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   Table of Contents - Current issue
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January-April 2020
Volume 37 | Issue 1
Page Nos. 1-217

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EDITORIAL  

Ovarian cancer: An undertreated and understudied entity in sub Saharan Africa Highly accessed article p. 1
Adepiti Clement Akinfolarin
DOI:10.4103/TJOG.TJOG_28_20  
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REVIEW ARTICLES Top

Improving undergraduate medical education in Nigeria: Insight into the past p. 3
Akinyinka O Omigbodun
DOI:10.4103/TJOG.TJOG_62_19  
The first three in the series of Society of Gynaecology and Obstetrics of Nigeria (SOGON) lectures on “Frontiers in Medical Education,” in honor of Professor Linus Ajabor, had focused on internship and postgraduate medical education. This fourth lecture is about the evolution of undergraduate medical education in Nigeria from its rudimentary beginning in 1930 to the present. Lessons from the past include the desirability of tailoring medical education toward meeting national needs, doing proper needs assessment before planning and implementation, setting minimum standards for training institutions, and enforcing these standards through a credible process of accreditation. Recommendations for the future include a harmonization of the guidelines on minimum standards published by the Medical and Dental Council of Nigeria (MDCN) and the minimum academic standards published by Nigeria's National Universities Commission (NUC), and the conduct of joint accreditation by both agencies to maximize efficiency and reduce waste. There should also be mandatory training in pedagogy for clinician teachers, periodic curriculum reviews must be enforced, and simulation laboratories should be provided in all accredited medical schools.
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Improving the quality of maternal health care in developing countries p. 18
Valentine O Otoide
DOI:10.4103/TJOG.TJOG_57_19  
Background and Aims: Quality of care is an important adjunct in the prevention of maternal morbidity and mortality in developing countries. The objective of this review was to assess components of maternal health care that have a bearing on quality of care. Source of materials for this article are from learned journals and reports on this subject. Conclusion: Quality of care in Obstetrics is a continuum that spans pre pregnancy period, pregnancy and the aftermath. Many parameters can be employed to define the quality of care received by women. The emphasis is however on the optimal utilization of the health system in providing the best possible care.
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ORIGINAL ARTICLES Top

Relevance of International Ovarian Tumor Analysis (IOTA) ultrasound rules and ADNEX risk calculator in the investigation of ovarian masses in a semi-rural Indian population p. 23
Archna A Tolani, Nevine Anandan, Nikhil M Bhuskute, Priti Kapoor
DOI:10.4103/TJOG.TJOG_33_19  
Aims: The study was undertaken to assess the efficacy of the International Ovarian Tumor Analysis (IOTA) ultrasound rules and the IOTA- Assessment of Different NEoplasias in the adneXa (ADNEX) model risk calculator in the investigation of ovarian masses in a semi-rural Indian population. Methods and Material: The study was a retrospective study. The pre-operative ultrasound images of all patients who had surgery for an adnexal mass over a two year period were looked at and classified according to the IOTA-ADNEX model calculator. Results: There were 45 patients who had surgery for an adnexal mass of which 78% had benign findings, 15% were malignant, and 6% were borderline on the final histological diagnosis. After retrospectively applying the ADNEX calculator, the study confirmed the low false positive (4%) and false negative (2%) rates, and this was despite not having cancer antigen 125(CA125) in hand at the time of the scan. There was one case where an adnexal lesion was classified benign on ultrasound, but was proven to be malignant on histology and as per the ADNEX model risk calculator. Conclusions: The study results showed vast potential in the management of adnexal masses in countries where costs, healthcare providers, infrastructure, and patient follow-up can be limited. The use of a predictive algorithm like the ADNEX model can help reduce anxiety, provide reassurance, and importantly avoid unwarranted surgery in patients with benign pathologies.
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Predictors of soil-transmitted helminthic infection among pregnant women attending antenatal clinic at the Federal Medical Center, Abeokuta, Nigeria p. 27
Mobolaji M Salawu, Adedamola H Salawu, Taofeek A Ogunfunmilayo, Victor U Nwadike, Adesoji S Adebayo
DOI:10.4103/TJOG.TJOG_40_19  
Introduction: Soil-transmitted helminth infection is a major contributor to anemia which is associated with morbidity and mortality during pregnancy in endemic regions like Nigeria. This study assessed the predictors of helminthic infections among pregnant women attending Antenatal clinics in the Federal Medical Center (FMC), Abeokuta, Ogun State. Methodology: A cross-sectional study was conducted among pregnant women attending the Antenatal (ANC) of the Department of Obstetrics and Gynecology, FMC, Abeokuta. Systematic random sampling was used for selecting study participants and semi-structured self-administered questionnaire was employed for data collection. Stool samples were collected from the participants and formol-ether concentration technique was used for stool examination. Besides, eggs of helminths were identified and quantified. Data were analyzed using statistical package for social sciences (SPSS) version 22. Associations were tested using the Chi-square test. Predictors of helminths infection were determined using the logistic regression analysis. Level of significance was set at 5%. Result: One hundred and seventy-four (174) women participated in the study. The mean age (SD) of the pregnant women was 30.44 (4.87) years. The majority (81.6%) had a tertiary level of education. The prevalence of intestinal helminth infection among the respondents was 21.8%. Ascaris lumbricoides (9.2%) was the most prevalent helminth, followed by hookworm infestation (7.5%) and Trichuris trichuria infestation (3.4%). The predictors for helminthic infestation among the respondents were aged 30 years and below (1.000; 0.23–1.20), pregnant women who had primary education and below (1.74; 0.72–3.06), and use of pit latrine and bush as waste disposal method (2.31; 0.86–6.21. Respondents who practiced handwash were less likely to have a helminthic infection (0.98; 0.11–9.08). Conclusion:Ascaris lumbricoides is the most commonly found helminth among the study population. Low education and poor hygiene were significant risk factors for helminthic infection among pregnant women.
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Comparison of outcomes of Foley's induced labors with different sonographic floater densities in fore-water p. 33
Samartha Ram Hemmanur, Sai Samyuktha Illa, Hanuman Rama Krishna
DOI:10.4103/TJOG.TJOG_111_19  
Background: Onset of spontaneous labor occurs on completion of fetal functional maturity at amniotic fluid optical density (AFOD) 0.98 ± 0.27 (mean ± SD). All three events occurring together at any time from 35 weeks to 42 weeks indicate the individualized term for each fetus. No failures of induction of labor were reported when labors induced at AFOD 0.98 ± 0.27. As AFOD estimation needs invasive amniocentesis, we tried to induce women with liquor with mature AFOD by observing the sonographic appearances of fore-water by transvaginal sonography. Methods: In this comparative study, three groups of gestational age and parity matched uncomplicated singleton term pregnant women, underwent fore-water trans-vaginal sonography before induction of labor with Foley's catheter. Sonographic images were divided into three grades based on floating particle densities. Each group consisted of 20 women with each grade of sonographic images. Uncentrifuged fresh AF samples collected at amniotomy were used for AFOD measurement with colorimeter at 650 nm in all groups. After Foley's expulsion, labor was augmented with vaginal misoprostol. The mean AFOD values, Foley's insertion expulsion intervals, Foley's insertion delivery intervals (FIDI), T misoprostol required, and neonatal respiratory distress were recorded in each group and compared. Results: In groups 1, 2, and 3, the mean AFOD was found to be 0.29 ± 0.09, 0.68 ± 0.14, and 1.15 ± 0.20, respectively. Mean Foley's insertion expulsion intervals were 10.57 ± 3.76 h, 5.83 ± 2.24 h, and 4.08 ± 0.86 h, respectively. Mean FIDI were 20.00 ± 6.20 h, 11.22 ± 4.20 h, and 8.95 ± 2.98 h, respectively. The mean numbers of T misoprostol required in each group was 3 ± 1, 2 ± 1, and 2 ± 1, respectively. Significant differences were observed in all outcomes between groups (P < 0.05) favouring inductions with Grade 3 sonographic images. Conclusion: Labor induction with Grade 3 sonographic images of fore-water was successful in all women with shorter FIDI, and with better perinatal outcomes.
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Incidence and determinants of pregnancy among women receiving HAART in Simiyu region: 14-year retrospective follow-up p. 38
Kihulya Mageda, Mohamed A Mohamed, Khamis Kulemba
DOI:10.4103/TJOG.TJOG_92_19  
Introduction: The introduction of highly active antiretroviral therapy has so far led to a comparable reduction in disease progression and restoration of normal functioning of reproductive system in female living with HIV infection. The main objective of this study was to find out the magnitude of pregnant and its determinants among ART-registered clients in Simiyu region, Tanzania. Methods: We used a retrospective cohort study of HIV/AIDS women initiated ART in Simiyu region from 2005 up to 2018. Kaplan–Meier survival graphics were used to explain the difference pregnancies experiences among different groups. Cox proportion hazard was used for model building to determine the predictors of pregnancy. Results: A total number of 525 women became pregnant, giving an overall incidence rate of 3.1/100 person year at risk (PYAR) (95% CI 2.84–3.37). The incidence of pregnant was higher between the age 15 and 29 years (5.86/100 PYAR, 95% CI: 5.23–6.55). Cohabited and those who are married were associated with high incident rate of pregnant (5.62/100 PYAR, 95% CI: 1.81–17.43 and 4.16/100 PYAR, 95% CI: 3.79–4.57). Weight >55 kg were associated with high incidence of pregnant (5.03 PYAR, 95% CI: 4.54–5.57), and WHO stage one have high incidence of pregnant (11.14/100 PYAR, 95% CI: 9.95–12.47). Conclusion: Young age and being healthier were the main predictors of pregnancy after ART initiation in this population. Policy for integration of family planning services into HIV care and treatment clinics should be strengthened but focused to young women. More follow-up is needed for pregnant and newborn outcome.
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Risk factors for hypertensive disorders of pregnancy in Abuja, Nigeria: A prospective case-control study p. 46
Malachy Emeka Ayogu, Godwin Otuodichinma Akaba, Richard A Offiong, Nathaniel D Adewole, Bissalah Ahmed Ekele
DOI:10.4103/TJOG.TJOG_88_19  
Background: Hypertensive disorders of pregnancy (HDP) are an important cause of maternal and perinatal morbidity and mortality throughout the world, particularly in developing countries like Nigeria. The study determined the risk factors for the development of HDP among women who booked early for antenatal care. Materials and Methods: This was a prospective case-control study conducted from March 2015 to March 2016 involving pregnant women with gestational age less than 20 weeks at booking and were followed up until delivery and 6 weeks postpartum. Information on gestational age at recruitment, at diagnosis of HDP, mode of delivery, and fetal outcome were recorded. Risk factors for HDP were compared between women who developed HDP (cases) and those who did not develop HDP (controls) by Fisher's exact test, Chi-square, and student's t-tests. Univariate and multivariate logistic regression analysis was used to test the relationship between certain risk factors and the development of HDP. A P value of less than 0.05 was considered statistically significant. Results: The prevalence of HDP in the study was 19.4%. Family history of preeclampsia (OR: 5.339, 95% CI: 1.149–24.818, P = 0.033); previous history of preeclampsia (OR: 10.819, 95% CI: 3.570–32.792, P < 0.001); multifetal gestation (OR: 13.275, 95% CI: 2.899–38.127, P = 0.010); chronic hypertension (OR: 3.431, 95% CI: 1.778–8.710, P < 0.001) and diabetes; (OR: 2.846 95% CI: 0.460–17.584, P < 0.251) were the risk factors associated with the development of HDP among the study population while nulliparity (OR: 0.726, 95% CI 0.366–1.440, P = 0.395); body mass index (BMI) (mean ± SD), (OR: 0.405, 95% CI: 0.173–0.945, P < 0.037);and low educational level (OR: 0.582, 95% CI: 0.070–4.857, P = 0.613) were not. Conclusion: The prevalence of HDP in the study group was high. Risk factors for HDP included family history of hypertension, previous history of preeclampsia, multifetal gestation, and chronic hypertension.
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Association between preeclampsia and cancer antigen 125 in women attending antenatal clinic in Usmanu, Danfodiyo University Teaching Hospital, Sokoto p. 53
Yetunde Bolatito Aremu-Kasumu, Emmanuel Ikechukwu Nwobodo, Ibrahim Godkobo Ango, Mohammed Bashir Abdulrahman, Fatusin Akinfemi Joel, Fatusin Bolatito Betty
DOI:10.4103/TJOG.TJOG_89_19  
Background: Preeclampsia is a hypertensive disorder of pregnancy that is characterized by the development of elevated blood pressure and proteinuria after 20 weeks of conception in a previously normotensive and non-proteinuric patient. It is one of the leading and most important causes of maternal and perinatal morbidity and mortality and it occurred in about 6% of human pregnancies. In Usmanu Danfodiyo Teaching Hospital Sokoto, preeclampsia and its complications were the leading causes of death in the year 2016. Preeclampsia has many suggested biomarkers, some of which are not well-defined. It has been assumed that failure in trophoblastic invasion and induction of an inflammatory process within the placenta in patients with preeclampsia may trigger the expression of CA-125 antigen. This study established a definite association between CA-125 and preeclampsia. Aims: This study was conducted to determine the relationship between cancer antigen 125 and preeclampsia and its correlation with severity. Settings and Design: Hospital-based study, comparative cross-sectional study. Methods and Materials: Ninety-seven pregnant women with preeclampsia were recruited as cases while 97 pregnant women without preeclampsia were similarly recruited as controls. In both groups (cases and controls), only women with singleton pregnancies at ≥32 weeks' gestational ages were recruited. Sociodemographic characteristics, obstetric history, family history, and clinical data were obtained using a standard interviewer-administered questionnaire. Anthropometric measurements were taken. Blood samples were taken for measurement of serum cancer antigen 125. Mean arterial pressure (MAP) was used as an indicator of the severity of the disease. Statistical Analysis Used: SPSS computer statistical software version 22, percentages, Chi-square, mean, Pearson correlation test. Results: The age range of the respondents was between 16 and 45 years. The mean age for the control was 28.6 ± 5.9 years, 27.9 ± 7.5 and 28.7 ± 7.2 years, for the control and severe preeclampsia groups, respectively. The mean level of CA-125 in the preeclampsia group was significantly higher than the control (36.13 ± 23.02 vs 24.53 ± 9.42). The mean levels of CA-125 in severe preeclampsia were significantly higher than mild preeclampsia (45.68 ± 23.38 vs 21.94 ± 13.18), P = 0.001. The MAP in mild and severe preeclampsia was 112.82 ± 3.55 mmHg and 130.63 ± 12.87 mmHg respectively. A negligible positive correlation was observed between the MAP and CA-125 in the mild preeclampsia group (r = 0.01, P = 0.48), while a positive correlation, that was statistically significant was observed between the MAP and CA-125 in the severe preeclampsia group (r = 0.62, P = 0.001). Conclusions: This study found a significant association between preeclampsia and CA-125. In addition, a positive relationship between the level of CA-125 and the severity of preeclampsia was established.
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Factor V Leiden mutation and acquired activated protein C resistance in Indian women with recurrent fetal loss p. 58
Pallavi Sinha, Meera Sikka, Satendra Sharma, Kiran Guleria, Priyanka Gogoi
DOI:10.4103/TJOG.TJOG_106_19  
Objectives: To study the prevalence and association of factor V Leiden (FVL) mutation and acquired APC resistance (APCR) in women with recurrent fetal loss (RFL). Patients and Methods: Fifty women with two or more RFLs and 50 age-matched controls with no history of fetal loss and at least one live birth were included in the study. Complete blood counts and screening tests for coagulation (PT, APTT), APCR, and FVL (PCR) were done in all women. Results: Age of the patients ranged from 20–42 years with a mean ± SD of 27.4 ± 4.8 years. Prolonged PT and APTT were observed in 2% and 8% cases, respectively. None of the controls had prolonged PT/APTT. APCR was observed in 8% cases and 2% controls. The prevalence of APCR was higher in women with first-trimester fetal loss (24.2%) as compared to women with the second trimester (13.3%) fetal loss. FVL was not observed in any of the cases or controls. Conclusion: This study indicates that FVL mutation is not associated with RFL in the Indian population while APCR is observed in Indian women with RFL.
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Evaluate the correlations of maternal systemic ınflammatory markers such as neutrophil to lymphocyte ratio and platelet to lymphocyte ratio with gestation age p. 62
Elif Didem Ozdemir, Halis Ozdemir
DOI:10.4103/TJOG.TJOG_34_19  
Objective: In this study, we aim to study the correlation between the maternal systemic inflammatory markers such as neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) including complete blood count (CBC) variables with gestation age, at the labor of our patients. Materials and Methods: This retrospective study was performed with 1127 patients and their infants. We used the maternal CBC variables analyzed within the last day before active labor. We analyzed the statistical differences between the NLR, PLR, and other CBC variables in terms of gestational age. Results: There was no statistically significant difference between the gestational age with NLR and PLR values, (P = 0.414 and P = 0.341, respectively). When we compare the NLR and PLR values in normal spontaneous vaginal delivery (NSVD) group, no statistically significant difference was found (P = 0.250; P = 0.995, respectively). In correlation analyses, no statistically significant correlation was detected between NLR and PLR with a birth weight of the infant and gestational age (P = 0.132 and P = 0.344, respectively). A linear, negative, weak correlation, and statistically significant correlation was detected between white blood cell count (WBC) with the infant's birth weight and gestational week (P < 0.01 and P = 0.024, respectively). Conclusions: Inflammation plays an important role especially at the beginning of the labor. In our study, we showed no correlation of the NLR and PLR with a gestational week or infant's birth weight at labor. Also, in our research, the NLR and PLR values did not differ statistically among the four groups in terms of the gestational age of delivery with the highest values in the preterm birth (<37 weeks) groups (P = 0.414, P = 0.341, retrospectively).
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Comparing the effectiveness of two different dosage regimes of oral nifedipine in the treatment of preterm labour p. 67
Abiodun S Adegoke, Olusola B Fasubaa
DOI:10.4103/TJOG.TJOG_15_20  
Objective: To compare the effectiveness and side effect of two different dosage regimes of oral Nifedipine in the treatment of preterm labour Methods: A double blinded randomized controlled trial in which 86 pregnant women with preterm labour were randomized to receive either the low or high dose regimen of Nifedipine for tocolysis. Low dose of 10 mg of oral Nifedipine then 5mg every 15min for 1hr 10mg 6hly for 48hrs, while the high dose was 20 mg of oral Nifedipine followed by 10 mg every 15 minutes for 1hr then 20mg 6hourly for 48 hours. The primary outcome was defined by mean uterine quiescence time and fetomaternal side effect were compared between the groups. Results: The mean uterine quiescence time for the low dose and high dose regime were comparable 13.60±11.69 hours versus 12.16±8.90 hours (P = 0.747) respectively, there was no statistical significance difference. None of the patients in both groups needed rescue treatment. Forty patients (93%) versus 41 patients (95%) (P = 0.506) of low and high dose respectively where able to achieve uterine quiescence within 48hours, there was no statistical significant difference. Maternal headache was higher in the high dose compared to the low dose but not statistically significant {19% vs 5% (p = 0.08)} None of the women in both groups had fetal heart rate abnormality. Discussion: The high dose regimen of oral Nifedipine for tocolysis does not have any advantage over the low dose regime in terms of effectiveness for tocolysis and infact low dose had a lower maternal side effect.
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A double-blind randomized controlled clinical trial of oral misoprostol versus ergometrine in the prevention of primary postpartum hemorrhage p. 72
Valentine O Otoide
DOI:10.4103/TJOG.TJOG_52_19  
Objective: The study was designed to investigate the effectiveness of orally administered misoprostol versus intravenous ergometrine (stored at tropical temperatures) in the prevention of primary postpartum hemorrhage (PPH) among parturients undergoing vaginal delivery in a teaching hospital. Study Design: A double-blind randomized controlled clinical trial was conducted at the University of Benin Teaching Hospital. One hundred and fifty parturients were offered 400 ug misoprostol and an intravenous placebo for the management of the third stage of labor while another 150 parturients received oral placebo and 0.5 mg intravenous ergometrine. Results: There was no significant difference in the incidence of PPH (blood loss > 500 ml) between the two groups: 8 (5.3%) for the misoprostol group compared with 7 (4.7%) for the ergometrine group (P = 0.79, relative risk (RR) = 1.07, confidence interval (CI): 0.66–1.74). The incidence of severe PPH (blood loss > 1000 ml) was similar between the two groups: 2 (1.3%) in the misoprostol group compared with 1 (0.7%) in the ergometrine group. Similarly, the indices of postpartum blood loss (hematocrit change, need for blood transfusion, and surgical intervention) were comparable between the two groups. A subgroup analysis of high-risk parturients revealed comparable indices. The misoprostol group, however, had a significantly higher risk of shivering in the early postpartum period (P = 0.00, RR = 2.01, CI: 1.69–2.38). Conclusions: The results suggest that oral misoprostol has comparable efficacy to intravenous ergometrine at tropical conditions in the prevention of PPH. However, in view of its easier mode of administration, oral misoprostol may be preferable in rural situations in Africa.
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Randomization of vaginal and sublingual misoprostol for cervical ripening and labor induction p. 78
Damilola Ifariola, Adebayo A Adeniyi, Olumide E Adewara, Akujuobi R Okere, Idowu O Adebara, Adewumi Bakare, Olabisi T Adeyemo
DOI:10.4103/TJOG.TJOG_47_19  
Background: Planned induction of labor for various indications has become an established part of modern Obstetric practice. While the efficacy of misoprostol, a prostaglandin E1 analog as a cervical ripening labor induction agent has been established, the appropriate route and dosage are still objected to ongoing research. Objective: This study aims at comparing the efficacy of vaginally administered with sublingual misoprostol for cervical ripening and labor induction. Methodology: One hundred (100) pregnant women at term who fulfill the inclusion criteria were equally randomized into the two arms of the study to receive either 25 μg of misoprostol sublingually or 25μg vaginally. The induction delivery interval and fetal outcomes were compared in the two arms of the study. Results: The vaginal group required more doses of misoprostol than the sublingual group (1.68 ± 0.74 versus 1.26 ± 0.44, P = 0.005). Time from the administration of the first dose of misoprostol to the achievement of a Bishop score of 7 or active phase labor was shorter in the sublingual group than the vaginal route group (5.04 ± 1.77 hours versus 6.32 ± 1.36 hours, P = 0.001). Induction-delivery interval was shorter in the sublingual group than the vaginal route (10.02 ± 2.37 hours versus 11.12 ± 3.97 hours) although the difference was not statistically significant (P = 0.098). The mean Apgar scores at 1 min and 5 min were slightly better in the vaginal group than the sublingual group but the difference did not assume statistical significance (Apgar scores at 1 minute: 7.62 ± 0.83 versus 7.72 ± 0.88, at 5 minutes: 8.94 ± 1.23 versus 9.22 ± 0.46 for the sublingual versus the vaginal group, respectively, P = 0.561). Conclusions: The two routes of sublingual and vaginal administration showed comparable safety and effectiveness for cervical ripening and induction of labor in low-risk pregnancies at term. However, the sublingual route appears to be superior in terms of easy administration and patients' satisfaction.
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Mental health outcome and perceived care needs of women treated for a miscarriage in a low-resource setting p. 85
Johnbosco Ifunanya Nwafor, Vitus Okwuchukwu Obi, Chuka Nobert Obi, Chukwunenye Chukwu Ibo, Darlington-Peter Chibuzor Ugoji, Blessing Idzuinya Onwe, Victor Uchenna Onuchukwu
DOI:10.4103/TJOG.TJOG_44_19  
Introduction: There have been many advances in the management of miscarriage in recent times including the introduction of expectant and medical management protocols. However, a study of the psychological impact of the condition and its management has not received similar attention. Aim: To determine the psychosocial consequences of miscarriages and perceived needs of the patients compared to the care provided by the hospital. Materials and Method: This was a prospective cohort study conducted between January 15, 2018 and April 30, 2019. Participants were recruited on admission and psychological morbidity was assessed at 1 week after a miscarriage in the gynecological clinics. They were screened for psychological morbidities using DASS 21 (Depression, Anxiety and Stress Scale). Results: Of 140 women that participated in the study, severe depression was reported in 8 (5.7%) whereas 12 (8.5%) participants reported symptoms of extremely severe depression. Moderate to severe anxiety was present in 23.5% while extremely severe anxiety was noted among 21.5% of the women. Stress was reported in over half of respondents and severe to extremely severe stress occurred in 19.9% of the participants. Factors significantly associated with psychological morbidities following miscarriage include age ≥35 years, no living child, subfertility, planned pregnancy, and assisted conception. Healthcare providers not listening to the patient's concern, non-participation in decision making, and dissatisfaction with care were associated with adverse psychological outcomes. Conclusion: Psychological morbidity following a miscarriage is common among participants in our study. The provision of the correct information and psychological debriefing may be useful in enabling women to adjust emotionally following miscarriage.
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Choice of delivery positions among multiparous women in Kano p. 95
Idris Sulaiman Abubakar, Ibrahim Garba, Ayyuba Rabiu, Umar S Suleiman
DOI:10.4103/TJOG.TJOG_86_19  
Background: Confining women to hospital bed with limited power of movement and involvement of decision making during labor process and restricting them to supine position in second stage of labor might contribute significantly to aversion to hospital delivery. Objective: To determine the different delivery positions women take during home delivery. Method: This was a cross sectional survey among 285 multiparous women who had vaginal delivery of life singleton babies. They were interviewed using questionnaire at Murtala Muhammad Specialist hospital Kano on choices of delivery position. Ethical approval was obtained from the ethical committee of the state. Data obtained were analyzed using SPSS Version 19. Qualitative data were summarized using frequencies and percentages. Chi (χ2) test was used for categorical data. A P value of ≤ 0.05 was considered statistically significant. Results: The mean age (±SD) of the respondents was 28.9 ± 7.12 years. Majority of the women that delivered at home assumed the squatting position for delivery (60%) and were mainly assisted by traditional birth attendants (TBA) (41.3%). Over 50% of those that delivered at home were instructed to take the position they delivered in by their assistants at delivery while those that chose their position by themselves did that because they felt more comfortable in that position (85%). Over 80% of those that were instructed to take a position at delivery did not ask their assistant the reason for advising on that position. There was statistically significant association between educational level and right to decide in which position to deliver the baby (χ2=28.517, P = 0.000). Conclusion: Squatting position was the most assumed position following home delivery. There was statistically significant association between educational level and right to decide in which position to deliver the baby.
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A randomized controlled trial of rectal diclofenac sodium and intramuscular pentazocine versus intramuscular pentazocine, diclofenac, and paracetamol analgesics for pain relief in the first 48 h after cesarean section p. 101
Ogochukwu L Obi, Jamilu Tukur, Aisha Abdurrahman, Ibrahim Salisu
DOI:10.4103/TJOG.TJOG_1_20  
Background: Cesarean section is one of the most commonly performed operations in obstetric practice. A multimodal approach to post-cesarean pain management has been shown to be more effective than a unimodal approach, though the most effective combination and preferred route of administration are still unknown. Aim: To compare the effectiveness of rectal diclofenac sodium and intramuscular pentazocine versus intramuscular pentazocine, paracetamol, and diclofenac analgesics for pain relief in the first 48 h after cesarean section at Federal Medical Centre, Katsina. Methods: This was a prospective single-blind, randomized controlled trial, in which 120 booked women planned for cesarean section were recruited and randomly allocated to the study or control group. The study group received 100 mg rectal diclofenac sodium 12 h and intramuscular pentazocine 60 mg 6 h, while the control group received intramuscular diclofenac 75 mg 12 h, pentazocine 60 mg 6 h, and paracetamol 600 mg 8 h for the first 48 h postoperatively. Pain perception, maternal satisfaction, and preferred route of drug administration were compared between the two groups. Results: The study group had significantly lower mean visual analog scale pain scores and higher maternal satisfaction in the first 48 h (P < 0.05). There were no significant differences in the maternal and newborn side effects of the analgesics. The rectal route of drug administration was more preferred (P < 0.05). Conclusion: The study showed that rectal diclofenac sodium and intramuscular pentazocine post-cesarean section analgesic efficacy and maternal satisfaction were superior to that of intramuscular pentazocine, diclofenac, and paracetamol.
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Knowledge and perception regarding surgical antibiotic prophylaxis among physicians in the department of obstetrics and gynecology p. 108
Usman Abubakar, Syed A Syed Sulaiman, Adebiyi G Adesiyun
DOI:10.4103/TJOG.TJOG_25_19  
Background: Evidence shows that compliance with surgical antibiotic prophylaxis (SAP) among obstetricians and gynecologists is poor. This study evaluates the knowledge and perceptions regarding SAP among doctors in Obstetrics and Gynecology units. Methods: This was a cross-sectional study conducted among physicians in the Department of Obstetrics and Gynecology in two public tertiary hospitals in Nigeria. Data was collected using a 30-item validated and pre tested self-administered questionnaire, and analyzed using SPSS. Results: A total of 41 respondents (response rate: 68.3%) returned the survey with a male preponderance (61%). Medical officers (Senior Registrars and Registrars) constituted almost two-third (63.4%) of the respondents. Only 26.8% had attended a workshop, seminar, conference or clinical meeting regarding SAP. Most respondents were not aware of the most common organism that causes surgical site infection and the appropriate time and duration of SAP. However, majority (90%) knew that the inappropriate use of SAP could lead to antibiotic resistance. More than two-third agreed that SAP malpractices were due to the lack of knowledge about SAP and poor awareness regarding antibiotic resistance. More than 90% agreed that education, audit and feedback, and guidelines would improve compliance with SAP. Respondents with 6–10 years working experience had significantly higher knowledge score than those with 1 –5 years experience. Respondents who had not attended any workshop or course pertaining to SAP had more positive perception. Conclusion: Respondents demonstrated inadequate knowledge of SAP and most of them were aware that inappropriate use of SAP could lead to antibiotic resistance.
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Effect of fluoride on the uteroplacental transfer of calcium and magnesium and their role in congenital anomalies in newborns p. 114
Abhra Ghosh
DOI:10.4103/TJOG.TJOG_42_19  
Introduction: Calcium and magnesium are one of the most important micronutrients for fetal development. Environmental pollutants like excess fluoride can hamper the action of calcium and magnesium resulting in a bad outcome of pregnancy. Aim: We aimed to find out the effect of fluoride on the uteroplacental transfer of calcium and magnesium and the role of these minerals as a causative factor of congenital anomalies in newborns. Materials and Methods: Out of 50, 25 newborns with congenital anomalies were included in group I and 25 healthy newborns were included in group II. Cord blood fluoride was estimated by the ion-selective electrode while calcium and magnesium were estimated by the autoanalyzer. Unpaired 't' test and Pearson's correlation test were applied for statistical analysis. Results: Serum fluoride levels were significantly raised and serum calcium levels and serum magnesium levels were significantly decreased in newborns with congenital anomalies as compared to newborns without congenital anomalies (P = 0.000). Serum fluoride levels showed a positive correlation with serum calcium in group II, which got inverted in group I. Both the results were statistically significant. Serum fluoride levels showed a positive correlation with serum magnesium levels in group II, which got inverted in group I. Both the results were statistically insignificant. Conclusion: Hypocalcemia and hypomagnesemia can affect fetal development. Environmental pollution due to fluorosis emerges as a factor as fluoride has a direct influence over calcium and magnesium absorption and transfer via the placenta to the developing fetus. Prophylactic measures have to be taken to counter the effect of fluorides on calcium and magnesium for proper development of the growing fetus.
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Comparative evaluation of efficacy and safety of methyldopa and labetalol in pregnancy-induced hypertension: A meta-analysis p. 119
Rudra Patel, Radhe Shah, Deshna Lad, Devang Rana, Supriya Malhotra
DOI:10.4103/TJOG.TJOG_87_19  
Introduction: Methyldopa and labetalol are the drugs that frequently used for the management of pregnancy-induced hypertension. But fewer data available for the efficacy and safety of their use. So, here we are doing a systemic review for the safety and efficacy of methyldopa in comparison to labetalol. Objectives: Assessment of efficacy and safety of methyldopa versus labetalol in pregnancy-induced hypertension. Method: A total of 10 randomized controlled trials (RCTs) following PRISMA guidelines (2015) and have included pregnant women who developed hypertension after the 20th week of gestation and receiving methyldopa (100–400 mg/day) or labetalol (250–1000 mg/day). All RCTs with changes in mean arterial pressure (MAP) before and after drug administration was collected. The adverse effects of the respective drugs were also noted. RevMan 5.3 software was used for the calculation of standardized mean difference (SMD). P value less than 0.05 will be considered significant. Result: Data of 1,200 patients were included in our study. Both the drug decreases MAP statistically significantly. In the labetalol group, P value was statistically significant (random effect model P < 0.005 and in the fixed-effect model <0.001). In methyldopa group, P < 0.001, significant in fixed effect. In the majority of the studies, the difference in the reduction of MAP was higher in labetalol than methyldopa. In labetalol vs methyldopa study using random-effect model SMD was 1.568 (95% CI, 0.735 to 2.401, P < 0.001). Drowsiness, headache, nausea, vomiting, weakness, and myalgia were associated with drugs. Out of the six adverse effects, there was a significant difference found in drowsiness (P = 0.023) which was seen more in patients receiving methyldopa. There was no significant difference in the prevalence of the other maternal side effects. Conclusions: Labetalol is more efficacious and safer as compared to methyldopa.
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Seroprevalence of hepatitis B virus infection among pregnant women attending antenatal clinic in Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State p. 126
Emmanuel Adejo Ogbe, Ruth N Bello, Esther S Audu, Blaise Ogedi Okwaraoha
DOI:10.4103/TJOG.TJOG_107_19  
Context: Hepatitis B virus (HBV) infection is a cause of chronic liver disease, causing cirrhosis and hepatocellular carcinoma, and pregnant women are not spared. Perinatal transmission is a significant way that the disease is spread from mother to children who will eventually become adults and chronic carriers. This study sought to determine the burden of the disease among pregnant women. Aims: To estimate the prevalence and investigate possible factors associated with HBV infection among pregnant women attending antenatal clinics in DASH, Lafia. Settings and Design: A hospital-based descriptive cross-sectional survey conducted at the Obstetrics and Gynecology Department of DASH, Lafia, Nasarawa Methods and Material: Around 200 pregnant women who attended the ANC clinic were consecutively enrolled, their venous blood samples collected, and hepatitis B profile was carried out using commercially available rapid chromatographic kits Statistical Analysis Used: Data were collected by trained data collectors using a proforma, then entered into a predesigned program in the Epi-info version 3.5.4 (CDC, Atlanta, Georgia, USA) and analyzed. Results: The seroprevalence of HBV infection was high (8%) and there were no statistically significant associations between the infection and the investigated sociodemographic and other risk factors. Conclusions: The study showed that HBV is hyperendemic in this region, and antenatal screening for this virus is desirable to avert its sequelae in both mothers and their newborn babies.
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The Effects of Leukocyte- and Platelet-Rich Plasma (L-Prp) and Pure Platelet-Rich Plasma (P-Prp) in a Rat Endometriosis Model p. 132
Ali Dogukan Anğın, Ismet Gun, Yasemin Alan, Önder Sakin, Muzaffer Seyhan Çıkman, Zehra Meltem Pirio, Kayhan Başak, Ahmet Kale, Pınar Kaygın, Serpil Oğuztüzün, Murat Alan
DOI:10.4103/TJOG.TJOG_110_19  
Objective: We aimed to investigate the effect of platelet-rich plasma (PRP) derivatives, which can be produced from the patient's blood and have minimal side effects, on endometriosis. Methods: To our knowledge, this is the first study in the literature that studies the relationship between PRP and endometriosis. Endometriosis foci were created in the first operation. In the second operation (30th day), four groups were formed wherein group 1 (n = 8) was administered saline, group 2 (n = 7) leukocyte and platelet-rich plasma (L-PRP), group 3 (n = 8) pure platelet-rich plasma (P-PRP) and group 4 (n = 10) was used to obtain PRP. In the last operation (60th day), the endometriotic foci was measured and then excised. Findings: There was no statistically significant difference between the pre and post volumes of the endometriotic foci, between their volume differences, and volume difference rates (P > 0.05). However, it was observed that existing implant volumes in all groups decreased statistically significantly within their groups by the end of the experiment compared to the previous volumes (P < 0.05). Conclusion: When the implants were assessed through histopathological scoring in terms of edema, vascular congestion, inflammatory cell infiltration, hemorrhage, epithelial line, and hemosiderin accumulation, and immunohistochemical staining was assessed in terms of VEGF, there was no significant difference in the comparison between the groups. Although L-PRP and P-PRP generated more reduction in the endometriosis foci, they did not create any statistical differences.
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Correlation between primary dysmenorrhea characteristics, age at menarche, anthropometric variables, gynecological history, management attitudes, and quality of life among undergraduates in Nigeria p. 140
Gabriel G Akunna, Olaleye Olabiyi, Oreoluwa Adenike, Linus Anderson Enye, Segun Ajeleti
DOI:10.4103/TJOG.TJOG_109_19  
Context: Menstruation is a natural event that occurs throughout the reproductive years of every woman. Most women during their menstrual period experience pain and discomfort called dysmenorrhea which is the most common gynecological complaint in young women and may result in absences from school, work, and social engagement. Aims: To study the relationship between BMI, hip circumference, menarcheal age, and management on the severity of dysmenorrhea among undergraduates. Methods and Materials: A self-administered structured questionnaire having four (4) sections including information on the sociodemographic data, data related to menstrual characteristics, information related to menstrual symptoms, and information on management attitudes of these students were used for data collection. Statistical Analysis Used: A non-probability convenient method was used to select 400 participants. A self-administered structured questionnaire was used for data collection and data were analyzed with SPSS software version 23.0. Results: The prevalence of dysmenorrhea was 87.1%, with most commonly felt symptoms being tiredness (72.5%) and mood swings (67.8%). Symptoms lead to decreased social activities (55.8%), low confidence (55.5%), and increased absenteeism (49.5%) from lectures. Although dysmenorrhea has no significant relationship with BMI, it was significantly (P < 0.05) higher (197) in participants with smaller hip circumference (0.80–1.00 m) and late (13–14 years) menarche (47.8%). There was a low rate (4.2%) of consultation with the majority (63%) opting for self-medication as previously advised by a relative (23.4%), self (21.1%), and friends (18.9%). Conclusions: Smaller hip circumference, late age at menarche, and increased BMI can increase the severity of dysmenorrhea which can further affect the quality of life.
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Conscious sedation for oocyte retrieval: Experience at a tertiary health facility in North-Central, Nigeria p. 151
Lukman O Omokanye, Abdulwaheed O Olatinwo, Kabir A Durowade, Abubakar A Panti, Ganiyu A Salaudeen
DOI:10.4103/TJOG.TJOG_22_19  
Background: A variety of anesthetic techniques have been used to make transvaginal oocyte retrieval (TVOR) safe and efficient. The optimal anesthetic technique during TVOR should provide safe, effective analgesia, few side effects, a short recovery time, and be nontoxic to the oocytes that are being retrieved. The concept of conscious sedation is widely accepted for the short-term management of pain. Objective: This study assessed patient's perception of pain using conscious sedation and in-vitro fertilization (IVF) outcomes. Materials and Methods: A cross sectional study of 71 eligible patients that underwent assisted reproduction program in our facility. All clients were treated with antagonist protocol for controlled ovarian hyperstimulation. Self-administered questionnaires were used as the research instrument. Pain was assessed using a 10 cm visual analogue scale (VAS), while client's overall satisfaction was rated using Likert scoring system. Results: Client aged 33.2 ± 4.2 years. Most of them had primary infertility with mean duration of 4.5 ± 2.9 years. Unexplained infertility was the commonest cause of infertility. The pregnancy rate per embryo transfer was 47.9%, miscarriage rate was 5.6%, while the live birth rate was 42.3%. The mean VAS scores at 1 h, 6 h, 24 h and at embryo transfer were 4.9 ± 1.7, 2.5 ± 1.2, 1.3 ± 0.9, and 0.5 ± 0.6, while the Likert score was 3.8 ± 1.1. Conclusion: Conscious sedation with Midazolam and Pethidine is a safe, effective, and acceptable method of analgesia/anesthesia for TVOR. However randomized prospective studies with larger sample sizes are recommended.
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Surgical management of uterine fibroids in a tertiary hospital in south-west Nigeria p. 156
Obehioye O Enabor, Folasade A Bello
DOI:10.4103/TJOG.TJOG_49_19  
Context: Symptomatic uterine fibroids are frequently encountered in gynecological practice in black populations. An evaluation of the surgical management is in order to audit practice, highlight complications, and facilitate care. Aims: This study aimed to evaluate morbidity following abdominal myomectomy and hysterectomy for symptomatic uterine fibroids. Settings and Design: A cross-sectional study retrospectively reviewing cases of symptomatic uterine fibroids that were managed surgically at a tertiary hospital in south-west Nigeria. Methods and Material: Surgeries performed over a five-year period were retrieved from the gynecological theatre of the hospital. The case notes were retrieved and information on socio-demographic, perioperative and postoperative characteristics was obtained. Statistical analysis used: Chi-square tests and Student's-t tests were performed to evaluate categorical and continuous variables, respectively. Significant P was set at < 0.05. Results: Of 214 eligible cases, 79 (36.9%) had hysterectomy and 135 (63.1%) had myomectomy. No other surgical treatment methods were employed. Age was the only significant socio-demographic feature; younger women were more likely to have myomectomy (P < 0.001). Mean blood loss and transfusion rates were comparable between the two groups. Complications included hemorrhage in 36.0%, wound infection in 4.7%, and postoperative fever in 1.9%. There were no conversions of myomectomy to hysterectomy and no mortalities. There was no significant difference in the prevalence of complications in either surgery group. Conclusions: Apart from hemorrhage, morbidities were few in this series. Gynecologists should ensure adequate preparations to control blood loss before and during fibroid surgery.
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Trends in vaginal hysterectomy in a Nigerian teaching hospital: A 14-year review p. 160
Emeka P Igbodike, Clement A Adepiti, Akaninyene E Ubom, Kayode O Ajenifuja, Olabisi M Loto, Olusola B Fasubaa, Uche Onwudiegwu, Okechukwu E Orji
DOI:10.4103/TJOG.TJOG_20_20  
Background: The procedure of vaginal hysterectomy is a fast disappearing art. This study looks at 14 years' experience of vaginal hysterectomy in Ile-Ife, Nigeria. Objectives: To determine and compare the rate, indications, and complications of vaginal hysterectomy over a 14-year period at Ile-Ife, Nigeria. Methods: The medical records of patients managed with vaginal hysterectomies performed from 1st January 2005 to 31st December 2018 were reviewed. The demographics and indications for vaginal hysterectomy were extracted. Data were analyzed using Statistical Package for Service Solutions – IBM version 22. Frequencies and percentages were calculated and associations compared where applicable using Chi-square with level of significance set at <0.05. Results: Pelvic organ prolapse accounted for 0.8% of gynecological admissions and vaginal hysterectomy accounted for 2.3% of major gynaecological operations. The mean age was 66.1 ± 9.2 years with a mean age of menopause of 15.2 ± 7.1 years. The mean parity was 6.2 ± 1.6. Pelvic organ prolapse was the commonest indication. The mean blood loss at surgery was 314.2 ± 184.8 ml. The modal post-operative complication was post-operative anemia, and hypertension was the commonest comorbidity. The mean duration of surgery was 3 ± 0.9 h and the mean duration of admission was 5.4 ± 2.7 days. Conclusion: The rate of vaginal hysterectomy is on the decline. This may be due to case under reporting, limiting of family size, or low uptake of farming occupation in our society.
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Predictors of location of rape: A survey of victim's location in Gombe state, North-East Nigeria p. 167
Christopher H Laima, Amina Mohammed, Samuel K Hembah-Hilekaan, Joshua D Abubakar
DOI:10.4103/TJOG.TJOG_74_19  
Aims: To determine the predictors of rape location among victims in Gombe. Settings and Design: Cross-sectional retrospective. Methods and Material: Cases of alleged rape that presented at a secondary health facility from August 2016-July 2018 were retrieved. Statistical Analysis Used: SPSS version 20. Results: The majority of cases were between the ages of 5–14 years (66.1%). Up to 26% of the victims were males. For 65.7% of the cases, the perpetrators were not known to the victim. The perpetrator's residence or office was the most commonplace of rape occurrence (49.5%). More victims (60.7%) who were less than 5 were raped in the perpetrator's home/office, compared to 43.6% of those who were between 15–24 years. Also, 50% of those with tertiary educational qualifications were raped in their homes compared to 10% of those with primary educational qualifications. Rape was carried out in uncompleted building/bush for perpetrators who were known to the victim compared to 6.3% of those who the victims did not know. There are a higher odds of rape carried out in the perpetrator's or victim's home among those who are familiar with the perpetrator compared to those who are not familiar to the perpetrator (odds ratio (OR): 0.36; confidence interval (CI): 0.200–0.656). The odds of rape occurring by a known person is 3.4 times more likely to occur in the perpetrator's house/office compared to it occurring in an uncompleted building or bush (P value 0.007 with a CI of 1.396–8.562). Conclusions: It is recommended that children should be placed in schools to minimize child labor and the public should be made aware of the possibility of rape by known persons in lonely places and at home.
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Appropriateness of antimicrobial prophylaxis practices according to the guidelines in two common gynaecological surgeries p. 172
Junaid Khan, Asghar Khan, Sohail Kamran, Muhammad Nasir Jamal, Sikandar Khan Sherwani, Zakir Khan
DOI:10.4103/TJOG.TJOG_85_19  
Background: Most postsurgical infections can be prevented through the effective use of antimicrobial. This study was conducted to investigate the antimicrobial prophylaxis practices and adherence to guidelines in gynecological surgeries. Methods: An audit based prospective study was carried out between February and April 2019 in the gynecological ward in a teaching hospital, Peshawar, Pakistan. This study included women who had two common surgical procedures (caesarean surgery and hysterectomy), did not undergo any previous surgery and having no infection at the time of surgery. The indication, choice/selection, timing and pattern of antimicrobials were the main evaluated parameters. The required information was collected from medical records through standardized data collection proforma. Observed prescribing practices were compared with antimicrobial prophylaxis guideline. Results: A total of 264 patients (caesarean surgery n = 173 and hysterectomy n = 91) with mean age: 32.6 ± 6.3 years were recruited in the analysis. Antimicrobial was prescribed to 241 patients (91.3%). The selection and timing of antimicrobial were adhered to guidelines in 40.7% and 56.4% cases, respectively (optimal value 100%). There was a statistically significant difference between guideline recommendations and antimicrobial practice in surgical procedures (P = 0.000).The commonly prescribed antimicrobials were ceftriaxone (22.4%) and cefazolin (22%).The combination usage of antimicrobial was also observed. Conclusion: Inappropriate use of antimicrobial prophylaxis and low adherence to standard guidelines was observed. Periodic audit and awareness about standard guidelines are required for the judicial use of antimicrobials in surgery.
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Pattern and relative frequencies of gynecological malignancies at the University of Abuja Teaching Hospital, Abuja p. 177
HI Abdullahi, ME Ayogu
DOI:10.4103/TJOG.TJOG_99_19  
Background: Gynecological cancers have been shown to contribute overwhelmingly to gynecological mortality worldwide, particularly in developing countries. An in-depth study of the patterns of the distribution will help to elucidate the estimates of the disease burden in University of Abuja Teaching Hospital (UATH). Objectives: The aim of this study was to determine the pattern and relative frequencies of gynecological cancers at UATH. Materials and Methods: Case notes of patients managed for gynecological cancers at UATH over a 5-year period from January 1, 2014 to December 31, 2018 were retrieved. Relevant data on age, parity, and type of cancer, clinical, surgical, and histopathological diagnosis were collated using a proforma and analyzed using Statistical Package for the Social Sciences (SPSS). Result: A total of 167 gynecological cancer cases of 3030 gynecological admissions were seen during the period putting its to prevalence at 5.5%. The most common gynecologic cancer was cervical cancer that constituted (88) 52.7% of the cases; ovarian 47 (28.1%), endometrial 17 (10.2%), choriocarcinoma 11 (6.6%), and vulva cancers 4 (2.40%) are not so common. The mean age and parity at presentation are cervical cancer (55.50 ± 12.71 and 4.41 ± 2.05), ovary (42.34 ± 14.91 and 2.94 ± 2.11), uterus (50.54 ± 15.18 and 3.39 ± 2.25), and vulva (63.50 ± 15.09 and 5.50 ± 2.38), respectively. The overall mean age for all cancers is 51.16 ± 14.95 and overall parity is 3.85 ± 2.21. Majority presented in advanced stage of the disease; the most common cause of death is renal failure. Conclusion: The burden of gynecological cancers is high, although cervical cancer is on downward trend in our environment and most cancer cases came as late presentations.
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Triglycerides and TG/HDL-C ratio as surrogate markers for insulin resistance in Nigerian women with polycystic ovary syndrome p. 182
Chinyere B N. Akpata, Patrick O Uadia, Friday E Okonofua
DOI:10.4103/TJOG.TJOG_104_19  
Background: Dyslipidemia is one of the most perplexing metabolic consequences in polycystic ovary syndrome (PCOS). Obesity, insulin resistance (IR), and hyperandrogenism, the pervasive features of PCOS, play significant pathophysiological roles in the lipidemic aberrations associated with the syndrome. Objective: This study aimed to assess the diagnostic utility of triglyceride (TG) and triglyceride to high-density lipoprotein-cholesterol (TG/HDL-C) ratio as surrogate markers for identifying IR in infertile Nigerian women with PCOS. Materials and Methods: Eighty-seven infertile women with PCOS were selected according to the Androgen Excess Society criteria and categorized into two groups. After anthropometric measurements, fasting blood samples were assayed for plasma glucose, serum insulin, total cholesterol, TG, HDL-C while lipoprotein ratios were calculated. Homeostasis model assessment for IR (HOMA-IR) was used in defining IR. The areas under the receiver operating characteristic (ROC) curve analysis were used to compare the power of the serum markers, and to obtain the optimal cutoffs of TG and TG/HDL-C with HOMA-IR. Results: TGs correlated significantly with HOMA-IR in the obese PCOS women. However, the areas under the ROC of potential markers showed no significant marker for HOMA-IR. The highest area under the curve of ROC for TG belongs to the obese group with a sensitivity of 56% and specificity of 53% (TG ≥ 92.5mg/dL) as a marker of IR in obese PCOS women. Conclusion: TG and TG/HDL-C would not be reliable markers of IR, and a concerted approach in finding surrogate markers will benefit future investigations.
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CASE REPORTS Top

Torsion of an Ovarian Cyst in Pregnancy p. 189
S Bello, K Tunau, B Bello, K Abdullahi, B Ugege, E Ukwu
DOI:10.4103/TJOG.TJOG_83_19  
Torsion of the ovary is the partial or total rotation of the ovary over its pedicle. It is unusual for it to occur in the second trimester. We report a case of a 35year old G10P9+0A7 at 17weeks gestation who presented with acute severe abdominal pain. She was found to have an ovarian cyst in pregnancy. She had Exploratory Laparotomy where a huge gangrenous cyst was found and Salpingoophorectomy was performed. The pregnancy continued without any problems. The histology report showed a Simple Cyst.
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Emergency hysterectomy for a ruptured intramural ectopic pregnancy: A case report p. 192
UR Yahaya, E Dase, AI Lawan
DOI:10.4103/TJOG.TJOG_87_18  
Intramural ectopic pregnancy is usually complicated by uterine rupture requiring emergency laparotomy and appropriate intervention. The diagnosis poses a serious challenge and the type of surgical intervention required depends on the hemodynamic status and the extent of damage to the uterus. A 38-year-old gravida 3, Para 2, abortion 0, who had an emergency hysterectomy due to a ruptured intramural pregnancy with massive hemoperitoneum. Pre-operative ultrasound was suggestive of the diagnosis which was confirmed by operative findings and histopathology report on the specimens. Intravenous infusion of normal saline, blood transfusion and emergency hysterectomy is essential for prevention of maternal mortality in intramural pregnancy complicated by uterine rupture.
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A case of Couvelaire uterus with coagulation dysfunction saved successfully with SR PPH suction cannula p. 195
Hemmanur Samartha Ram, Dommety Swetha
DOI:10.4103/TJOG.TJOG_73_19  
Couvelaire uterus is one of the complications associated with placental abruption, and the incidence is around 1%. Blood seeps into the uterine musculature and reaches beneath the serosa. The uterus shows the signs of ecchymosis, flabby, cannot contract and retract and results in atonic post partum hemorrhage (PPH). As this uterus likely to bleed in postoperativee period, the treatment of choice is obstetric hysterectomy. In such cases, the women lose their fertility function. In this case, we have successfully used samartha ram post partum hemorrhage (SR PPH) suction cannula to achieve contraction and retraction and saved the uterus.
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Sonographic detection of umbilical cord presentation before induction of labor or labor admission: Presentation of 4 cases p. 198
Samartha Ram Hemmanur, Sneha Bandlapalli
DOI:10.4103/TJOG.TJOG_108_19  
Umbilical cord prolapse is a serious obstetric emergency that endangers the life of the baby. Perinatal mortality is as high as 44% when it occurs outside a well-equipped hospital. Women with malpresentations and positions, multifetal pregnancies, and polyhydramnios are at risk of developing this complication. Detection of cord presentation by transvaginal sonography before induction of labor, or at the time of labor admission, can prevent this potentially fatal obstetric emergency. We present successfully managed four cases of cord presentation at our institution.
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Planned cesarean myomectomy at term for huge intramural fibroids coexisting with pregnancy: A case report p. 201
Olumide A Adeniyi, Olaniyi J Olayemi, Titilayo A Ojumu, Simeon O Olateju, Olufemiwa N Makinde
DOI:10.4103/TJOG.TJOG_70_19  
With about 2–11% of pregnancy co-existing with fibroids, one in 10 women will have complications related to myoma in pregnancy. The procedure of cesarean myomectomy has been much discouraged and the need to perform inevitable myomectomy during the cesarean section (CS) when fibroids obstruct wound closure has been presented. A case of a primigravida with huge uterine fibroids displacing the fetus into a persistent oblique lie and causing maternal discomfort is presented. A planned cesarean myomectomy was performed. Hemorrhage was controlled with tourniquet using Foley catheter, misoprostol, and high dose oxytocin infusion. The mother and baby had a satisfactory outcome. Elective cesarean myomectomy is safe but should only be done by an experienced surgeon and in centers equipped with facilities for comprehensive emergency obstetric care.
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Traumatic splenic rupture in pregnancy with favourable pregnancy outcome: Case report p. 204
Adebayo D Agboola, Peter C Osuala, Oludolapo O Afuwape, Akinyinka O Omigbodun
DOI:10.4103/TJOG.TJOG_84_19  
Trauma complicating pregnancy is one of the causes of deaths that are not captured in the maternal mortality ratio, yet it occurs in about 1 in 15 pregnancies. This is a report of a case of splenic rupture occurring after a vehicle hit a pregnant woman who was a pedestrian. Splenectomy was done and, in spite of having a hemoperitoneum of about 2 litres, she recovered without further complication and was able to sustain the pregnancy to term, with the delivery of a healthy female infant. Clinicians should seek to exclude splenic rupture in cases of blunt trauma to the abdomen during pregnancy because of the risk of severe haemorrhage, shock, and possibility of pregnancy loss.
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Vaginal birth after laparoscopic management of heterotopic pregnancy at the Douala general hospital, Cameroon: A case report p. 207
Thomas O Egbe, Theophile Nana-Njamen, Henri Esome, George E Enow-Orock
DOI:10.4103/TJOG.TJOG_97_19  
Heterotopic pregnancy is the simultaneous presence of an intrauterine and ectopic pregnancy. The prevalence of the condition is unknown in Cameroon. We report a case of heterotopic pregnancy managed by laparoscopy. MS a 33-year-old G2P0010 woman was admitted to our department because of 7 2/7 weeks' amenorrhea, mild vaginal bleeding, and severe lower abdominal pain. She has a 6 years' history of secondary infertility, one induced abortion, and chlamydia infection treated with doxycycline. Furthermore, she has a history of left laparoscopic salpingotomy for tubo-ovarian abscess. She became pregnant after receiving clomiphene citrate and timed intercourse. Her beta hCG assay was 97000 mIU/mL and transvaginal sonography confirmed ruptured heterotopic pregnancy. She underwent laparoscopic left salpingectomy and the intrauterine pregnancy evolved normally and she gave birth to a healthy female that weighed 3050 g at 38 5/7 weeks gestation. The diagnosis of heterotopic pregnancy needs a high index of suspicion. Laparoscopic treatment of heterotopic pregnancy needs to become widespread in Cameroon.
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Carvenous hemangioma of the uterine cervix: A case report p. 210
Olumuyiwa A Ogunlaja, Gbemi Ano-Edward, Idowu P Ogunlaja, Matthew Lasisi
DOI:10.4103/TJOG.TJOG_23_19  
Carvenous hemangioma of the uterine cervix is a rare clinical condition which has the potential of being life threatening. This rare clinical condition can manifest with patients presenting with abnormal uterine bleeding, menorrhagia with eventual anaemia. The case report here is that of a 27 year old Para o+o lady who was admitted to the Accident and Emergency Unit of our hospital with a day history of a huge mass protruding per vagina and a history of significant bleeding per vagina. Packed cell volume was 16% on admission and she had 4 units of blood transfused. She subsequently had examination under anaesthesia and excision of the prolapsed mass done via the vaginal route. Histology of the excised mass was in keeping with cavernous hemangioma of the uterus. Her Postoperative clinical state was satisfactory.
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Scar endometriosis as a complication of surgically treated utero-cutaneous fistula p. 213
Ishak Kayode Lawal, Aliyu Kabir Suleiman, Nanthaniel Ketare, Chimezie Augustus Obiokonkwo
DOI:10.4103/TJOG.TJOG_78_19  
Extra-pelvic endometriosis is a rare form of endometriosis, however cesarean section scar is a common site for the rare condition. Scar endometriosis can be associated with obstetric or gynecologic surgeries. Utero-cutaneous fistula is an abnormal communication between the endometrium and the skin, this is another rare clinical condition that may complicate cesarean section. We report a case of a 23-year-old woman presenting with features suggestive of scar endometriosis about 20 months after surgical treatment of utero-cutaneous fistula. The utero-cutaneous fistula developed 2 months after cesarean section. This case is presented to highlight scar endometriosis as a complication of surgical management of utero-cutaneous fistula and emphasize the importance of complete surgical excision in the management of both rare conditions.
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LETTER TO EDITOR Top

The prevalence of syphilis in pregnant women in Akwa Ibom State, Southern Nigeria p. 216
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/TJOG.TJOG_91_19  
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ERRATUM Top

Erratum: Office cystometry in a resource-constrained setting: Spectrum of diagnoses and correlation with QUID p. 217

DOI:10.4103/0189-5117.292287  
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