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   Table of Contents - Current issue
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September-December 2018
Volume 35 | Issue 3
Page Nos. 217-376

Online since Monday, February 11, 2019

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REVIEW ARTICLES  

Training the future trainer – The “double-barrel” postgraduate training model: A pathway to the development of sustainable obstetrics and gynecological specialists in the West African subregion Highly accessed article p. 217
JI Brian-D Adinma
DOI:10.4103/TJOG.TJOG_80_17  
An obstetrician and gynecologist is a physician specialist who provides medical and surgical care to women and has particular expertise in pregnancy, childbirth, and disorders of the reproductive system. Obstetrics and gynecological practice is usually generalist, although four distinct primary subspecialties have been recognized globally – reproductive medicine (reproductive endocrinology and infertility), uro-gynecology (female pelvic medicine and reconstructive surgery), maternal and fetal medicine, and gynecological oncology. The past two decades have witnessed an evolution in the pattern of training of resident doctors in obstetrics and gynecology, the world over. The West African subregion harbors countries ravaged by poverty and poor health system, with resultant poor reproductive health indices to the extent that calls to question the relevance of the present pattern of Obs/Gyn specialist training toward addressing the reproductive healthcare needs of the subregion. The objective of the study is to evaluate the evolution of postgraduate medical training in some developed countries and Nigeria; highlight the pattern of Obs/Gyn postgraduate training in the United Kingdome, the United States, West African, and Nigeria; and recommend a dual training model that is expected to produce sustainable obstetrics and gynecological specialist in West African subregion. Material and Methods used was a Review involving Internet and literature search. Postgraduate medical training in Nigeria and other Anglophone West Africa countries commenced as a hybrid of UK, USA, and Canadian postgraduate training models. The postgraduate Ob/Gyn educational training program in the United Kingdom has three components – basic, intermediate, and advanced – related to 7 years duration – ST (Specialist Training) 1 to 2 (basic), ST3–ST5 (Intermediate), and ST6–ST7 (advance). They are determined in context and structure by the Royal College of Obstetricians and Gynaecologists and approved by the Postgraduate Medical Education and Training Board. There are three-part assessment to the exam: Part 1 MRCOG, Part 2 MRCOG, and Part 3 MRCOG – which on completion leads to the award of a Certificate of Completion of Training or a Certificate of Eligibility for Specialist Registration. The obstetrics and gynecological postgraduate residency training program of West Africa College of Surgeons has a minimum duration of 3 years (after passing the primary exams for the award of membership certificate (Part I), and additional minimum of 2 years for the award of fellowship certificate of West Africa College of Surgeons. The training program in Obs/Gyn of the National Postgraduate Medical College adopts a similar pattern to that of West African College. After passing the primary exams, the resident trainee is expected to carry out a 2.5 years training as a junior resident, and an additional 2 years senior residency training to become eligible for the award of the fellowship certificate (FMCOG). American MD/PhD programs are specifically designed for those who want to become research physicians (physician-investigators or physician-scientists). The program runs a “2-3-2” or “2-4-2” track, consisting of 2 years of basic medical science courses; 3–4 years of PhD research and completion of thesis; and a further 2 years of clinical residencies. The proposed “double-barrel” (dual) postgraduate training model requires that the doctor commencing residency training in Obs/Gyn simultaneously enrolls to commence the master's degree program in any of the subspecialties of Obs/Gyn. By the completion of Part I section of residency training program, the trainee will have also completed the master's degree in the subspecialty of choice, and by the completion of the full training program for award of fellowship, he/she will also be completing the doctorate degree program in the subspecialty. The dual postgraduate training model will produce robust research-strengthened Obs/Gyn subspecialist clinicians; add value to the present fellowship certificate and thereby conform to the qualification demand of National University Commission for academic lecturership; encourage the establishment of Obs/Gyn subspecialty centers with appropriately skilled personnel and stem the exit of wealthy nationals abroad to seek such expert healthcare; and encourage the wide spread deployment of Obs/Gyn clinicians with subspecialty skills to various parts of the West African subregion, thereby providing expert reproductive health services to both the rich and the poor alike in the subregion.
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In vitro fertilization embryo transfer processes and pathway: A review from practice perspective p. 227
Faye Iketubosin
DOI:10.4103/TJOG.TJOG_83_18  
Infertility affects approximately 10%–15% of reproductive-aged couples. In Nigeria, it is an important reproductive health issue and a common reason for gynecological clinic consultations. Significant improvements in fertility treatment have made it possible for many patients to conceive with medical assistance. For example, women with fallopian tube blockage can conceive with in vitro fertilization (IVF). Modern IVF generally involves controlled ovarian stimulation with exogenous gonadotropins, oocytes collection through transvaginal ultrasonographic-guided aspiration, coculture of eggs and sperm in culture (or intracytoplasmic injection of sperm into the oocyte), and placement of the resultant embryos (2–5 d later) directly into the uterus. Some of the major drawbacks to IVF are its high cost of treatment and paucity of availability in our sub-Saharan region.
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Birth control: Contraceptive drugs/pills and methods in the last decades Highly accessed article p. 233
Buhari Aliyu, Chinedu Onwuchekwa
DOI:10.4103/TJOG.TJOG_11_18  
Man had always tried to regulate births through various means involving the use of one or more actions such as medications, agents, sexual practices, or surgical procedures to prevent conception or pregnancy. The existing birth control methods include traditional and modern. The traditional methods are celibacy or sexual abstinence and withdrawal or coitus interruptus while the modern methods include male and female condoms, spermicide, contraceptives, sponge, diaphragm, pills, and vasectomy. Research has shown that hormonal approach to male contraception may be effective, reversible, and even safe. Efforts are ongoing to develop newer male contraceptives that will allow men to become full partners in the prevention of unintended pregnancy. This work reviews existing methods of birth control including current researches in birth control especially in the male.
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ORIGINAL ARTICLES Top

FertilScore: A tool for active management of infertility p. 241
I Wada, N Ameh, T Odeku, S Hati
DOI:10.4103/TJOG.TJOG_85_18  
Background: Active management of infertility involves the reduction of the diagnostic workup time for infertility. However, the timing of decision for assisted conception by the couple and medical personnel is often challenging. FertilScore was developed to simplify this decision timing and make the process more objective. Materials and Methods: A scoring tool was developed using the Delphi method. This involved 3 experts in assisted conception assigning scores to a list of the etiological factors for infertility. The tool was administered to 35 couples presenting to a gynecology clinic and 15 couples who completed the tool on that hospital's website. Grading for couple's need for in vitro fertilization (IVF) was low (1–9), moderate (10–14), and high (15–96). The information obtained has been analyzed. Results: Twenty-four (48%) couples had low need for IVF, 17 (34%) moderate need, and 9 (18%) high need. Seventeen were true positive and 9 false positive. There was no false negative and 24 were true negatives. The sensitivity of the tool was 100%, specificity 72.7%, positive predictive value 65.4%, negative predictive value 100%, and accuracy 82%. Conclusion: FertilScore is sensitive at identifying infertile couples that would require IVF and should help in reducing the time and resources deployed to evaluation. The tool would need to be validated in a larger multicenter population.
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Pattern of infertility among infertile couple in a secondary health facility in Delta State, South South Nigeria p. 244
WO Odunvbun, DV Oziga, LO Oyeye, CL Ojeogwu
DOI:10.4103/TJOG.TJOG_61_18  
Background: Infertility is a worldwide problem, affecting 8%–15% of couples in their reproductive age. There is a wide variation in the pattern of infertility in different parts of the world, being highest in the infertility belt of Africa, which includes Nigeria. Materials and Methods: This was a retrospective descriptive study, involving infertile couples attending the gynaecology clinic of Eku Baptist Government Hospital, a secondary health facility in Delta. The study was conducted from January 1, 2015, to December 31, 2015. Case notes of all eligible couples attending the gynecology clinic were retrieved; relevant information was extracted and subsequently analyzed. Results: The incidence of infertility was 32.0%. The mean age of infertile women was 34 ± 6 years, mean duration of infertility was 5 ± 3 years, 58.9% of women had secondary infertility, 56.0% of male partners of women had abnormal seminal pattern, resulting in a high (40.6%) contribution of male factor to infertility in our study. Conclusion: This study has established a 32.0% institutional incidence rate of infertility in Delta State, similar to the findings in other parts of the country. It has also confirmed the predominance of secondary infertility in this part of the country. The high level of abnormal seminal pattern in this study was responsible for the high male factor contribution to infertility in the study area.
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Risk factors associated with secondary infertility in women of childbearing age: A matched case–control study p. 249
Madonna Ogechukwu Emmanuel, Joseph Ayodeji Olamijulo, Ekanem Effiong Ekanem
DOI:10.4103/TJOG.TJOG_44_18  
Background: Childbearing and rearing are important events in every human life and are associated with the feeling of completeness, family integration, and happiness. However, approximately 1 in 10 couples worldwide experience difficulty in achieving conception. Objective: This study aims to determine the risk factors associated with secondary infertility in women attending the obstetrics and gynecology clinics of a tertiary hospital in Lagos, Nigeria. Methodology: This individually matched case–control study was carried out from July to October 2015. A total of 160 cases were recruited from the gynecology clinic and 160 matched controls were recruited from the antenatal clinic. Data were collected using a structured interviewer-administered questionnaire. The information collected included sociodemographic characteristics, social history, and obstetric and gynecological history. A conditional logistic regression analysis controlling for possible confounders, which included variables significant at the univariate level, was undertaken. Results: Association with secondary infertility was found with a history of unsafe abortion (adjusted odds ratio [AOR] = 9.3607, confidence interval [CI] = 3.7664–23.2645), alcohol use (AOR = 16.8102, CI = 1.3972–202.2487), family history of secondary infertility (AOR = 4.7346, CI = 1.4892–15.0523), and history of sexually transmitted infections (AOR = 4.5428, CI = 1.7658–11.6866). Contrariwise, a history of regular menses and normal vaginal delivery, respectively, were found to be protective. No statistically significant relationship was observed between educational level or alcohol use of partners and secondary infertility in this study. Conclusion: The extrinsic risk factors identified in this study should be taken into consideration when designing preventive and treatment programs toward reducing the burden of secondary infertility.
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Semen profile of male partners of women attending infertility clinic in Zaria, Nigeria p. 256
Abdulrazaq Eneye Garba-Alkali, Adebiyi Gbadebo Adesiyun, Abdullahi Jibril Randawa
DOI:10.4103/TJOG.TJOG_18_18  
Background: Semen analysis is an important investigation in the evaluation of male factor infertility. Diminishing semen profile has been widely reported mostly attributed to the environmental factor and lifestyle changes. Methodology: A cross-sectional study of 154 male partners of women attending infertility clinic at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. The study was done between January and October 2011. The data were collected using questionnaires, semen analyses, semen cultures, and body mass index (BMI). Results: The semen analyses done showed normozoospermia rate of 46.8% while 53.2% had abnormal semen profile. In this study, only 3.9% of the participants' semen that had significant round cells also cultured bacteria. There was no significant statistical association between the round cells count and bacteria culture. Bacteria growth was mainly staphylococcus aureus. There was also a significant statistical association between abnormal semen profile and the risk factors in male infertility, medication use, coital frequency per week, and positive semen culture for bacterial growth. Conclusions: Proportion of participants with abnormal semen profile was high in this study. Significant round cell count did not translate to infected semen. There should be properly coordinated and heightened health education program on awareness and prevention of male infertility.
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Seminal fluid analysis of male partners of infertile couples in Abakaliki, Ebonyi State, Nigeria p. 261
Azubuike Kanario Onyebuchi, C Ifeoma Ekwunife, Johnbosco Mamah, Bobbie Iwe, Emmanuel Afogu, Vitus Okwuchukwu Obi
DOI:10.4103/TJOG.TJOG_56_18  
Context: Procreation is one of the greatest desires of every couple, especially in the developing countries like ours. Male infertility is an important but neglected reproductive health issue, and it appears to contribute significantly to infertility in our environment. Aims: The aim of the study is to review the seminal fluid analysis parameters of male partners of infertile couples attending infertility clinic at the Federal Teaching Hospital, Abakaliki (FETHA). Materials and Methods: This was a 5-year retrospective study of male partners of couple attending the infertility clinic in FETHA between January 1, 2012, and December 31, 2016. Case notes of couples managed for infertility were reviewed. Information extracted includes the sociodemographic characteristics, duration of infertility, type of infertility, and seminal fluid analysis results with emphasis on the semen volume, sperm morphology, motility, pH, and the microbacterial isolates. Statistical Analysis: Data were entered into an excel spreadsheet on a personal computer, and statistical analysis was performed using Epi Info 7.2.1 software. Sociodemographic characteristics are presented in frequencies and simple percentages. Means of categorical variables were compared using the Chi-squared test whereas continuous variables were analyzed using Student's t-test. A value of P ≤ 0.05 was considered statistically significant. Assessment of semen analysis was done using the 2010 World Health Organization human values for semen parameters. Results: Case records of 922 couples attending the infertility clinic were retrieved; however, 756 folders had semen analysis results. During the study, the contribution of the male partner to infertility was 41.0%. The mean age of the patients was 40.10 ± 10.23; the modal age was 34 years; and most of the patients were traders. Majority had normospermia 380 (50.3%) whereas 376 (49.7%) had abnormal semen parameters. There was a high level of leukocytospermia (≥80%) in this study, and the predominant organism cultured was Staphylococcus aureus 328 (43.4%). Oligospermia was the most frequent (33.0%) derangement in semen analysis results. The age and duration of the infertility were not significantly related to abnormal semen analysis; however, men who are resident in urban areas, or who consume alcohol or tobacco, and those who were managed for primary infertility had a significant relationship with abnormal semen parameters (P < 0.05). Conclusion: Semen analysis remains an indispensable tool in the overall diagnosis of male infertility in our environment. Men who are resident in the urban areas or consume tobacco/alcoholic beverage had a significant risk of abnormal semen parameters.
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Contributions of uterine fibroids to infertility at Ile-Ife, South-Western Nigeria p. 266
Olusola B Fasubaa, Oluwaseun O Sowemimo, Oluwole E Ayegbusi, Zainab F Abdur-Rahim, Bolutife S Idowu, Omilakin Ayobami, Olajide E Babalola, Akinyemi J Akindojutimi
DOI:10.4103/TJOG.TJOG_71_18  
Background: Uterine fibroid is the most common tumor of the female genital tract. The benign tumors often grow into large sizes and assume unsightly shapes with concomitant symptoms and signs. Being a predominantly reproductive age disease, concurrent infertility and symptomatic uterine fibroids pose management challenges. Individualization of the patient is thus essential to the success of the reproductive outcome. Objectives: This study determined the prevalence, trend, management modalities, pregnancy outcome, and exposition of factors affecting pregnancy outcome among patients presenting with uterine fibroids and infertility at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). Materials and Methods: This is a retrospective study of case records of 106 women managed for uterine fibroids and infertility over a 5-year period (January 1, 2012, to December 31, 2016) at the OAUTHC. The outcome measure is the pregnancy rate among those who had a myomectomy. Results: About a quarter of women with infertility had symptomatic uterine fibroids and this represents about 35%–40% of the overall number of women presenting as uterine fibroid within the study. About 84.9% had uterine size >12 weeks at presentation. Two-third of the patients had open myomectomy alone with 43.9% achieving conception thereafter. Conception rate for myomectomy with tuboplasty was 31.3% whereas myomectomy with subsequent in vitro fertilization (IVF) was 50%. Pregnancy rate decreased with increasing size of the uterus before myomectomy. Conclusion: Symptomatic fibroid was significantly prevalent among women with infertility. Myomectomy improves fertility potential and success rate of IVF. Uterine fibroid has both direct and indirect effect on infertility and pregnancy rate in this group of the patient can be improved through routine screening for uterine fibroids and early removal of the fibroids before they grow into giants size.
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The relationship between chlamydia infection and infertility at the Lagos University Teaching Hospital, Lagos, Nigeria p. 271
Joseph Ayodeji Olamijulo, Olalekan Olaleye
DOI:10.4103/TJOG.TJOG_36_18  
Context: Infertility affects 10–15% of couples worldwide and tubal factor is a major component in sub-Saharan Africa. Pelvic inflammatory disease due to chlamydia infection is a known risk factor for tubal infertility. Objective: This case-control study was carried out to determine the relationship between chlamydial infection and infertility as seen at the Lagos University Teaching Hospital, Lagos, Nigeria. Methodology: This was a case-controlled study of 180 participants recruited from the Gynaecology Outpatient and Family Planning Clinics of the Lagos University Teaching Hospital, Lagos, Nigeria (LUTH). The cases were 60 females diagnosed to have tubal infertility and 60 other infertile females with patent tubes. The control group comprised of 60 females attending the family planning clinic. The females were tested for serum chlamydia IgG antibody using a kit that detects serovar specific Chlamydia trachomatis antibody. Endocervical swab samples were also tested for chlamydial antigen using a kit that detects C. trachomatis genus specific lipopolysaccharide antigen. The results were collated and analyzed using the statistical package for the social sciences (SPSS) version 18. Results: All the females tested negative for chlamydia antigen. The odd ratio for having a case testing positive for chlamydial antibody compared to control was 4.0 [95% CI = 1.47–10.88]. The odd ratio for infertile females with blocked tubes compared with those who had patent tubes testing positive for chlamydia antibody was 3.52 (95% CI: 1.46–8.49). Conclusion: This study suggests an etiological relationship between chlamydial infection and infertility in general and tubal infertility in particular.
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The impact of dysmenorrhea on activities of Ghanaian undergraduate students p. 276
Ayokunle Osonuga, Martins Ekor
DOI:10.4103/TJOG.TJOG_27_18  
Background and Aim: Dysmenorrhea is one of the leading causes of gynecological hospital visits globally, with resultant physical, psychological, academic, and social consequences. There exists a paucity of research on dysmenorrhea in Ghana and those available focus on the adolescent population. Our study intends to add to the body of knowledge by describing the negative experiences of dysmenorrhea among undergraduate females. Methodology: The study was a descriptive, cross-sectional study involving to 200 female undergraduate students (100 medical and 100 nonmedical students) of the University of Cape Coast, Ghana. Data were analyzed using standardized and acceptable statistical tools. P < 0.05 was considered to be statistically significant. Results: Dysmenorrhea caused significant disturbance in academic and nonacademic activities of the respondents, thus increasing with increase in severity of the menstrual pain. It resulted in mood disturbances, disruption in social interaction (relationship with colleagues and university staff), limitation in sleep, and hospital admission in 39.9%, 19.1%, 10.1%, and 5.4%, respectively. Furthermore, it resulted in disruption in academic activities of the respondents (42.3%), lack of concentration (41.7%), inability to study (23.2%), and school absenteeism (12.5%). Conclusion: Dysmenorrhea is a major public health burden among females of reproductive age. We advocate that it should be given much more priority and attention than its receiving presently in Ghana, so as to reduce the negative consequences attached with it.
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Menstrual hygiene practices among female adolescents seen in general outpatient clinic p. 281
Ibrahim Aliyu, Bukar Alhaji Grema, Godpower Chinedu Michael
DOI:10.4103/TJOG.TJOG_31_18  
Introduction: Menstruation is a normal physiologic phenomenon which is indicative that a woman is ready for her reproductive roles. Adolescents are often uninformed and inexperienced on most health-related issues including menstruation. This study therefore hopes to determine the common menstrual hygiene practices among adolescent females. Materials and Methods: This was a cross-sectional study involving women aged 14–18 years. A pretested questionnaire was administered by trained female clinical assistants to those who cannot read and write; however, literate respondents self-administered the questionnaires. Results: Three hundred and ninety-six (95.4%) of the respondents were aware of menstruation before their first period. Four hundred and two (96.9%) respondents believed menstruation was caused by the age of maturity, while 13 (3.1%) reported failure of fertilization of the ovum resulted in menstruation. Close relations were common source of information on menstruation; however, the age of menarche ranged from 9 to 18 years, with a mean age of 13.4 ± 1.5 years. Sixty-one (14.7%) respondents used clean cloth for menses, 271 (65.3%) used sanitary pad, while 83 (20.0%) used tampon. However, 55 (13.3%) reused their sanitary wares. Most respondents changed their sanitary wares twice in a day; they mostly bath twice in a day even during their periods. Conclusion: Most respondents were aware of menstruation before their menarche and their close relatives were their common source of information on menstruation, 13 years was the mean age of menarche; most respondents used sanitary pads; however, 20% of them still used tampons.
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Early pregnancy body mass index and obstetric outcomes in Ibadan p. 286
Richard O Olayide, Olubukola A Adesina, Timothy A Oluwasola
DOI:10.4103/TJOG.TJOG_45_18  
Introduction: Obesity in pregnancy has been associated with adverse pregnancy outcomes. In this study, we estimate the prevalence of early pregnancy obesity and the impact on materno-fetal outcomes. Materials and Methods: A cohort of 176 pregnant women were purposively recruited before 20 weeks. Women <18 years, with multiple pregnancies or chronic medical conditions, were excluded from the study. Body mass index (BMI) grouping was done at the first clinic. Data were presented as means (standard deviation) and proportions and differences compared using Chi-square or ANOVA. Results: Early pregnancy weight of 173 women followed up from booking to delivery showed 41.2%, 24.3%, and 32.2% were normal weight, overweight, and obese, respectively. At recruitment, the mean age, mean BMI, and mean gestational age were 31.7 ± 4.4 years, 27.1 ± 5.3 kg/m2, and 14.4 ± 3.2 weeks, respectively. Compared to normal weight women, the obese were older (31.1 ± 4.0 vs. 32.8 ± 4.1, P = 0.06) and of higher parity >2 (19.2% vs. 36.9%, P = 0.17). Compared to those with normal BMI, occurrence of gestational diabetes mellitus (1.3% vs. 10.53%) and preeclampsia (6.9% vs. 14.0%) were more in obese women whereas overweight women had higher occurrence of pregnancy-induced hypertension (6.9% vs. 16.3%) and preeclampsia (6.9% vs. 13.95%). At delivery, compared to normal weight, obese women had more cesareans (57.5% vs. 69.7%), more deliveries <37 weeks (20.6% vs. 41.07%), more babies <2.5 kg (13.7% vs. 25.0%), acrosomic (9.6% vs. 12.5%), and more special care baby unit admissions (4.1% vs. 10.7%). Conclusion: Even in low-resource setting, obesity in pregnancy is not uncommon. Affected women would benefit from prepregnancy interventions.
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Intimate partner violence and fertility-related issues: A cross-sectional survey of women attending antenatal clinic at the university college hospital, Ibadan p. 292
Oluwasomidoyin Olukemi Bello, Gbolahan Oladele Obajimi, Cecilia Olusade Adetayo
DOI:10.4103/TJOG.TJOG_30_18  
Background: Intimate partner violence (IPV) in pregnancy is of great public health importance because it involves two lives (mother and fetus). It is a range of behavior exhibited by a current or former partner with the potential of causing physical, emotional, or sexual harm to the receiver. This study aims to establish the prevalence and predictors of IPV and its association with fertility-related characteristics and behaviors. Methods: A descriptive cross-sectional survey involving 322 consenting pregnant women. A semi-structured self-administered questionnaire was employed for data collection. Data were analyzed using the Statistical Package for Social Sciences version 20. Results: The mean age of the respondents was 30.8 ± 4.5 years with parity ranging from 0 to 5. The prevalence of IPV was higher (81.0%) among respondents who had children compared to those who had no children (19.0%). The common forms of IPV experienced by the women in this study were shouting (86.7%), verbal abuse (76.2%), and slapping (57.1%). Other serious forms of IPV experienced included forced sex (14.3%) and threats to the life of the respondents (4.8%). Polygamy and low educational attainment were strong predictors of IPV risk (P < 0.05). Contraceptive use before pregnancy and husband's support of its use were not statistically significant (P > 0.05). Conclusion: IPV is an unpalatable event. The prevalence rate of IPV was 6.5% in this study with the most common forms being shouting and verbal abuse. Polygamy and low educational attainment were significant risk factors for IPV. The desire for conception in this study was 76.2% with IPV prevalence slightly higher in respondents with children (7.9%). Educating the girl child would bring stability to the home by reducing the prevalence of IPV.
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Missing intrauterine contraceptive device string: Diagnosis and management at federal medical center Bida, Northcentral, Nigeria p. 298
Folorunsho Benard Adewale, Adewale Ashimi
DOI:10.4103/TJOG.TJOG_56_17  
Background: Intrauterine contraceptive device (IUCD) is a widely accepted method of contraception. Displacement of this device is an important complication of this method of family planning. Objective: This study aims to determine the biosocial characteristics of patients with missing intrauterine devices (IUDs), complication of missing IUD, the diagnostic and management modalities at Federal Medical Centre (FMC), Bida. Materials and Methods: This is a 5-year retrospective study of all cases of missing IUDs that were managed at both the family planning and gynecological clinics of the FMC, Bida, between January 1st, 2010, and December 31st, 2014. A list of clientele that had IUD inserted during the study was compiled from the family planning record book, and the case files were retrieved from the medical records section. Data were collected using a pro forma and analyzed. Results: A total number of 1540 IUDs were inserted within the period under review while 21 of the inserted IUD were missing hence a prevalence rate of 1.4% of missing IUD. Within the 5 years' review, 4854 clients were seen at the family planning clinic for various family planning services out of which 1540, used IUD giving a 31.7% of total contraceptive use thus making IUD the third-most commonly used method of contraception after norethisterone-enanthate and depomedroxyprogesterone acetate at FMC, Bida. Associated with the missing IUD were a lower abdominal pain, irregular vaginal bleeding, vaginal discharge, and co-existing pregnancy. There was no ectopic pregnancy or death recorded. Conclusion: IUCD is an acceptable and common form of contraception worldwide and is the third-most commonly used contraceptive method at FMC, Bida. It requires minimal effort at follow-up; and missing IUD, one of the complications associated with its use could be a source of psychological disturbance to the client and also an indication for major surgery among IUD users.
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Prevalence of prenatal ultrasound diagnosed single umbilical artery in a cohort with associated congenital malformations p. 304
Janet A Akinmoladun, Oluwasomidoyin Olukemi Bello
DOI:10.4103/TJOG.TJOG_22_18  
Introduction: Single umbilical artery (SUA), a developmental abnormality of the umbilical cord occurs following primary agenesis or secondary atrophy of one of the arteries. It occurs in 0.08%–2% of pregnancies and associated with intrauterine growth restriction, preterm delivery, stillbirth, and congenital anomalies. Usually, the attending midwife or doctor determines the number of umbilical arteries at delivery. However, with the advent of prenatal ultrasound screening, the umbilical cord vessels can be determined as early as 14 weeks prenatally. The study aimed at determining the prevalence of SUA in University College Hospital (UCH), Nigeria, with associated anomaly (ies). Materials and Methods: This is a prospective cohort study of 989 fetuses who had detailed anomaly scan over 4 years at the ultrasound unit of the antenatal clinic, UCH. Results: Sixty-two fetuses had various anomalies, of which three had SUA, and these cohorts were followed up. The prevalence of SUA was 0.3% in both singleton and multiple gestations. Other anomalies detected with SUA include abnormal-shaped head, hypoplastic cerebellum, bilateral renal pyelectasis, bilateral ventriculomegaly, cavum septum defect, and ventricular septal defect. Conclusion: SUA is more common in twin gestations than in singletons, and if found in a fetus, it is a high risk for other anomalies which must be determined prenatally.
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Maternal determinants of estimated fetal weight (EFW) at mid-pregnancy p. 310
Idowu A Taiwo, Kehinde T Bamgbopa, Ottun A Micheal, Faye Iketubosin, Olufemi A Oloyede
DOI:10.4103/TJOG.TJOG_23_18  
Background: Assessmentof fetal biometry is a vital component of prenatal care in many parts of the world. Objective: To assess correlation between some maternal variables and fetal weight estimated from mid-pregnancy ultrasound biometric data with a view to identifying significant maternal predictors of fetal weight in a sample of Nigerian women. Methods: A prospective study involving 87 pregnant women scanned at 18-23 weeks of pregnancy was carried out. The fetal measurements were head circumference (HC), abdominal circumference, femur length, and biparietal diameterwhile the maternal variables were age, parity, height, weight and BMI. Results: Maternal weight and BMI were the most correlated variables (r = 0.92; P < 0.001). The significant correlation between maternal age and weight (r = 0.28; P < 0.01) and between maternal age and BMI (r = 0.30; P < 0.01), onsimple correlation,vanished with partial correlation (P > 0.05). In contrast, significant correlation which was not observed between estimated fetal weight (EFW) and maternal weight (r = -0.06; P > 0.05); EFW and maternal height (r = 0.03; P>0.05); and between EFW and BMI appeared with partial correlation (P < 0.05). Multiple regression analysis gave statistically significant models (ANOVA: F = 22.2; P < 0.01). Conclusion: Maternal height, weight, parity, BMI, and estimated gestational age at scan (EGA) are significant predictors or determinants of EFW.
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Might high body mass index contribute to anemia in pregnancy in malaria-endemic areas? p. 316
Ikeola A Adeoye, Timothy AO Oluwasola, Chioma E Umezurike, Oluwafunke A Oluwatoba
DOI:10.4103/TJOG.TJOG_43_18  
Background: Anemia in pregnancy has remained a public health challenge in the developing countries. The emerging epidemiological and nutritional transitions as well as the decrease in malaria burden make investigating other causes of anemia imperative. We hypothesized that high body mass index (BMI) might contribute to anemia in pregnancy in malaria-endemic regions. Materials and Methods: Using a two-stage sampling technique, we interviewed 338 pregnant women and antenatal care attendees at primary health-care centers in Ibadan, Oyo State. Blood and stool samples were collected from all the study participants. Thick and thin blood films were prepared for the identification of malaria parasite while Kato–Katz technique was used for quantification soil-transmitted helminthes in the stool samples. Multivariate logistic regression analysis was performed to assess the association between malaria and high BMI with anemia while controlling for the established causes of anemia in pregnancy. Results: The prevalence of anemia was 47.9%. About half, 50.8% of the study population had normal weight while 43.8% were overweight/obese. Malaria (AOR 2.54 and 95% CI: 1.40 - 4.61), gestational age (AOR: 1.96 and 95% CI: 1.18–3.25), and being overweight/obese (AOR: 1.96 and 95% CI: 1.18–3.25) were associated with anemia in pregnancy. Conclusion: Malaria remains a significant cause of anemia in pregnancy, but the association between BMI and anemia will require further investigation among the Nigerian pregnant population.
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Placental weight and perinatal outcome among parturients at a university teaching hospital in Lagos, Nigeria p. 322
Chidinma Magnus Nwogu, Imoleayo E Adetuyi, Kehinde Sharafadeen Okunade, Gbemisola Eniola Osanyin, Ayodeji Ayotunde Oluwole
DOI:10.4103/TJOG.TJOG_76_17  
Background: The growth and survival of the fetus are essentially dependent on formation, full development, and functions of the placenta. Examination of the placenta would demonstrate important information about whatever has happened to the fetus in utero. Aim: The aim of this study was to determine the sociodemographic characteristics that affect placenta weight and then assess the association between placental weight and perinatal outcome among parturients in a tertiary hospital in Lagos, Nigeria. Materials and Methods: This was a retrospective review of all women who delivered at the labor ward complex of the hospital between January 2014 and December 2015. The data of all parturients with uncomplicated singleton pregnancies were obtained from the labor ward register, and their case notes were subsequently retrieved from the medical records department for extraction of all relevant information. Descriptive statistics were computed for all data and analyses were done using Statistical Package for the Social Sciences version 22.0 for Windows (manufactured by IBM Corp., Armonk, New York, United States). The associations between groups of continuous variables were tested using the independent sample t-test or one-way analysis of variance where applicable. All significances were reported at P < 0.05. Conclusion: Parity, maternal booking weight, gestational age at delivery, baby's birth weight, umbilical cord length, and neonatal 5-min Apgar score had positive correlations with placental weight. Further longitudinal studies are needed to examine the extent to which placental weight will affect the future growth and development, nutritional status, and health of newborns. Result: The overall mean cord length was 59.6±11.7cm and the mean placental weight was 657.5±96.1 grams with majority (46.3%) of the parturients having normal placental weight range of 500-749 grams. Placental weights at term have statistically significant positive correlations with the gestational age at delivery (P = 0.041), baby's birth weights (P = 0.003), 5-minute Apgar score (P = 0.016), and the umbilical cord length (P = 0.035).
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Knowledge, attitude and practice of Nigerian specialist doctors in training of cervical cancer and its screening p. 327
Chidi Ochu Uzoma Esike, Robinson Chukwudi Onoh, Chukwuemeka Ikechi Ukaegbe, Christian Obioma Aluka, Paul Olisaemeka Ezeonu, Odidika Ugochukwu Joannes Umeora
DOI:10.4103/TJOG.TJOG_25_18  
Introduction: Cancer of the cervix is the second commonest cancer among women worldwide, the commonest female genital-tract malignancy in Nigeria, and one of the leading causes of morbidity and mortality among women in Nigeria. Health workers are the trusted source of medical information and their attitude and practice toward diseases of public health importance like cervical cancer are very critical if the country must make progress toward the prevention of such diseases. This work assesses the knowledge, attitude, and practice of Nigeria's specialist doctors in training toward cervical cancer and its methods of screening because this is critical to its prevention in the country. Materials and Methods: This is a cross-sectional study involving the administration of pretested structured questionnaire to fifty specialist Nigerian doctors in training in various disciplines from different parts of the country. Results: The knowledge of the participants regarding cervical cancer and its screening is very good, with an average of 98%, but their attitude toward cervical cancer screening is poor as only 7 (14%) had ever recommended a woman for cervical cancer screening. The practice of cervical cancer screening among the participants is poor as only 5 (22.7%) of the 22 female doctors in training had ever screened for cervical cancer and only one male specialist doctor in training out of the 28 of them had the partner screened for cervical cancer before this study. Only 4 (9%) of the 28 males had ever recommended cervical cancer screening to their female partner and 44 (88%) of the specialist doctors in training had never spoken to any organization about cervical cancer screening. Conclusion: Though the knowledge of Nigerian specialist doctors in training on cancer of the cervix and its screening is very good, their attitude to it and practice are very poor.
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Effect of asymptomatic malaria parasitemia on the uterine and umbilical artery blood flow impedance in third-trimester singleton Southwestern Nigerian pregnant women p. 333
Adetayo Mojeed Adelodun, Ademola Joseph Adekanmi, Adebola Roberts, Abiodun Oludotun Adeyinka
DOI:10.4103/TJOG.TJOG_5_18  
Background: Asymptomatic malaria parasitemia (AMP) in pregnancy is a major public health issue in tropical countries and represents a vast percentage of malaria infection in pregnancy. It is nonsymptomatic, neglected from treatment but significantly affects uteroplacental and fetoplacental hemodynamic blood flow, with negative pregnancy outcome that includes miscarriages, preterm labor/delivery, low birth weight, and intrauterine fetal death. Doppler ultrasound is a reliable, non-invasive, ionizing radiation-free, and repeatable method in the assessment of uterine and umbilical arteries vascular flow dynamics and resistance in malaria parasitemia in pregnancy. Materials and Methods: This comparative cross-sectional study was conducted between June 2016 and January 2017 was to assess and compare the vascular flow of the uterine and umbilical arteries in healthy pregnant women with AMP and those without malaria parasitemia in the third trimester of singleton pregnancy using Doppler ultrasound. Results: The mean uterine arteries Doppler indices were significantly higher in AMP than controls. The mean Doppler indices values for pulsatility index (PI), resistive index (RI), and systolic to diastolic ratio (SDR) were 0.85 ± 0.16, 0.59 ± 0.11, and 2.12 ± 0.17 for the subjects and 0.77 ± 0.09, 0.51 ± 0.06 and 2.05 ± 0.22 for the controls, respectively. These differences were statistically significant: PI was (P < 0.001; 95% confidence interval [CI]: −0.11, −0.051), RI was (P < 0.001; 95% CI: −0.10, −0.063) and SDR was (P = 0.01; 95% CI: −0.11, −0.015). However, the mean umbilical arteries PI and RI were not significantly different between subjects and the controls. Conclusion: There were statistically higher uterine artery impedance indices in the third trimester among singleton pregnant women with AMP than controls. This study also showed that the uterine artery impedance indices increased with the severity of malaria parasitemia.
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Managing sickle cell disease in pregnancy, the success and the challenges: Our experience in a semi-urban tertiary health-care facility, Southwest, Nigeria p. 342
Awolola Olalekan Olugbenga
DOI:10.4103/TJOG.TJOG_37_18  
Background: Pregnancy complicated by sickle cell disease (SCD) is known to be associated with poor maternal and fetal outcomes. However, the challenges encountered in managing these patients in the rural and semi-urban areas are yet to be evaluated by many of these studies. Objectives: The objective of the study is to determine the maternal and fetal outcomes of pregnancy complicated by SCD, the importance of the pregestational counseling and care and the challenges faced by the health-care givers in giving them optimal care in Nigeria, especially in rural and semi-urban settings. Materials and Methods: This is a prospective study. All diagnosed SCD pregnant women seen between May 2013 and April 2016 were recruited into the study, after taking informed consent from them. They were all subjected to the standard management of sickle disease in pregnancy. The antenatal, intrapartum, immediate postdelivery and the puerperal events were documented in structured obstetric data sheets. The information obtained from these data sheets were used to generate a database for analysis. Results: The total number of the patients recruited into this study was 54. They were all booked patients or those referred from other centers with adequate antenatal records. The incidence of SCD in this study was 1.15% (HBSS; 0.49%, HBSC; 0.55%, and HBCC; 0.11%). The mean maternal ages at booking were 26.35 ± 5.76, 27.12 ± 3.28, and 27.004 ± 0.69 years for HBSS, HBSC, and HBCC, respectively. The mean gestational ages at delivery were 37.43 ± 1.36, 38.58 ± 1.21, and 35.80 ± 0.84 weeks for HBSS, HBSC, and HBCC, respectively. The antenatal bookings were all in the second and third trimesters. Similarly, only 10 (39.96%) had pregestational counseling and care before pregnancy. The patients were mostly middle social class status and with poor antenatal clinic visits. Discussion: Poor maternal and fetal outcomes were seen more in HBSS than HBSC and HBCC. However, statistical analysis showed statistically significant differences only in the prematurity, preterm labor, and the mean fetal weights. Factors such as pregestational counseling and care, social class, parity, and early antenatal booking play important roles in achieving optimal care and excellent outcomes. Conclusion: Many authors documented poor maternal and fetal outcomes in pregnancies complicated by SCD. The focus now should be identifying factors that may militate against achieving excellent results from the optimal care of these patients. This we have initiated in this study.
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Comparison of intramuscular paracetamol and intramuscular pethidine as analgesic in the first stage of labor p. 348
Ramon Sunday Omotayo, Samuel O Faturoti, Richard Rotimi Ehinmitan, Folorunsho Obaifo Alao
DOI:10.4103/TJOG.TJOG_33_18  
Background: In general, opioid use as labor analgesic has been associated with some maternal and neonatal side effects including maternal sleepiness and reduced neonatal Apgar score among other side effects. In view of this, many mothers have been undergoing labor without analgesia. The search for safer and effective alternative has continued over the years. Objective: The study was aimed at comparing the efficacy and side effect profile of intramuscular paracetamol and intramuscular pethidine as analgesia in labor. Study Design: This study is a prospective randomized double-blind comparative study. Materials and Methods: Two groups of 54 consenting parturients each were recruited following a computer-generated randomization pattern. Parturients in one group had 600 mg of intramuscular paracetamol and the other 50 mg intramuscular pethidine, and mean pain reduction at 30 min, 1, 2, 3, and 4 h was obtained using a visual analog scale in both groups and compared. Demographic data and primary and secondary outcomes of both groups were compared using t-test (for quantitative measures). The Statistical Package for the Social Sciences (SPSS) version 17 was used for statistical analysis. Results: There was comparable efficacy of labor pain reduction in paracetamol and pethidine after 1 h of drug administration and up till 3 h after (P < 0.001), however, pain reduction was more in pethidine group as expected. The maternal and fetal side effect profile of paracetamol was found to be better than that of pethidine. Conclusion: This study has shown that paracetamol can be used for labor pain with the added advantage of better side effect profile as compared with pethidine.
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Blood donation and transfusion: Perception of pregnant women at the University College Hospital, Ibadan p. 358
Olubukola A Adesina, Tamunosaki W Abo-Briggs, Foluke A Fasola
DOI:10.4103/TJOG.TJOG_46_18  
Background: At the University College Hospital (UCH), Ibadan, there is a policy of compulsory blood donation by relatives of pregnant women registered for care. This study assesses the perception of these women about blood donation and transfusion and compliance with the policy. Materials and Methods: This cross-sectional study was among women registered for antenatal care at UCH. By nonprobability purposive sampling, 300 pregnant women >18 years were recruited from July 1, 2017, to September 30, 2017. Women presenting for emergency care and Jehovah's Witnesses were excluded from the study. Information was obtained using pretested questionnaires. Data are presented as means (standard deviation), simple frequency, and percentages. Results: Among the 300 participants, the mean age was 31.0 (±3.7) years, 194 (64.6%) were multiparous, 94.4% had postsecondary education, and 263 (87.7%) were Yoruba by ethnicity. Concerning perception about blood donation, 221 (73.7%) agreed that blood can be donated and stored for the future use, 279 (93.0%) thought that blood donation is good, 214 (71.3%) agreed that voluntary blood donation is best, and both men and women could donate (269, 89.7%). Concerning the effect of blood donation, 229 (74.6%) agreed/strongly agreed that donation could cause weakness. However, 195 (65.0%) and 194 (64.0%) disagreed/strongly disagreed with donation causing loss of sexual drive or death. Concerning transfusion, 273 (90.7%) and 253 (84.3%), respectively, agreed that women may need blood during pregnancy/delivery, and hemorrhage during labor/delivery may lead to death. Finally, 266 (88.7%) were aware of the hospital policy although only 133 (44.3%) had complied. Conclusion: The positive perception was unmatched with compliance suggesting unidentified factors for further research.
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CASE REPORTS Top

Successful pregnancy in a unicornuate uterus p. 364
Osemen Ehidiamen Okojie, Babasola O Okusanya, Edirin Edward Agadagba, Adesumbo Kayinsola Odeseye
DOI:10.4103/TJOG.TJOG_10_18  
Uterine anomalies are generally rare and are usually asymptomatic. When present, these anomalies are implicated in complications such as recurrent miscarriages, preterm labor, malpresentation, intrauterine growth restriction, uterine rupture, and a variety of menstrual disturbances. We report a case of a pregnancy carried to term in a unicornuate uterus with an accessory horn, diagnosed intraoperatively during an emergency cesarean section with favorable outcome to the mother and baby.
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Incidental hemoperitoneum from ruptured superficial uterine veins in twin pregnancy p. 367
Emmanuel Owie
DOI:10.4103/TJOG.TJOG_35_18  
Hemoperitoneum in pregnancy is rare (especially from ruptured uterine vessels) and potentially life-threatening for both the mother and the fetus. It commonly occurs in the third trimester and in labor. The clinical presentations vary from severe abdominal pain and shock to nonspecific symptoms. Prompt and correct diagnosis, adequate fluid and blood resuscitation, and surgical intervention are essential to prevent maternal and perinatal morbidity and mortality. A 26-year-old primigravida with twin gestation at 34 weeks presented in labor with footling breech presentation, cervical dilatation of 5 cm, and fetal tachycardia. She had an emergent cesarean section, and incidental hemoperitoneum of 1.1 L was encountered as well as bleeding anterior and posterior uterine serosa veins. The neonates were safely delivered, and the bleeding veins were ligated with vicryl suture. The mother and twins were discharged home afterward in stable condition.
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LETTER TO EDITOR Top

A rare case of ovarian dysgerminoma in a 6-year-old child in Lagos: A case report p. 370
Mahmood Dhahir AL-Mendalawi
DOI:10.4103/TJOG.TJOG_78_17  
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EDITORIAL REVIEW Top

Society of obstetrics and gynecology of Nigeria – Clinical practice guidelines: Guidelines for the prevention of cervical cancer p. 371
Oluwarotimi I Akinola, Christopher O Aimakhu, Oliver C Ezechi, Olusola B Fasubaa
DOI:10.4103/TJOG.TJOG_88_18  
Clinical practice guidelines have been developed by professional societies globally. Each guideline although based on published scientific evidence reflected each country's socioeconomic peculiarities and unique medical environment. The Society of Obstetrics and Gynaecology of Nigerian has published guidelines in other clinical areas; however, this is the first edition of practice guidelines for the prevention of cervical cancer. The Guidelines Committee was established in 2015 and decided to develop the first edition of this guideline following Delphi pool conducted among members which selected cervical cancer prevention as the subject that guideline is urgently needed. These guidelines cover strategies for cervical cancer prevention, screening, and management of test results. The committee developed the draft guideline during a two-day workshop with technical input from Cochrane Nigeria and Dr. Chris Maske, Lancet Laboratories, South Africa. The recommendations for each specific area were developed by the consensus, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the prevention of cervical cancer.
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