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   Table of Contents - Current issue
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May-August 2019
Volume 36 | Issue 2
Page Nos. 161-318

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EDITORIAL REVIEW  

Society of obstetrics and gynecology of Nigeria – Clinical practice guidelines: Guidelines for the prevention of cervical cancer p. 161
Oliver C Ezechi, Babasola O Okusanya, Chris O Aimakhu, Olubukola A Adesina, Aigbe G Ohihoin, Hadiza A Usman, Odidika U Umeora, Rotimi Akinola, Rose Anorlu, Atiene Sagay, Bala Audu, Olusola B Fasubaa, Adekunle Oguntayo, Olutosin Awolude, Michael Ezeanochie, Adegboyega Fawole, Munirdeen Ijaiya, Azubuike Onyebuchi, Lamaran Dattijo, Osayande E Osagie, Adetokunbo Fabanwo, Faye Iketbuson, Bukola Fawole, Bose Afolabi, Chris Agbogoroma, Habib Sadauki, Anthony Okapani, Ibrahim Yakasai, Josiah Muthir, Patrick Okonta
DOI:10.4103/TJOG.TJOG_72_19  
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 2-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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ORIGINAL ARTICLES Top

Obstetric morbidity and mortality: Exploration of the use of Maternal Early Warning Scores (M-EWS) for recognition and escalated timely interventions in acute obstetric emergencies in Nigeria p. 165
AO Isemede, JA Unuigbe
DOI:10.4103/TJOG.TJOG_6_19  
Severe Obstetric Emergencies: Use of Maternal Early Warning Scores (M-EWS) in Nigeria. Maternal Early Warning Scores (M-EWS) is a patient illness severity scoring system that aids tracking and timely escalation of acutely deteriorating obstetric patients. M-EWS has been demonstrated to reduce substandard care, obstetric complications, and maternal mortality in the United Kingdom and a number of other countries. Background: Successes in the prevention of maternal mortality attributed to this tool in the United Kingdom where it is in established use coupled with high potential for its usefulness in other countries prompted the inclusion of the M-EWS in the post 2015 United Nations Sustainable Development Goals for the 193 member nations. Aims: We set out to explore the availability of M-EWS for the recognition and escalated timely interventions in obstetric emergencies in Nigeria and a desire for its application. Methods: A combination of SurveyMonkey (online) and paper-based questionnaires distributed to clinicians of all teams and grades involved in obstetric care was used. Results: In all, 76 responses (17 online and 59 paper-based questionnaire) were received out of 30 e-mails and 70 paper-based questionnaires. Nineteen (25%) clinicians reported use of a physician-specific calling system but none had the M-EWS in use. Three respondents (4%) were not certain whether M-EWS would be welcomed in their service, but 73 (96%) welcomed the introduction of the M-EWS. Conclusion: This survey shows the lack of M-EWS in obstetric practice in Nigeria and strong desire for its introduction. Consequently, some collaborative work aimed at refining this tool for the Nigerian obstetric environment has commenced.
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Awareness, attitude and use of labor analgesics by pregnant women at State Specialist Hospital, Akure p. 170
RS Omotayo, O Akinsowon, SE Omotayo
DOI:10.4103/TJOG.TJOG_92_18  
Background: Pain relief during labor has always been associated with myths and controversies. Several groups of people think that God has made this process painful and no interference should be done in it. In the present civilization, there is no circumstance where it is considered acceptable for a person to experience severe pain, amenable to safe intervention while under a physician's care. Objective: This study assessed the level of awareness of pregnant women about labor analgesia and factors preventing them from having analgesia in labor. Study Design: This study is a descriptive cross-sectional study. Methodology: Questionnaires were used to obtain information on awareness, attitude and use of labor analgesia from pregnant women at the booking clinic visit. Three hundred (300) consenting pregnant women were recruited into the study including provision for attrition. Data were analyzed with the Statistical Package for Social sciences (SPSS) 20. Proportions were calculated for independent variables while crosstabulation was done for related variables to find P value for statistical significance. Results: Level of awareness of labor analgesia was 21%. Majority of the respondents (70.3%) believe that among all health professionals, it is doctors that should inform them about labor analgesia. Only 4.4% had used labor analgesic in their previous deliveries. About 81% of respondents desire labor analgesia in their next delivery. Among factors analyzed, only severity of last labor had significant influence on the patient's desire for analgesia in their next delivery (P value = 0.026). Conclusion: The awareness rate of pregnant women about labor analgesia is very low. Therefore, all efforts must be made to ensure that discussions about labor analgesia are commenced as early as at the booking visit to improve on pregnant women's awareness about labor analgesia and help their acceptability and choices. Attitude towards labor analgesia is not influenced by type of facility where the delivery took place suggesting possibility of socio-cultural influence of the people in the area of study on the practice of labor analgesia.
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Outcome of induction of labor with prostaglandin E1 25 mg vaginal tablet – A retrospective study p. 177
G Puliyath, A Balakrishnan, L Vinod, H Hameed
DOI:10.4103/TJOG.TJOG_24_19  
Context: Labor induction with prostaglandin E1 (PGE1) vaginal tablet results in shorter induction delivery interval and decreased rate of failed induction of labor and reduced caesarean section rate. However, higher doses may be associated with uterine hyper stimulation. It is therefore necessary to determine the safe dose of PGE1 for labor induction. Aims: To assess the maternal and neonatal outcome with use of 25 mg vaginal misoprostol for induction of labor. Settings and Design: A retrospective analysis conducted in an obstetric department of a tertiary care teaching institute. Materials and Methods: The sample consists of women with singleton term pregnancy, with Bishop's score <6 compared with women with spontaneous onset of labor. Statistical Analysis Used: Statistical significance was assessed at 5% level of significance. Chi-square test, with correction for continuity where applicable, was carried out to compare proportions across subgroups or between induction and spontaneous onset groups. Results: The rate of vaginal delivery was higher among spontaneous onset group compared with induction group (χ2 (1) = 30.3, P < 0.001). The induction delivery interval of vaginal delivery was less than 24 h in 91.85% of women. Neonatal intensive care unit admission frequency was similar among both groups (χ2 (1) = 0.14, P = 0.704). The induction group was with less frequency of meconium staining than the control group (χ2 (1) = 8.05, P = 0.0046). Conclusion: Our study showed a higher rate of vaginal delivery with induction delivery interval less than 24 h in a majority of women with better neonatal and maternal outcomes.
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Twin pregnancies at federal medical centre Katsina: A 5 year review p. 183
Abdulfattah Mohammed Lawal, Ojonigwu Dadi Atabo-Peter, Aisha Abdurrahman
DOI:10.4103/TJOG.TJOG_82_18  
Background: Multiple gestation is associated with higher risk of maternal complications in the antenatal, intrapartum, and postpartum periods compared with singleton pregnancies, as well as higher risk for perinatal morbidity and mortality. Objective: The objective of this study was to determine the incidence and obstetric outcomes of twin deliveries in Federal Medical Centre Katsina. Methods: It is a retrospective study of twin deliveries over a 5-year period from January 1st 2010 to December 31st 2014 conducted at the Federal Medical Centre Katsina (FMCK), Katsina state. Results: There were 172 cases of twin deliveries out of 9,947 deliveries giving an overall twinning rate of 17.3 per 1,000 deliveries. There were three cases of triplet delivery during this period. The most common complication was preterm delivery which occurred in 40.1% of cases. The mode of delivery was vaginal in 64.5% while 35.5% had caesarean section. Emergency caesarean section for delivery of both babies was carried out in 24.42% while elective caesarean section for both babies accounted for 8.72%. Combined vaginal and abdominal delivery occurred in 2.33% of deliveries. The stillbirth rate was 81.4 per 1,000 births. There were 11 (6.4%) and 17 (9.9%) stillbirths among the first and the second babies respectively. Babies that had normal birth weight constituted 42.2%. The male to female ratio was 1:1.15. Conclusion: The rate of twin deliveries in our centre is high. There is also associated high rate of maternal complications and adverse perinatal outcomes.
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A comparison of oral versus vaginal misoprostol for induction of labor at term, at the Ahmadu Bello University Teaching Hospital, Zaria p. 189
S Umar Hauwa, SO Shittu, Hajaratu Umar-Sulayman, BM Audu
DOI:10.4103/TJOG.TJOG_27_19  
Background: The comparison of same,equal and low dose of misoprostol by the oral and vaginal routes for induction of labour at term requires further elucidation. Objective: To compare the efficacy and safety of 25 micrograms (ug) of oral misoprostol with 25ug vaginal misoprostol for induction of labor at term. Methods: A randomised control trial that involved 169 consented women with indication for induction of labor. A total of 85 women had oral misoprostol while 84 women had vaginal misoprostol. The oral misoprostol dose (25ug) was repeated every 2 hours, while the vaginal dose (25ug) was repeated every 6 hours for a maximum duration of 24 hours or when need arose for intervention. Data was analysed using SPSS version 20. Results: The mean induction-delivery interval was significantly shorter (18.48 +/- 2.01 vs. 22.82 +/- 2.50, P = 0.00), with more vaginal deliveries (88.2% vs. 85.7%, P = 0.00) in the oral group compared to the vaginal group respectively. The cardiotocographic abnormalities in the vaginal group were significantly higher than the oral group (8.3% vs. 1.2%, P = 0.03). There were more foetal distress and meconium stained liquor in the vaginal group but not statistically significant.
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Misoprostol versus oxytocin in preventing postpartum hemorrhage: A randomized controlled trial p. 196
OO Owa, AS Lemadoro, BA Temenu, JA Ayeyemi, OM Loto
DOI:10.4103/TJOG.TJOG_16_19  
Objective: To compare low dose sublingual misoprostol with the standard 10 IU of intramuscular oxytocin in active management of third stage of labor. Materials and Methods: A total of 104 women with term pregnancy were randomized to receive either 200 μg misoprostol sublingually or 10 IU oxytocin intramuscularly after vaginal delivery. Primary outcome measured was mean blood loss and incidence of primary postpartum hemorrhage (PPH). Secondary outcome measured included duration of third stage of labor, side effects of drugs and need for additional oxytocics to treat life-threatening hemorrhage. Results: A total of 104 women with term pregnancy in two groups of 52 were studied. The mean blood loss with sublingual misoprostol and oxytocin groups was 320.58 ± 244.12 vs. 253.27 ± 171.74 ml; P = 0.11. There was no significant differences between the misoprostol and oxytocin groups with regard to the incidence of PPH (19.2% vs. 13.5% respectively; P = 0.43). More women in the misoprostol group experienced side effects compared with those in oxytocin group; however, the difference was not statistically significant (P = 0.26). The mean duration of third stage of labor was similar and the difference was statistically not significant (6.65 ± 3.47 vs. 6.08 ± 3.07 minutes) (P = 0.38), as well as need for additional oxytocics (13.5% vs. 5.8% P = 0.18) misoprostol and oxytocin, respectively. Conclusion: Sublingual misoprostol has similar efficacy to standard intramuscular oxytocin in preventing PPH following vaginal birth. Misoprostol at 200 μg with its thermostability may be an effective alternative to intramuscular oxytocin in active management of third stage of labor.
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Determinants and outcomes of elective and emergency caesarean section at a tertiary hospital in Abakaliki, Southeast Nigeria: A 6-year review p. 200
Obiora Godfrey Asiegbu, Uzoma Vivian Asiegbu, Emmanuel Johnbosco Mamah, Chidebe Christian Anikwe, Onwe Emeka Ogah, Ugochukwu Uzodimma Nnadozie
DOI:10.4103/TJOG.TJOG_19_19  
Background: Despite its increasing acceptance as a safe alternative to vaginal delivery, caesarean section (CS) in developing countries continue to be associated with maternal and fetal morbidity and mortality. Objectives: This study was aimed at evaluating the indications, outcomes and factors associated with increased CS at the Federal Teaching Hospital, Abakaliki. Methods: This was a six year retrospective study covering 2012 to 2017. Case notes of patients were identified and retrieved from the records unit of the hospital. Information extracted include sociodemographic variables, indications and types of CS performed and the complications. These data were entered into a personal computer and analysed with Epi Info version 7. Results: These were presented using tables and percentages. A p-value of 0.05 was considered significant. In 6 years, 11,215 women were delivered, 2405 (21.4%) had emergency CS while 1445 (12.9%) had elective CS; giving a CS rate of 34.3%. The most common indication for emergency CS was cephalopelvic disproportion (22.0%) while previous caesarean section (27.7%) formed the major indication for elective CS. Severe birth asphyxia was recorded in 17.2% and 4.2% of babies delivered by emergency and elective CS respectively. Booking status, parity and patient's age had statistically significant association with the chance of having a CS. Maternal and perinatal deaths were recorded in 2.6% and 5.0% for emergency CS compared to 1.0% and 0.2% for elective CS. Although lifesaving, CS, due to an existing condition or complication in the patient, may be associated with an increase in maternal and fetal morbidities and mortalities. Conclusion: There was a higher burden of complication with emergency CS due to its associated determinants. Adequate training of healthcare personnel on ways of minimizing complications against the backdrop of an existing problem and an efficient referral system will help reduce these morbidities and mortalities.
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Outcomes of induction of labor with mature and premature amniotic fluid optical density (AFOD): A preliminary case control study p. 206
Hemmanur Samartha Ram, IS Samyuktha, Vasudeva Nagasree
DOI:10.4103/TJOG.TJOG_90_18  
Background: Onset of spontaneous labor occurs on completion of fetal functional maturity at amniotic fluid optical density (AFOD) value 0.98 ± 0.27 (Mean ± SD). All three events occurring together at any time from 35 to 42 weeks indicate individual term for each fetus. Babies born with AFOD ≤0.40 are functionally premature and develop varying degrees of respiratory distress syndrome (RDS). In this study, we tested the hypothesis, labors with AFOD 0.98 ± 0.27 are functionally mature with well-established labor cascades and may respond well t o induction. On the other hand, labors with AFOD ≤0.40 are functionally premature with poorly established labor cascades and may not respond well t o induction. Methods: In this gestational age and parity-matched case control study, cases consisted of 36 uncomplicated singleton laboring women who delivered normally with premature (≤0.40) AFOD values. Controls consisted of 36 similar laboring women who delivered normally with mature AFOD (0.98 ± 0.27) values. Uncentrifuged fresh AF samples collected at amniotomy were used for OD measurement with colorimeter at 650 nm. Women were assigned to groups based on AFOD values. In both groups, labor was induced with vaginal T. Misoprostol 25 mcg 6 hourly up to 4 doses. Labor outcome measures; Bishop score at induction, induction- delivery intervals (IDI), induction failures, number of T. Misoprostol required, presence of fetal distress, RDS, and NICU admission days were recorded in both groups and compared. Results: Median Bishop scores at induction in cases and controls were 5.0 (IQR 4.25--6), 7.0 (IQR 6--8), respectively. Median IDI in cases and controls were 18 h (IQR 12.25--21.5 h) and 7.0 h (IQR 5--9.5 h), respectively. Number of induction failures in cases and controls were 8 and 0, respectively. Outcomes of Induction of labor with…. Statistically significant differences observed in all these outcomes between groups (P = 0.00) favoring inductions with mature AFOD. Conclusion: Labor induction with mature AFOD value was successful in all women with shorter IDI and with better perinatal outcomes.
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Maternal death surveillance and response system in Northern Nigeria p. 212
S Ochejele, J Musa, MJ Abdullahi, P Odusolu, DI Attah, G Alobo
DOI:10.4103/TJOG.TJOG_73_18  
Introduction: The maternal death surveillance and response (MDSR) responds to MDG 5 and Sustainable development goal 3. It was designed to achieve this goal by obtaining and strategically using information to guide public health actions and monitoring their impact. Objective: To determine the burden and avoidable causes of maternal mortality in midwives service scheme (MSS) communities in Northern Nigeria. Methodology: This was a cross-sectional study using baseline MDSR data on confidential enquiry into maternal deaths in all health facilities and their host communities under the MSS in Northern Nigeria from July 1st to December 31st, 2011. Results: The MMR was 181/100,000 live births. Most (80.9%) of the deaths were due to direct obstetric complications with obstetric hemorrhage and eclampsia accounting for 66.6% of the deaths. Most deaths occurred postpartum (93.6%) with the first 48 h accounting for 85.1% of cases. At presentation, 76.5% were in critical conditions. The TBAs conducted 50.0% of the deliveries. Delays in decision making contributed to 51 (63.8%), delay in arriving at the facility accounted for 48 (60.0%), financial constraints 28 (35.0%), unsafe traditional practice 27 (33.8%), and use of traditional medicines 22 (27.5%). The TBA failed to refer early in 42 (52.5%), failed to recognize dangers signs in 27 (33.8%). Stillbirths occurred in 22.2% of cases. Conclusion: Most maternal deaths in Northern Nigeria are preventable. Operational research using the MDSR is very useful in determining the causes and designing appropriate response to maternal deaths at the community level in Nigeria.
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Maternal side effects of efavirenz-containing highly active antiretroviral therapy (HAART): A comparative study of HIV-positive pregnant and nonpregnant women in a tertiary hospital p. 218
Kayode Makinde, BO Okusanya, OR Akinajo
DOI:10.4103/TJOG.TJOG_1_19  
Background: Efavirenz is now a first-line non-nucleoside reverse transcriptase inhibitor used as highly active antiretroviral therapy (HAART) though its use is fraught with maternal side effects, usually of the central nervous system (CNS) and fetal complications. Objective: The study aims to comparatively document the maternal side-effect profile of an efavirenz-containing fixed-dosage HAART and compliance with its use in HIV-positive pregnant and nonpregnant women at the Lagos University Teaching Hospital (LUTH), Idi-Araba. Methodology: A prospective study among HIV-positive pregnant (40) and nonpregnant women (40) on efavirenz-containing fixed-dose HAART (Atripla®) who were recruited purposively at the antenatal clinic and AIDS Prevention Initiative Nigeria (APIN) clinics of LUTH. Data analysis was done with EPI Info 2014, and the results are presented in frequencies. Results: The mean age of respondents was 31 ± 5.7 years. Atripla® was the only fixed-dose combination used. Fifty-three percent and 62.5% of pregnant and nonpregnant HIV-positive women, respectively, reported CNS side effects of Atripla® [odds ratio: 0.66, 95% confidence interval 0.27–1.62]. Adherence to the use of Atripla® was 100% among HIV-positive pregnant women. Women with baseline viral load values greater than 400 copies/mL reported more side effects to Atripla®. Conclusion: There are similar side-effect profiles of Atripla® in HIV-positive women irrespective of pregnancy. Education and counselling can help foster adherence, resulting in improved immunological and virological outcome.
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The prevalence of syphilis in pregnant women in Akwa Ibom State, Southern Nigeria p. 224
CA Opone, AM Abasiattai, MN Utuk, EA Bassey
DOI:10.4103/TJOG.TJOG_97_18  
Background: Treponema pallidum, the causative organism of syphilis has been a public health challenge for centuries. Syphilis is a significant cause of morbidities and mortalities in pregnant women, and information regarding its prevalence in Nigerian pregnant women is scanty particularly from the south-south zone. Objective: To determine the prevalence of syphilis in women receiving antenatal care in twelve health care centres in Akwa Ibom State, Nigeria. Methodology: Pre-coded structured questionnaires were administered to 911 participants over an eight week period. Venous blood samples were collected from each participant and tested with a Treponema pallidum immunochromatographic test. Results: There were about 18 women (1.98%) tested positive to syphilis. Prevalence rates in urban and rural areas were 2.63% and 1.32% respectively. The women from urban areas had a 3.22 (95% CI 1.05-9.85) increased risk of acquiring syphilis when compared to the rural dwellers. Women with tertiary level of education had a significantly reduced risk of acquiring syphilis compared to those with primary level education while having an unemployed husband increased the risk of acquiring the infection by 10 times. Conclusion: Though VDRL is part of routine antenatal care screening, a policy of its use in the screening of all women receiving antenatal care in Akwa Ibom state should emphasized and it should be incorporated into the state Government's free antenatal care program. Preferably, a single rapid test should be employed for screening, so that women testing positive could be treated at same clinic visit. Economic empowerment of women should be accorded priority and the practice of safe sex and use of contraception, especially barrier methods should be promoted.
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Knowledge and practice of HIV testing for PMTCT among antenatal clinic attendees p. 232
TA Irinyenikan
DOI:10.4103/TJOG.TJOG_96_18  
Background: Mother-to-child transmission (MTCT), is the main route of paediatric human immunodeficiency virus (HIV) infection. While paediatric HIV has been virtually eliminated in most developed countries with structured interventions, many developing countries still record high transmission rates. Maternal knowledge on MTCT is a corner stone for effective implementation of the World Health Organization (WHO) recommendation of the four-pronged approach to reduce mother-to-child transmission of HIV. Aims and Objectives: The study was carried out to assess the knowledge of prevention of mother-to-child transmission (PMTCT) of HIV among our pregnant women as well as their attitude and practice of HIV counselling and testing. Methodology: The study population included pregnant women attending antenatal clinic at the State Specialist Hospital, Akure, Ondo State. It was an institutional based descriptive cross-sectional study conducted over a period of one month (May 2018). Systematic random sampling technique was used to select 400 pregnant women. Data was obtained using structured pre-tested questionnaire, and analysed using SPSS Windows 20. Results: The study showed that majority were between 30-39 years, were educated, and married. Among the respondents, 389 (97.3%) have heard about HIV while 11 (2.8%) have not heard about HIV. Overall 85.3% of the respondents had a good knowledge of HIV and its mode of transmission. Among the women, 83% were aware of mother-to-child-transmission of HIV with the information mostly obtained from health workers. Only 252 (63.2%) had been tested for HIV in this pregnancy while 148 (36.8%) were not yet tested with many of them blaming this on lack of counsellors. On multivariable analysis, younger women were more knowledgeable about HIV and MTCT, those who were public servants and had partners educated to tertiary level were more likely to practice PMTCT. Conclusion: The knowledge of HIV and PMTCT was high among the women. However, not all the women were tested for HIV in the index pregnancy as a result of lack of counsellors. Adequate counsellors are essential for effective PMTCT programme.
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Unwanted pregnancy and induced abortion among female undergraduates in University of Ibadan, Nigeria p. 238
Chinedum A C Onebunne, Folasade A Bello
DOI:10.4103/TJOG.TJOG_35_19  
Objectives: To assess the prevalence of unwanted pregnancies and induced abortion among female undergraduates. Methodology: A cross-sectional survey was conducted among female undergraduates in University of Ibadan, Nigeria. The survey used a structured, self-administered questionnaire. Data analysis was conducted using Statistical Package for the Social Sciences version 20 with Chi-square and t-tests. Statistical significance was set at P < 0.05. Findings: The mean age of the participants was 20.3 (±2.7) years and 80% were single at the time of the study. The prevalence of induced abortion was 51%. The overall prevalence of unwanted pregnancy was 17%, and 92.7% of students who had ever been pregnant had considered the pregnancy unwanted. Only 7.3% reported willingness to be pregnant while engaged and 58.3% were unwilling to keep pregnancy if engagement ends. Unwanted pregnancy was less among those ever married (χ2 = 49.96, P < 0.001), and more of the induced abortions were found in the unmarried group albeit not statistically significant (χ2 = 0.21, P = 0.640). Unwanted pregnancy occurred more during the engaged period than any other time, which was statistically significant (χ2 = 20.24, P < 0.001), although no significant difference in induced abortion was found. Conclusion: The prevalence of unwanted pregnancy and induced abortion is high especially among university undergraduates. As it appears to happen more often while they are engaged, unprotected sex during the engagement period needs to be targeted.
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Relationship between 25-hydroxyvitamin D and ovarian reserve in premenopausal Nigerian women p. 243
CC Makwe, Z Aliyu
DOI:10.4103/TJOG.TJOG_99_18  
Context: Despite the increasing knowledge about the potential effect of vitamin D deficiency on ovarian reserve of premenopausal women, the burden of this disorder among 'at risk' women in sub-Saharan Africa is notably scanty. Aims:
  • To determine the prevalence of vitamin D deficiency among premenopausal Nigerian women
  • To assess the relationship between serum 25-hydroxyvitamin D [25(OH)D] and serum anti-mullerian hormone (AMH).
Settings and Design: A prospective cross-sectional study of 218 premenopausal Nigerian women, attending a tertiary hospital in Lagos. Materials and Methods: Serum levels of 25(OH)D and AMH were assayed using ELIZA technique, for each eligible participant. Statistical Analysis Used: To determine the association between serum vitamin D and serum AMH were Kruskal-Wallis test and Pearson's correlation coefficient. Data analysis was performed on 211 participants with complete data. Results: The mean (± SD) concentrations of serum 25(OH)D and AMH were 37.8 (± 21.4) ng/ml and 1.6 (± 0.6) ng/ml, respectively. The proportion of study participants with serum vitamin D deficiency, insufficiency and sufficiency were 18.5%, 24.6%, and 56.9%, respectively. There was no statistically significant difference in the mean serum AMH among participants with deficient, insufficient, and sufficient vitamin D levels (1.41 ng/ml versus 1.56 ng/ml versus 1.59 ng/ml, P value = 0.539). Overall, there was no correlation between serum 25(OH)D, and serum AMH (r = 0.056, P > 0.05). Conclusion: Although the proportion of women with subnormal levels of serum vitamin D was relatively high, there was no association between serum levels of vitamin D and AMH.
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The incidence of retained fetal bones after 1,002 hysteroscopies in an environment with restrictive abortion laws p. 249
Jude Okohue
DOI:10.4103/TJOG.TJOG_91_18  
Background: Retained fetal bones within the uterine cavity are rare. The incidence in an environment with restrictive abortion laws is however unknown. Aim: To document the incidence of retained fetal bones in an environment with highly restrictive abortion laws. Methods: Case records of patients who had hysteroscopy on account of retained fetal bones from April 1, 2010 to March 31, 2017 were retrieved. Data including age, number of terminations of pregnancy, gestational age at termination of pregnancy, duration of infertility, and treatment outcome were retrieved. Results: A total of 1,002 patients had hysteroscopy for various indications. Of these, 26 patients had retained fetal bones giving an incidence of 0.26%. The age range of the patients was 28--42 years, mean 34.7 ± 4.6 SD. Duration of infertility ranged from 2 to 8 years, mean 4.6 ± 2.3 SD. The number of terminations of pregnancy ranged from 1 to 6, mean 2.6 ± 1.7 SD. One patient had an unexplained intrauterine fetal death of one of a set of twins at 20 weeks gestation with subsequent elective cesarean section at 37 weeks gestation. All the cases had histological confirmation of fetal bones. Of the 24 patients who had secondary infertility, 6 (25.0%) achieved spontaneous pregnancies. Eight women underwent in vitro fertilization treatment with 2 (25%) clinical pregnancies. Conclusion: The incidence of intrauterine retained fetal bones in our environment with highly restrictive abortion laws is 0.26%. A review of these laws is probably long overdue.
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Psychosocial characteristics of infertile women in a Nigerian tertiary hospital p. 252
AO Olarinoye, PO Ajiboye
DOI:10.4103/TJOG.TJOG_54_18  
Introduction: High premium is placed on childbirth particularly after marriage in our society. Sub-Sahara Africa is known to have the high incidence of infertility and the woman is usually blamed for the problem. Stress is known to have effect on ovulation and therefore conception thereby forming a vicious cycle. The study was to determine the psychosocial problems and psychiatric morbidity among infertile women and to determine the difference in psychosocial problems in primary and secondary infertility patients. Method: The Satisfaction with Life Scale (SWLS) questionnaire, the 12 -item General Health Questionnaire (GHQ-12) and the HADS (Hospital Anxiety and Depression Scale) were administered to 111 patients. Result: The mean age for the respondents was 33.6 ± 5.8 years. There were more cases of secondary infertility 58 (52.3%) compared to primary fertility 53 (47.7%). The study revealed a fairly high degree of psychological morbidity among the respondents, a depressive rate of 39.6%, anxiety rate of 48.6% and psychiatry morbidity of 39.6%.There was no significant difference in prevalence of these morbidity between the patients with primary and secondary infertility. Conclusion: Both primary and secondary infertility are associated with significant psychosocial and psychiatric morbidity. Psychological strain itself can also be a cause or aggravate infertility therefore psychological assessment and co-management with the psychiatrist should be encouraged.
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Effect of honey and intensity of swimming exercise on semen parameters of male albino Wistar rats p. 258
HM Abdullahi, MK Atiku, Y Abdulmumin, WH Sadiya
DOI:10.4103/TJOG.TJOG_5_19  
Background: The impairment of male fertility has been linked to exercise in a volume-, intensity-, and modality-dependent manner. Infertility is a worldwide problem and male factor infertility is found to be increased. Chronic administration of honey results in elevating sorbitol dehydrogenase activity and decreases lactose dehydrogenase activity, which was found to be in abundance in spermatids and spermatozoa, and a decrease in this enzyme significantly affects the semen parameters and decreases ATP synthesis due to oxidative stress. Objective: The study aimed to evaluate the effect of honey and intensity of swimming exercise on semen parameters of male albino Wistar rats. Methodology: A randomized control trial study was adopted involving 50 sexually mature male Wistar rats (180 ± 20 g). The selected rats were divided into five groups of 10 rats each: group I served as normal control while group II was induced with honey only and served as study control. Groups III–V were study groups induced orally with 7.5 mL/kg of honey twice per week for 8 weeks and exposed to mild, moderate, and high-intensity swimming exercises 5 days/week for 8 weeks, respectively. Results: Chronic oral administration of pure honey showed that motility, viability, sperm count, and semen morphology were significantly lower, and percentages of abnormal morphology were found to be significantly higher (P < 0.05) in group II compared with normal control rats (group I). There was a significant decrease in motility, viability, and morphology in group V when compared with groups I, III, and IV. However, they were significantly higher when compared with test control group. The decrease was found to be swimming exercise time-dependent. Conclusion: Chronic consumption of pure honey has a deleterious effect on semen parameters, and mild, moderate, and intensity swimming exercises were found to have a positive effect of induced semen parameters of male albino Wistar rats.
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Correlation between transabdominal ultrasound features of ectopic gestation and surgical findings at the university college hospital, Ibadan: A preliminary review p. 265
GO Obajimi, AE Smart, AJ Adekanmi, A Adeniji-Sofoluwe, FO Jinadu
DOI:10.4103/TJOG.TJOG_39_18  
Introduction: Ectopic pregnancy in Sub-Saharan Africa has an incidence of 1%-5% of all deliveries and 5%-10% of all gynaecological admissions. The fallopian tube is the most common site of occurrence of an ectopic pregnancy and ruptured ectopic is the commonest variety seen in low resource settings. Materials and Method: This is a 2-year retrospective diagnostic accuracy test of transabdominal ultrasonographic findings in ectopic pregnancy, using surgical findings as the gold-standard. The study was conducted at the Radiology Department of the University College Hospital, Ibadan, Nigeria between 1 January 2013 and 31 December 2014. Radiological request cards of 41 women who were clinically suspected to have an ectopic pregnancy and had a transabdominal ultrasound scan were retrieved, however, only 34 were suitable for analysis. Data analysis was done using the Statistical Package for Social Sciences (SPSS) version 20 (Chicago, IL, USA). A P value of <0.05 was regarded as statistically significant. Results: The ages of the women ranged between 20 and 40 years with a mean age of 29.94 ± 5.06 years. The mean gestational age at time of scan was 44.8 days (6 weeks + 3 days). Out of 34 patients reviewed in this study, 29 had surgical interventions in the course of their management and 26 had ectopic gestation confirmed at surgery. This study found a Sensitivity of 88.4%, Specificity of 37.5% and Positive and Negative predictive values of 82.1% and 50%, respectively. Conclusion: This preliminary study suggests that transabdominal ultrasonography is a useful and reliable means of diagnosing ectopic pregnancy particularly in low-resource settings where availability and or technical skill for transvaginal ultrasonography is not readily available.
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Awareness and knowledge of cervical cancer and its screening methods among women attending primary healthcare centers in Zaria, North-Western, Nigeria p. 271
A Yahya, AT Mande
DOI:10.4103/TJOG.TJOG_26_19  
Background: Cervical cancer is a leading cause of cancer death in many developing countries. Cervical cancer can be prevented by screening and treatment of premalignant lesions of the cervix. Primary healthcare centers are the health centers closest to the grassroots in Nigeria and thus may be appropriate for population-based cervical cancer screening programs. This study sought to assess awareness of cervical cancer and its screening methods among women attending primary healthcare centers in Zaria, Nigeria. Methodology: It was a cross-sectional study. Participants were women accessing healthcare in primary healthcare centers in Zaria. Eight primary healthcare centers in Zaria were purposively selected for the study. Data were obtained by focus group discussions (FGDs). The FGDs were tape-recorded and transcribed verbatim. The transcripts obtained were analyzed into themes based on the objectives of the study. Results: The mean age of respondents was 26 years (standard deviation 4.9 years). Many participants were aware of symptoms of cervical cancer; however, they were not aware of the risk factors. Pap smear was the only screening method known to participants. Conclusion: Awareness of cervical cancer and cervical screening did not reflect adequate knowledge about cervical cancer and screening methods. There is a need for healthcare providers to offer adequate health education about the disease and screening methods.
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Pregnancy and prosthetic heart valves: A case series p. 277
B Barnali, S Ranjan
DOI:10.4103/TJOG.TJOG_68_18  
Objectives: To assess the problems faced by pregnant women with prosthetic cardiac valves in terms of maternal and neonatal outcomes. Settings: Tertiary-level teaching hospital. Population: All pregnant women with prosthetic cardiac valves visiting the hospital in the period between January 2008 and September 2012. Method: Retrospective observational case series study. Results: Among the women presenting for antenatal visits to the hospital in the study period, eight were found to be have prosthetic cardiac valves. All cases had rheumatic origin of their cardiac lesion. Five cases had a mitral valve replacement. One had aortic and two had double-valve replacement. All patients had mechanical valves and were on anticoagulant regimen. Among them, one patient developed valve thrombosis and another developed embolic transient ischemic attack while in labor. Two patients developed symptomatic arrhythmia requiring treatment, while one patient had pneumonia with parapneumonic effusion. Three cases had abortions, while the other five pregnancies delivered live babies. All deliveries took place by lower segment Caesarean section (LSCS) for indications other than the cardiac condition. One pregnancy was complicated by intrauterine growth restriction and oligohydramnios. No patient developed any complications during the LSCS. There were no cases of warfarin embryopathy observed. Conclusion: Maternal complications tend to be higher in pregnant women with prosthetic cardiac valves requiring strict adherence to anticoagulant regimens and specialized treatment in tertiary care centers.
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Menstrual health management: Knowledge and practices among adolescent girls p. 283
R Khatuja, S Mehta, B Dinani, D Chawla, S Mehta
DOI:10.4103/TJOG.TJOG_93_18  
Objectives: To assess the knowledge and attitude of adolescent girls regarding menstruation and menstrual hygiene. Material and Methods: After approval by the ethical committee , the study was conducted on 340 adolescent girls aged 12-19 years, belonging to an urban slum area of Delhi. This was a questionnaire based cross-sectional study conducted over a period of 9 months in a tertiary hospital. Confidentiality of the subjects was ensured. Results: Out of 340 girls 69 % were between 16-19 years. Source of information about menstruation in majority of the cases was mother (60%). Only 48% girls knew menstruation before menarche and 24% girls knew uterus as the organ for menstruation. 71 % girls used sterile sanitary napkins as absorbent. Satisfactory changing of pads (>2pads/day) was done by 68 % and 77% girls cleaned the genitalia satisfactorily (>2 times/day). 41% girls were aware of the fact that unhygienic use of pad could be a source of genital infection and 8% girls had associated vaginal discharge. Social restrictions during menses in the form of religious activities, drop out from school, avoiding certain foods etc were practiced in many families. Conclusion: Although the menstrual practices appear to be satisfactory in major percentage of girls but knowledge regarding menstrual hygiene is worrisome, as maximum girls are unaware of menarche and physiology of menstruation. Inclusion of such information in the school curriculum and wider coverage in mass media will help to bridge this gap.
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Pattern of birth defects at a university teaching hospital in Northern Nigeria: Retrospective review over a decade p. 287
IU Takai, SA Gaya, MT Sheu, M Abdulsalam
DOI:10.4103/TJOG.TJOG_28_19  
Background: Major birth defects are common causes of perinatal morbidity and mortality which have become a global phenomenon. Its occurrence in the developing nations like Nigeria requires due consideration most especially to its pattern and risk factors. Objectives: This review was conducted to determine the pattern of birth defects and investigate the factors associated with birth defects and its outcome at Aminu Kano Teaching Hospital (AKTH), Kano. Methods: This was a 10-year retrospective study conducted in the Department of Obstetrics and Gynaecology and the Department of Paediatrics (Special Care Baby Unit) of AKTH, Kano, between April 2007 and March 2017. Data retrieved from patients' file were collected using a purpose-designed proforma to obtain information on the required parameters and analyzed using IBM SPSS version 20, 2009 software. Frequencies and percentages were calculated and the results were presented in tabular forms. Results: There were 6990 deliveries within the study period, out of which 305 babies had birth defects, giving a prevalence of 4.4%. Among women who delivered baby with birth defects, maternal age ranged from 16 to 45 years with a mean age of 30 ± 5 years. The highest incidence (48%) of birth defects occurred among the 26–35 years age group. Anomalies that affected single system are significantly higher than anomalies that affected multiple systems. A higher percentage (52.5%) of birth defects occurred in male neonates. The gastrointestinal system was the most commonly affected (32.5%), while musculoskeletal system was the least (3.75%) affected system. Drug intake among 120 mothers who delivered neonates with birth defects when considered as a risk factor was found to constitute 81% of traditional concoction/herbs; while 12.5% were orthodox and intake of social drug was found to be only 6.5%. Hypertension was found to be the highest chronic medical disorder, while chorioamnionitis following premature rupture of membrane was recorded as the most commonly occurring maternal infection. Sixty percent of these neonates with birth defects were managed conservatively, surgical treatment was given in 23.5%, while 16.5% underwent medical treatment. Discharge rate was 82.5%; 9% left against medical advice, while neonatal mortality rate was about 8.5% and a majority (91.8%) of the death occurred among the neonates with multiple birth defects. Conclusion: The prevalence of birth defect in AKTH was 4.4% of the total deliveries over the study period. Gastrointestinal system was found to be the most commonly affected system. Hypertensive disorders of pregnancy and ingestion of traditional herbs were found to be the most common medical disorder and drug intake, respectively, among the mothers who delivered neonates with birth defects. Although the outcome of the management was good, and the study could not establish direct causation, there is need to counsel mothers on the inherent dangers of traditional herbs ingestion and the need to pay adequate attention to medical conditions in pregnancy.
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Risk factors of prelabor rupture of membranes at University of Maiduguri Teaching Hospital, Maiduguri: A cross-sectional study p. 293
ZM Lawan, B Bako, A Idrisa, M Bukar, GB Gadzama
DOI:10.4103/TJOG.TJOG_51_19  
Background: Prelabor rupture of membranes (PROM) is a common obstetrics problem associated with maternal and perinatal morbidity and mortality. Patients and Methods: This was a hospital-based cross-sectional study to determine the risk factors for PROM among women presenting to the Department of Obstetrics and Gynecology of the University of Maiduguri Teaching Hospital, Maiduguri. It was conducted between 1st May 2016 and 28th February 2017. Sociodemographic and obstetrics variables were obtained from the patients, and risk factors such as previous preterm delivery, previous PROM, miscarriages, fever, abnormal vaginal discharge, urinary tract infection, abdominal distension, trauma, and coitus were sought. For each patient, an endocervical swab, high vaginal swab, and urine samples were taken for microbacteriologic studies. The next patient without PROM is used as control. Data were analyzed using SPSS 20. A total of 258 (129 with PROM and another 129 without PROM) were analyzed. Results: The mean age, gestational age, and parity were 27 ± 6 years, 33 ± 0.3 weeks, and 1 ± 0.92, respectively. A majority of the women (55%) had parity between 1 and 4. Term PROM recorded the highest frequency [49 (37.9%)]. Previous history of PROM [odds ratio (OR) 5.18, 95% confidence interval (CI): 2.31–11.62], history of Preterm Delivery (OR 3.26, 95% CI: 1.16– 9.19), low socioeconomic status (OR 1.95 95%, CI: 1.15–3.31), and genitourinary infection are highly predictive of PROM. Conclusion: The modifiable or treatable risk factors should be addressed during the antenatal care to reduce the risk of PROM. High-risk patients should be counseled and monitored closely to optimize pregnancy outcomes.
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CASE REPORTS Top

Conjoined twin presenting as a case of “hanging breech” in labor – Case report p. 299
CH Laima, TB Meller, G Nwukwa
DOI:10.4103/TJOG.TJOG_29_19  
Conjoined twin is a rare phenomenon. This is a report of suspected undiagnosed bicephalus conjoined twin that presented as hanging breech which was delivered by craniotomy. It presented with management challenge, from attempted home delivery to a primary healthcare facilty and finally refered to the Specialist Hospital. The diagnosis was made after delivery. The finding was a male stillborn infant with normal body parts but two heads. Clinicians should look out for these complications when confronted with hanging breech.
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Traumatic transperineal delivery, a tragedy in unassisted vaginal delivery: A case report and review of literature p. 301
A Rabiu, ZD Ahmed, AI Yola
DOI:10.4103/TJOG.TJOG_94_18  
Transperineal delivery is a traumatic childbirth whereby the baby is forcefully ejected out through a contraction and pushing-induced laceration of the perineum in the presence of intact vaginal and anal orifices. We presented a 23-year-old primipara who presented 3 days after delivery with infected perineal injury and pains following unsupervised childbirth. She delivered a fresh stillborn baby through the perineum (between the fourchette and the anal orifice). She was, however, continent of urine and feces. She was optimized and repair of the perineal injury was scheduled after puerperium. The postoperative condition was satisfactory. We therefore call and appeal on the relevant stakeholders, to provide more skilled birth attendants, especially at the densely populated areas and ensure their presence and willingness to participate in conducting all deliveries with good supervision in all health facilities, so as to prevent future occurrence of transperineal delivery.
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Clinical improvement of status epilepticus after delivery: A case report p. 304
Chinedu G Obikili, Makshwar L Kahansim, Amaka N Ocheke
DOI:10.4103/TJOG.TJOG_2_19  
Status epilepticus is a rare neurological complication of pregnancy, associated with significant maternal and fetal morbidity and mortality. Termination of pregnancy is not currently a management strategy. The clinical case was 35-year-old known epileptic presented with complaints of multiple convulsions of 2 days and loss of consciousness of a day. On examination, she was unconscious, with Glasgow Coma Scale 5/15, having repeated seizures, and blood pressure was normal. The assessment was status epilepticus and she was shortly admitted into the intensive care unit. She was eventually paralyzed and put on mechanical ventilation. She had a spontaneous delivery, subsequently improved, and was discharged on oral carbamazepine. Key aspects of this patient's management buttressed that status epilepticus can mimic eclampsia. That she significantly and progressively improved following delivery and that previous similar cases have been reported brings to bear that delivery might need to be considered as a management strategy for refractory status epilepticus.
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Angiomyofibroblastoma: Imaging and histopathology of a rare benign mesenchymal tumor p. 308
AR Kulkarni, Mohammed Ashfaque Tinmaswala, SV Shetkar, S Kondekar
DOI:10.4103/TJOG.TJOG_79_17  
Angiomyofibroblastomas, aggressive angiomyxomas and cellular angiofibromas are rare mesenchymal tumours with many overlapping radiological, histopathological and immunohistochemical features. Amongst these tumours angiomyofibroblastoma is relatively benign mesenchymal tumour with very low chances of recurrence. It is clinically confused with bartholin gland cyst due to its well demarcated and smooth appearance. Due to overlapping histopathological features its very difficult even for experienced pathologists to differentiate between these mesenchymal tumours. Earlier desmin reactivity was thought to be specific for angiomyofibroblastoma but recently many aggressive angiomyxomas have also been found to be positive for desmin. Ultrasound, computed tomography and magnetic resonance imaging may be useful in diagnosis and ruling out more sinister malignancies. A well demarcated lesion with characteristic histopathological appearance of alternating hypo and hypercellular edematous regions with abundant blood vessels and stromal cells with dispersed chromatin is usually seen in angiomyofibroblastoma. Immunohistochemistry may further help in diagnosis. We here report a case of vaginal angiomyofibroblastoma. The diagnosis was made on the basis of imaging and was confirmed by histopathology and immunohistochemistry.
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Endometriosis with massive recurrent hemorrhagic ascites: A case report p. 312
Edouard N'guessan, N'goran Kouamé, Franck Gbeli, Privat Guie
DOI:10.4103/TJOG.TJOG_9_19  
Ascites is a rare manifestation of endometriosis. The case reported is that of a 26-year-old woman with recurrent massive hemorrhagic ascites. The analysis of biopsy specimens made at laparoscopy confirmed the diagnosis. The report noted pelvic endometriosis associated but there was no umbilical or pleural involvement. The evolution was favorable under a long term hormone treatment (by GnRH analogues) with relay through continuous estrogen-progestogen. The diagnostic and therapeutic difficulties of this rare form of endometriosis are presented through a review of the literature.
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A stone age conduct of unsafe abortion in adolescent: Complicated by gangrenous uterus and bowel p. 315
BA Olofinbiyi, JT Ige, OD Olaogun, OO Alao, OA Adewumi, RO Olofinbiyi
DOI:10.4103/TJOG.TJOG_15_19  
Unsafe abortion in adolescents is of great public health challenge and it occupies a large armamentarium in contemporary adolescent reproductive health issues. This case report was that of induced unsafe abortion, done without analgesia and inside a sitting room, in a 15-year-old, secondary school girl, nullipara; complicated by gangrenous uterus and bowel for which she had subtotal hysterectomy, bowel resection, and anastomosis. Primary preventive strategies should be the cornerstone of prevention with more emphasis on advocacy for adolescent sexuality and reproductive health education, information, and family planning/emergency contraception.
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