness (x2 = 7.35, P < 0.01), severe blood pressure (x2 = 8.42, P < 0.01), and fetal death (x2 = 8.71, P < 0.01), while antepartum eclampsia (x2 = 6.23, P = 0.04), late presentation (>24 hours) (x2 = 16.76, P < 0.001), vaginal delivery (x2 = 4.82, P = 0.03), and maternal death (x2 = 12.00 P < 0.001) were determinants of fetal demise. Conclusion: Eclampsia is still a huge burden in our environment affecting maternal and perinatal morbidity and mortality profile. Early presentation and adequate treatment can help to reduce the incidence of this preventable obstetric disaster in our environment.
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Persistent pain after caesarean and vaginal delivery: Experience at a public tertiary hospital, Benin city, Nigeria p. 73
NO Enaruna, NP Edomwonyi
DOI:10.4103/TJOG.TJOG_41_18  
Background: Recent observation has revealed that persistent pain (PP) might follow both vaginal delivery (VD) and cesarean delivery. The present study sought to examine the development of PP following delivery in Nigerian women. Methods: Questionnaires were administered to all consenting women at their 6-week post-delivery visit to hospital to ask about persistence of abdominal scar, pelvic, or perineal pain. They were subsequently called on phone to enquire about the duration of previously documented pain, or the persistence of pain at 6 months and 1 year post-delivery. Information on the frequency and intensity of pain, the impact on daily activities, as well as the quality of life was also sought. Chi-square test or Fisher's exact test was done for differences in proportion, prevalence ratio (PR) and cross tabulation was done for association using SPSS 20.0 and GraphPad Instat 3. Results: Cesarean section (CS) was associated with higher prevalence of PP at 6 weeks postpartum than VD {(37/88, 42%) and (26/144, 18%), respectively; PR 2.1, 95% CI: 1.2--3.7, P = 0.01)}. The majority (93.7%) had mild to moderate pain. PP was associated with previous pain problem (PR 2.3, 95% CI: 1.2--4.5; P = 0.02). The women with PP recalled more severe peripartum pain (P = 0.01), and primiparity was highly predictive of PP (0.001). Conclusion: PP is more common after 6 weeks of CS than VD, but pain beyond 6 months appears rare. PP is associated with poorly managed chronic pain and severe peripartum pain especially in primiparas. We advocate a deliberate attempt to screen for and treat pain on an individualized basis.
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A 5-year audit of diagnostic gynaecologic laparoscopy under conscious sedation at the university college hospital, Ibadan p. 80
O Adesina, GO Obajimi, T Abo-Briggs
DOI:10.4103/TJOG.TJOG_15_18  
Introduction: Diagnostic laparoscopy affords smaller incisions, shorter recovery time, and fewer complications. In developing countries, access is limited by cost, infrastructural deficit, and expertise. In a bid to reduce cost at our center, conscious sedation for diagnostic laparoscopy was introduced as far back as 1980. We present here a 5-year audit of our outpatient diagnostic laparoscopy highlighting the various indications, findings, and complications observed. Methodology: A retrospective review of case files of patients who had diagnostic gynecological laparoscopy between 1st January 2011 and 31st December 2015. The retrieved case files had data extracted and analysed using the Statistical Package for Social Sciences version 20 (Chicago IL USA). Data was presented as simple percentages using tables and figures. Results: During the period, 1,329 outpatient gynecological procedures were performed with 207 diagnostic gynecologic laparoscopies (15.6%). Only 187 case notes were retrieved (retrieval rate of 90%). The mean age was 33.04 (±5.2) years, 84.5% (158) had post-secondary education, and 69.0% (129) were nulliparous. Majority, 131 (70.0%), had laparoscopy and dye test, 26 (14.0%) had laparoscopy alone, and 30 (16.0%) had a combination of laparoscopy, dye test, and hysteroscopy. The commonest indications were secondary infertility (51.9%), primary infertility (24.1%), and chronic pelvic pain (11.2%). Common findings at laparoscopy were pelvic adhesions (53.5%), uterine fibroids (35.1%), and bilateral tubal blockage (30.3%). Normal findings were reported in only 19 patients (10.3%). Conclusion: Diagnostic laparoscopy under conscious sedation is cost-effective and safe. It has very minimal complications when performed by skilled personnel. It is thus recommended for low resource settings with the view to avail low income patients the opportunity for endoscopic evaluation.
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Prevalence of bacterial vaginosis among antenatal attendees with abnormal vaginal discharge in a secondary health facility in Delta State, Nigeria p. 85
S Amalokwu, PI Okonta, E Ebunu
DOI:10.4103/TJOG.TJOG_29_18  
Introduction: Bacterial vaginosis (BV) is the most common lower genital tract syndrome among women of reproductive age with significant adverse outcome in pregnancy. Routine screening of antenatal patients for BV is not recommended, however, it is important to determine its prevalence especially in pregnant women who complain of abnormal vaginal discharge. Methods: This was a cross-sectional study of 340 antenatal attendees who complained of an abnormal vaginal discharge. The high vaginal swab was collected from each woman and subjected to wet film and Gram reaction. The diagnosis of BV was made using the Amsel's clinical criteria. Data were analyzed using the EPI-INFO statistical package and the results were presented as percentages and proportions. Results: BV was detected in 105 pregnant women with abnormal vaginal discharge, therefore, giving a prevalence rate of 30.4%. Positive correlates of BV included multiple sexual partners (P = 0.0001) and cigarette smoking (P = 0.008). Conclusion: BV is a prevalent disorder in pregnant women with abnormal vaginal discharge.
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Maternal determinants and fetal outcome of multifetal pregnancies in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria p. 89
SM Adelaiye, H Adelaiye, PI Onwuhafua
DOI:10.4103/TJOG.TJOG_75_18  
Background: Multifetal pregnancies remain a challenge to both parents and clinicians. With the increasing application of assisted reproductive technology in infertility management, the incidence is likely to continue to rise. Aim and Objective: To determine maternal characteristics of multifetal pregnancies, maternal and fetal outcomes, at the Ahmadu Bello University Teaching Hospital (ABUTH), Nigeria. Patients and Methods: A retrospective observational study of women who had multifetal pregnancy in ABUTH Zaria over a period of 5 years was conducted. Information regarding maternal determinants and fetal outcome was collated. The data were analyzed using SPSS version 20.0. Demographic variables were presented using tables and figures, while summaries were done using means, standard deviation, and percentages. Test of association was done using Chi-square. P value <0.05 was considered statistically significant. Results: The total number of deliveries during the study period was 9399 out of which 254 were twins and 2 were higher order multifetal pregnancies. Giving us a rate of 27/1000 multifetal deliveries, majority of the women were booked (91%) and the average number of antenatal visits was 7.4 ± 3.1. The mean maternal age was 29 ± 6 and the mean parity was 2.4 ± 2.2. The mean gestational age at delivery was 36.5 ± 2.2. History of ovulation induction was present in 33% and 57% gave a family history of twinning. The Yoruba ethnic group had the highest incidence with 42.7%. A total of 19% were admitted for various indications, the commonest indication was hypertensive disorders (18%), 64% of the women had preterm deliveries, and 7.5% of the women delivered before 34 weeks. The caesarean section (CS) rate was 39.7%. The commonest presentation was cephalic. There was statistical significant difference between presentation and mode of delivery X2 = 31.579 and P = 0.000. The mean birth weight of T1= 2.3 ± 0.5, and that of T2= 2.7 ± 3, and 68.3% of T1 compared to 60.2% of T2 had weight <2.5 kg. There was statistically significant difference between the mean birth weight and Apgar score of the leading fetuses P = 0.009. Up to 92.6% of T1 were delivered alive, compared to 84.6% of T2, Mean interbaby delivery interval between T1 and T2 was 11.7 minutes. Male:female ratio was 1:1.1. A total of 23% were admitted to neonatal intensive care unit and the commonest indication for admission was low birth weight (35%). The commonest causes of perinatal mortality were asphyxia and sepsis. Perinatal mortality was 114 per 1000 births and maternal mortality rate was 1,639/100,000 live births. Conclusion: Parity, ethnicity, maternal age, ovulation induction, and family history were the major determinants of multifetal pregnancies. There was association between presentation and mode of delivery and also the birth weight and Apgar score of the leading twins. Our multifetal pregnancy rate and cesarean section rate were high, associated with high maternal and perinatal morbidity and mortality.
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Vaginal bacteriome of Nigerian women in health and disease: A study with 16S rRNA metagenomics p. 96
KC Anukam, NR Agbakoba, AC Okoli, CB Oguejiofor
DOI:10.4103/TJOG.TJOG_67_18  
Introduction: The argument on what bacteria make up healthy vagina and bacterial vaginosis (BV) remain unresolved. Black women most often are placed in grade IV vaginal communities as lacking Lactobacillus-dominated microbes. We sought to determine the vaginal microbiota compositions of healthy and those with BV using 16S rRNA metagenomics methods. Materials and Methods: Twenty-eight women provided vaginal swabs for Nugent scoring. Fifteen had BV (Nugent score 7–10), whereas 13 were normal (Nugent score 0–3). DNA was extracted and 16S rRNA V4 region amplified using custom bar-coded primers prior to sequencing with MiSeq platform. Sequence reads were imported into Illumina BaseSpace Metagenomics pipeline for 16S rRNA recognition. Distribution of taxonomic categories at different levels of resolution was done using Greengenes databases. Manhattan principal component analysis was used for similarity clustering. Results: Non-BV subjects were colonized by 12 taxonomic phyla that represent 182 genera and 357 species. Overall, 23 phyla representing 388 genera and 805 species were identified in BV subjects. Firmicutes represented 95% of the sequence reads in non-BV subjects with Lactobacillus-dominated genera and Lactobacillus crispatus–dominated species, followed by Proteobacteria (3.78%), Actinobacteria (0.74%), and Bacteriodetes (0.05%). In BV subjects, Firmicutes represented 59% of the classified sequence reads, followed by Bacteroidetes (19%), Actinobacteria (15.8%), Fusobacteria (4.08%), Proteobacteria (1.48%), and Tenericutes (1.25%). Conclusion: Non-BV healthy Black African, Nigerian women had Lactobacillus genera as the predominant microbiota, contrary to published reports. The study shows that BV subjects had varying proportions of diverse bacteria similar to studies from other parts of the world.
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Obstetric outcome of teenage pregnancy and labour in Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife: A ten year review p. 105
OA Ijarotimi, OR Biobaku, OO Badejoko, OM Loto, EO Orji
DOI:10.4103/TJOG.TJOG_13_19  
Background: Teenage or adolescent pregnancy is a recognized problem of public health significance. Every year, in excess of 14 million teenage girls give birth to a child; most of these young mothers are living in non-industrialized countries. In view of the high prevalence, there is a need to audit such cases regularly to identify areas of possible improvement in its management. Results obtained from the audit can help in policy formulation and strengthen advocacy on issues ranging from abortion complications to early marriage. Objectives: The objectives of this 10-year retrospective study are to document the pattern of prevalence, presentation, obstetric outcome of teenage pregnancy, and labor at the Ife Hospital unit of obafemi awolowo university teaching hospitals complex (OAUTHC), Ile-Ife. Materials and Methods: The study involved a 10-year retrospective analysis of the data collected from the records of all cases of teenage pregnancies during the period from January 1999 to December 2008. Results: During the period studied there were 6,250 deliveries of which teenage pregnancies accounted for 255 giving an incidence of 4.08% of the total deliveries. Majority (51.76%) of the pregnant teenagers were unbooked for antenatal care and 92.12% of them were nulliparous. Antepartum hemorrhage, abnormal presentations, obstructed labor, and anemia were the commonest complications seen occurring in 54.5, 36.5, 14.1, and 11.4 per cent of the teenagers respectively which was significantly higher when compared to the adult pregnant women (P = 0.000). Delivery was by caesarean section in 32.2% of the teenagers compared to 22.6% in the other women (P = 0.000). The overall perinatal mortality rate was 68.8/1000 births while teenagers had a perinatal mortality rate of 106/1000 births (P = 0.013). Conclusion: Teenage pregnancy still remains a major recognized problem of public health significance. Most of these patients are from low socio-economic class and their obstetric performance is relatively poor compared to the adult group. The concept of women's sexual and reproductive health rights needs to be reinforced in most developing countries. Improving access to contraception and discouragement of early marriage will help to reduce teenage pregnancy and the overall burden of maternal mortality. Optimal care should be given to teenage mothers not only to improve the pregnancy outcome but also to enhance their social, educational, and emotional adjustment.
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Is menarche really occurring earlier? A study of secondary school girls in Ile-Ife, Nigeria p. 112
AM Tijani, IO Awowole, Olusegun O Badejoko, BO Badejoko, AO Ijarotimi, OM Loto
DOI:10.4103/TJOG.TJOG_12_19  
Context: A secular trend of progressively earlier attainment of menarche has been described in various populations. The existence of this trend in Ile-Ife, Nigeria, has not been documented. Aim: To determine the current age of menarche and its trend in comparison with previous studies among secondary school girls in Ile-Ife, Nigeria. Settings and Design: School-based cross-sectional analytical study. Materials and Methods: Three-hundred secondary school girls in the lower four classes (JSS 1--SSS 1) were studied. Sociodemographic and menstrual data such as cycle length, duration of menstrual flow, and presence of dysmenorrhoea were obtained using a structured self-administered questionnaire. The mean age at menarche was compared with figures from previous local studies to determine the trend in Ile-Ife. Menstrual characteristics were also analyzed. Statistical Analysis: Data was analyzed with SPSS version 20. Means and standard deviations were generated for continuous variables, while frequencies and proportions were determined for categorical variables. Results: Out of the 300 subjects studied, a total of 198 (66%) had attained menarche at the time of this study. Their reported ages at menarche ranged from 11 to 17 years with a mean of 13.08 ± 1.61 years. This was lower than the 13.98 ± 1.30 and 13.94 ± 1.31 years reported in Ile-Ife in 1992 and 1997, respectively. These three figures show a trend of progressive decline in the mean age at menarche. The subjects' mean duration of menstrual flow was 4.26 ± 0.87 days, with 97.5% of them reporting flow of ≤5 days. Only 22 (11.1%) of the respondents had a cycle length of 28 days. Dysmenorrhoea was reported by 75% of the respondents and 24% reported loss of concentration during periods. Conclusion: Similar to the widely reported secular trend, menarche indeed appears to be occurring progressively earlier in Ile-Ife, Nigeria.
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Office cystometry in a resource-constrained setting: Spectrum of diagnoses and correlation with QUID p. 117
SK Bola-Oyebamiji, OO Badejoko, IO Awowole, ZF Abdur-Rahim, M Ajayi, AA Salako
DOI:10.4103/TJOG.TJOG_4_19  
Background: Office cystometry is an appropriate technology alternative to urodynamics, especially in resource-poor settings. The combination of a validated screening tool such as the Questionnaire for Urinary Incontinence Diagnosis (QUID) and office cystometry stands as the gold standard in the evaluation of urinary incontinence, where urodynamics is not available. Objectives: This study aimed to determine the spectrum of urinary incontinence diagnoses using a combination of urogynecological examination and office cystometry among women in a resource-constrained sub-Saharan African setting and to correlate this with their QUID diagnoses. Methods: Sixty consenting women who had urinary incontinence diagnosed with QUID were recruited from a related study. The cough stress test was performed to elicit stress incontinence. Standard digital and speculum examinations were performed. Postvoid residual urine volume was determined by catheterization. Simple cystometry was performed to detect detrusor overactivity. Using urogynecological examination and simple cystometry as the gold standard, sensitivity, specificity, positive, and negative predictive values were calculated for QUID. Results: The spectrum of diagnoses made using urogynecological examination and office cystometry included no incontinence 13 (21.7%), urge incontinence 23 (38.3%), stress incontinence 18 (30.0%), mixed incontinence 5 (8.3%), and overflow incontinence in 1 (1.7%) woman, respectively. Using this as the gold standard, QUID demonstrated sensitivity of 87.0%, 55.6%, and 60.0% for urge, stress, and mixed incontinence, respectively, with corresponding specificity of 73.0%, 81.0%, and 83.6%, respectively. Conclusion: Urogynecological examination and office cystometry identified stress, urge, mixed, and overflow urinary incontinence in the study population. Overall, good correlation existed between the QUID and office cystometric diagnoses.
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Thrombogenic indices in an evaluation of pregnant Nigerian women with pregnancy loss p. 122
H Okoye, J Chinawa, EC Aniwada, L Eweputanna, T Nwagha, U Nwagha
DOI:10.4103/TJOG.TJOG_65_18  
Background: Pregnancy losses (PLs) are usually a source of pain and psychological stress to the expectant couples. The association between ABO blood groups and some thrombogenic markers with PL among Nigerian women is mostly unknown. Aim: This study investigates the association between ABO blood group, deficiencies of protein C (PC), and protein S (PS) and PL. Patients and Methods: A cross-sectional study involving 170 pregnant women grouped into two, those with or without a history of clinically- or ultrasonographically recognizable PL. ABO blood groups using the tile method, plasma concentrations of free protein S (fPS) antigen, protein C antigen (PCAg) by the enzyme-linked immunosorbent assay-based method, and PC activity (PCAc) by PROTAC method was determined. Results: There was no difference in mean values between the two groups for PCAg, PCAc, FPS, and blood group (P > 0.05). The chances of PL were; non-O blood group (AOR 1.29; 95% CI 0.65--2.54), deficient PCAg (AOR 1.75; 95% CI 0.87--3.54), and deficient PCAc (AOR 1.05;95%CI 0.25--4.13). There was a very poor correlation of miscarriage with FPS (rho 0.04), PCAg (rho 0.09), and PCAc (rho = 0.05). Conclusion: There was no significant association between PLs and ABO blood group phenotypes, PCAg, PCAc, fPS.
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Harm elimination project for unsafe abortion in Nigeria: An operations research p. 126
Ehigha Enabudoso, Gregrey A Oko-Oboh, Alfred E Ehigiegba, Jedidiah Dase Kingsley Sodje, Julie Erhabor, Matthew Oriakhi, Joseph UE Onakewhor
DOI:10.4103/TJOG.TJOG_70_18  
Context: The harm elimination model is designed to improve access to pre- and postabortion care including free contraception and address the challenges posed by unsafe abortion to the sexual and reproductive health of the women recruited for the study. Aims: To determine the impact of the “Harm Elimination Project For Unsafe Abortion in Nigeria” (HELPUSAN) model on the rate of decision to keep the pregnancy by women seeking termination of pregnancy and the determinants of this decision. Subjects and Methods: Over the 6-month period of this pilot survey, all women presenting for abortion were offered preabortion and postabortion counseling and services according to the study protocol. The study did not offer abortion services based on the abortion law in Nigeria. The clients were followed up for 6 weeks and assessed on decision to continue the pregnancy or not. Results: Of 105 attendees, 12.4% declined enrolment, 59.8%had induced abortion, and 45.8% had spontaneous abortion. Among those who presented for postabortion care following induced abortion, the main method used for inducing the abortion process was drugs (80.5%). A total of 90 (97.8%) of the participants were confirmed to be pregnant of which 52 (57.8%) were viable. Also, of the 52 participants with viable pregnancies, 19 (36.5%) decided to retain their pregnancies, while 33 (63.5%) decided not to retain their pregnancies. Conclusion: Almost 40% of clients presenting as pre abortion clients decided to retain the pregnancy. This work also once again highlights the high unmet need for contraception in Nigeria.
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CASE REPORTS Top

Herlyn–Werner–Wunderlich syndrome p. 133
SK Jena, SS Naik, L Mishra
DOI:10.4103/TJOG.TJOG_69_18  
Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), also known as Herlyn–Werner–Wunderlich syndrome, is a rare syndrome constituting 0.16–3% of all the mullerian duct anomalies. Patients are symptomatic shortly after menarche when hematocolpos develop during menstruation, resulting in dysmenorrhea and a pelvic mass. Ultrasonography and magnetic resonance imaging (MRI) are the usual investigations for the diagnosis. Vaginoplasty with septum resection is the treatment of choice to prevent complications such as endometriosis or adhesions from chronic infections with subsequent infertility. Here, we present a case of 13-year-old girl with similar presentation during her second menses and who was symptomatically relieved by vaginal septostomy with marsupialisation.
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Retention clitoral cyst following female genital cutting; clitoral cyst excision: A case report p. 136
A Rabiu, IS Abubakar
DOI:10.4103/TJOG.TJOG_28_18  
Female genital cutting involves partial or total removal of the female external genitalia for cultural or other nontherapeutic reasons. It is found to interfere with natural functioning of the body and can result in several complications with associated lasting health consequences. One of the complications of this practice is clitoral inclusion cyst. This occurs due to the invagination of squamous epithelium and sebaceous glands in the line of the scar following female genital cutting which desquamates and produces secretions to form a cystic mass. It is usually following type 1 female genital cutting. We presented a 15-year-old sickle cell anemia patient who had female genital cutting during childhood and presented with clitoral cyst. She was the second of a set of twins. She had normal female external genitalia with a solitary, firm, well-circumscribed mass on the clitoris which was centrally located. The prepuce covering the clitoris and part of the clitoris were amputated. The labia minora, majora, the urethral orifice, the vaginal orifice, and the hymen were all normal. The problems were explained to the parent and the child. She was counseled on her condition and the possible cause. Assent was sought and obtained for surgical removal, and the cyst was removed under spinal anesthesia with light sedation.
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Pregnancy following in-vitro fertilization and embryo transfer in a patient with gonadal dysgenesis p. 140
OM Loto, AE Adebayo, TE Ademulegun, AJ Akindojutimi
DOI:10.4103/TJOG.TJOG_81_18  
Gonadal dysgenesis is a congenital condition in which there is gonadal dysfunction as a result of anomalies of sex chromosomes or mutations in the genes involved in the development of the indifferent embryonic gonads. It usually remains undiagnosed until when puberty fails to occur in patients. There is absence of development of female secondary sexual characteristics and primary amenorrhea. Infertility is an important manifestation of this condition, and this has a significant impact on the quality of the reproductive and family life of the patients, especially in areas where importance is placed on childbirth in marriages. This case is that of a woman with pure 46, XX gonadal dysgenesis with primary infertility who was able to achieve conception following IVF (in-vitro fertilization) with donor oocyte at our facility. This has helped to buttress the fact that with proper evaluation and effective application of hormone replacement therapy and assisted reproductive techniques, women with such cases can be helped to achieve conception and give birth.
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Lithopedion coexisting with a huge uterine fibroid: A case report p. 144
B Sulaiman, MT Sani, AH Binji, R Ibrahim
DOI:10.4103/TJOG.TJOG_32_18  
A lithopedion (stone baby) is a rare phenomenon seen in advanced abdominal pregnancy. There are few cases reported in Africa. This is a case report of a 50-year-old woman who presented with a complaint of an abdominal swelling for 15 years. She was suspected to have a uterine fibroid. She was subsequently prepared for myomectomy. Intraoperatively, she was found to have a calcified intact fetus with a coexisting huge uterine fibroid. She had extirpation of the calcified fetus and myomectomy. She did well postoperatively and was discharged home on the 7th day.
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Case report of vulvar schwannoma and literature review p. 147
RA Vhriterhire, TZ Swende, EP Onche, N Terhemba
DOI:10.4103/TJOG.TJOG_62_18  
Schwannoma is a rare benign encapsulated tumor derived from neural sheath cells. The tumor is more common in the head and neck regions and the extremities. Its location in the vulvovaginal region is a rare phenomenon with a few reported cases worldwide. We report a case of a large vulvar schwannoma occurring in an 18-year-old woman, primigravidae at 35 weeks gestation. The ulcerated tumor mass which measured 10.5 × 7 × 6.5 cm and weighed 249.2 grams was located on the right labium majus with extension into the vagina. The tumor evoked strong immunohistochemical reactivity to S-100. There was no evidence of recurrence after several weeks of excision of the neoplasm.
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Wernicke encephalopathy associated with hyperemesis gravidarum: A case report and literature review p. 152
J NF Correia, L ABG Farias, B HL do Nascimento, LI Machado, HN Feitosa
DOI:10.4103/TJOG.TJOG_98_18  
Wernicke encephalopathy (WE) is a neurological pathology caused by thiamine deficiency, which usually manifests with ataxia, confusion, nystagmus, and ophthalmoparesis. The most common cause is alcohol, but other conditions such as hyperemesis gravidarum (HG) have been described. Herein, we report the case of 37-year-old Brazilian pregnant woman who presented to our department with HG complicated with WE and discuss the typical imaging findings, clinical presentation, therapeutics, and prognosis.
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“High-dose hook effect” - negative urine β-HCG in molar pregnancy p. 156
R Jain, S Agrawal, M Baid, A Jain, M Baid
DOI:10.4103/TJOG.TJOG_58_18  
The hydatidiform mole, commonly known as molar pregnancy is characterized by the abnormal proliferation of trophoblasts. A hallmark of diagnosing hydatidiform mole is a positive β- hCG assay pregnancy test. Currently used β- hCG assays are sandwich chromatographic immunoassays and may sometimes produce false-negative results in the presence of excessively high antigen concentrations, a phenomenon known as the “high-dose hook effect”. We report an atypical case of molar pregnancy in a 24-year-old primi gravida female who presented to us in emergency department with a huge abdominopelvic mass, respiratory distress and bilateral pedal edema with a negative urine pregnancy test. Ultrasongraphy suggested it to be hydatiform mole and on further evaluation serum β- hCG was found to be raised. Repeat urine β- hCGassay showed positive result on 1:10 dilution. After resuscitation, patient was treated with suction and evacuation which demonstrated grape like vesicles with no fetal parts. Histopathology report revealed it to be complete hydatiform mole.
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