Postgraduate Medical Education (PME) in Nigeria: Past, Present and Future was a solicited paper delivered at the Annual Scientific Conference of Society of Obstetrics and Gynaecology of Nigeria held in Abuja in November 2015 in honour of Professor L. N. Ajabor, the doyen of medical practice and a foremost practitioner and researcher in Obstetrics and Gynaecology whose several achievements and influences on professional practice in undergraduate and postgraduate medical education span over 40 years within and outside Nigeria. This lecture was a befitting tribute to a hero, mentor and benefactor, who with several of his colleagues championed the development and implementation of PME in Nigeria in the 70s, the assessment undertaken in this paper suggests that while the main purpose of PME have largely being achieved in Nigeria, a lot remains to be done in propelling it beyond its original vision to enable it compare favourably with similar medical post graduate training in other parts of the world. This lecture is organized in four main areas: Professor Linus Ajabor autobiography, The history, origin and intention of postgraduate medical training from the international perspectives, the history of postgraduate medical education in Nigeria, status of residency training in Nigeria, challenges facing medical education in Nigeria. The PhD versus fellowship controversy in Nigeria and the future of postgraduate medical education in Nigeria.

Background: Caesarean section is one of the most commonly performed surgical procedures in obstetrics and certainly one of the oldest operations in surgery; the incidence of caesarean section is steadily rising. The increasing use of CS as a mode of delivery is due to improved safety of the procedure because of increasing use of antibiotics, blood availability, and improved anesthetic techniques. Despite all these, problems of safety and cost still pose some concern, particularly in resource-poor countries. Objective: To evaluate the incidence, indications, and outcomes of caesarean section in this hospital during the period under review. Materials and Methods: This is a retrospective descriptive analysis of all the caesarean sections carried out at the University of Abuja Teaching Hospital, Gwagwalada from 1^st January 2012 to 31^st December 2016. The labor ward delivery register and theatre operation register were also reviewed. The nature and indications for the procedure were analyzed. Other parameters reviewed included booking status of the patient, parity, and fetal outcome. Results were presented using simple percentages and ratios. Results: Out of 9,604 deliveries during the study period, 2,053 cases were by caesarean section, giving a caesarean section rate of 21.4%. Most cases 1647 (80.2%) were by emergency caesarean sections and elective caesarean section accounted for 406 (19.8%) cases. The rate of caesarean section was higher among unbooked patients 1304 (63.5%) than booked patients 749 (36.5%). Cephalopelvic disproportion was the most common indication 633 (30.8%) followed by fetal distress 484 (23.6%) and severe pre-eclampsia/eclampsia 224 (10.9%). Anemia was the most common postpartum morbidity and there were 17 maternal deaths and the maternal case fatality rate was 0.8%, and there were 62 (2.9%) perinatal deaths due to birth asphyxia following emergency caesarean section. Conclusion: The rate of caesarean section has been increasing gradually and is associated with maternal and perinatal morbidity and mortality. There is need for education of the populace to reduce late presentation.

Context: While reasonable progress has been made worldwide in reducing maternal mortality at the end of the millennium development goal, the same cannot be said of underserved rural communities where the tragedy continuous unabated. Aim: To determine the maternal mortality ratio, causes, and some socioeconomic determinants of maternal deaths in the last triennium of the Millennium Development Goal (MDG) in a rural tertiary center in Northeast Nigeria. Materials and Methods: Retrospective descriptive study of maternal mortality at the Federal Medical center (FMC) Nguru, Northeast Nigeria from January 1^st 2013 to December 31^st 2015. The center attends largely to underserved rural populace. Results were presented in simple percentages and means with a P value <0.05 considered as significant. Results: The maternal mortality ratio for the triennium was 7,364/100,000 live births with 2015 having the highest MMR of 8,517/100,000. Majority of the deaths occurred in unbooked (n = 87; 46.5%) women with no formal education (n = 120; 64.2%). A third of the maternal deaths occurred in women at the peak of their reproductive age of 25 to 34 years (n = 69; 36.9%). Grandmultiparity is a major risk factor for maternal deaths (43.9%; P = 0.02) compared to nulliparous women (31.5%; P = 0.08). Eclampsia (n = 64; 34.2%), Obstetrics hemorrhages (n = 22; 11.8%) and sepsis (n = 18; 9.6%) still remain the most common direct causes of maternal deaths while anemia was responsible for nearly 60% of the indirect causes. Significant number (36%) of these women reside in communities with secondary or tertiary health care facilities. Majority (39.5%) presented to a health care facility more than 24 hours from the onset of obstetric incidence with 52% of them dying within 24 hours of presenting to the FMC. Interestingly, 82% of the deaths from Nguru local government area are in those who reside within 5 kilometers of the FMC. Conclusion: This region has consistently maintained high MMR but this ratio of 7,364/100,000 live births is the highest so far. The causes of maternal deaths are still the same as they were 2 decades ago. The question still remains unanswered: why are many women not seeking healthcare services even when it is as close as 5 km from their residence? Why do women present with obstetric emergencies when over 70% of them reside were there are health care facilities? We recommend further research to answer these questions and to guide policies and programs that will lead to the achievement of sustainable development goal 3.1 by the year 2030.

Background: Data regarding burden of illness borne by women affected with cancer of the cervix (CaCvx) has been largely anecdotal. This study aimed to evaluate disability and cost burden of the illness in northern Nigeria. Materials and Methods: Cost of illness was determined using the bottom-up approach and involved estimating costs of managing various stages of the illness while disability adjusted life year (DALY) was estimated sing CaCvx survival data from northern Nigeria. Results: Overall cost of illness ranged from ₦191,338 ($524) to ₦1,001,298 ($2,743) for local to metastatic diseases, respectively. Of these, direct medical costs accounted for up to 75.4% while indirect costs accounted for up to 48% in different stages of the disease. Productivity losses ranged from 18.3% to 43.1%, while surgical, medical, and radiotherapies accounted for losses between 37.2% and 46%. Estimated DALY was 269 years/100,000 women with cost/DALY saved on treatment estimated at between $19 and $1,443 for different stages. At the discounted rate, it was estimated that it would be 16 to 902 times cheaper to screen for the disease than to treat (P < 0.0001). Conclusion: Though burden of illness borne by women with CaCvx in northern Nigeria is similar to that borne by women in other developing countries, it is still too high; and the only panacea to this is institution of early screening programs and immunization. In addition, concerted effort is needed to ensure extension of health insurance coverage for cancer therapy and increase in availability of radiotherapy service as a means of reducing waiting times for treatment.

Background: The scope of endoscopy is expanding more and more as experience is gained with training and collaborations, however, these expansions could be slowed by challenges. Objectives: To determine the experiences and challenges of gyne-endoscopic surgery. Materials and Methods: This study was a prospective analysis of all women undergoing gynecologic endoscopy at Federal Teaching Hospital Abakaliki (FETHA), Nigeria from 2012 to 2014. Patients were recruited based on eligibility for endoscopy surgery. Written informed consent was obtained before any of the gyne-endoscopic surgery. Ethical approval for the study was given by the ethics and research committee of FETHA. Laparoscopy and hysteroscopy were performed by the managing team. EPI Info version 3.5.1 statistical software (Atlanta, GA, USA) was used for data analysis. Results: Seventy-three different gyne-endoscopic surgeries were done, with dye test accounting for majority 28 (77.8%). The duration of surgery ranged from 23 to 248 minutes, and the surgery with the longest duration was total laparoscopic hysterectomy while laparoscopy and dye test had the shortest operating time. The mean duration of hospitalization was 20.3 ± 14.4 hours. There were 2 (5.6%) conversions to open surgery. Most common complication was abdominal pain 26 (72.2%). The challenges include third party partnership, lack of vital equipment, poor maintenance, epileptic power supply, late presentation of cases, and misconception. Conclusion: Gyne-endoscopy is essential in contemporary medicine. Reduction in operating time occurs as skills and experience improve; the challenges are many.

Context: An optimally functional reproductive system and fecundity is fundamental for the sustenance of life. Undiagnosed and untreated thyroid disease may cause infertility. Aim: To evaluate and compare thyroid function tests of infertile women with those of fertile women. Settings and Design: There were 216 infertile women and 200 fertile women in this study. Materials and Methods: Serum thyrotropin (TSH), free thyroxine (FT4), free triiodothyronine (FT3), antibodies to thyroid peroxidase (TPOAb), follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, progesterone, and estrogen were analysed using ELISA techniques. Statistical Analysis Used: Statistical Package for Social Sciences (SPSS) version 17.0 (SPSS Inc. Chicago, Illinois, U.S.A.). Results: Overall prevalence of thyroid disorders in infertile women was 4.6%. They had higher prevalence of thyroid autoimmunity (TAI) (2.8%) compared to controls (1.0%). They also had overt hypothyroidism (0.9%) and overt hyperthyroidism (0.9%) whereas controls had only subclinical hypothyroidism (1.0%). Infertile patients had significantly higher FSH, LH, prolactin, and estrogen, but lower progesterone values than controls. There was no significant difference in the mean FT3, FT4, TSH, and TPOAb between patients and controls. However, after further stratification, women with TSH >2.5 mIU/L were observed to have higher mean TSH and prolactin, and lower FT4 and FT3 levels than women with TSH ≤2.5 mIU/L. Conclusions: Significant findings were observed only in infertile, and also fertile, women with TSH >2.5 mIU/L, who had lower levels of FT4 and FT3 and higher levels of TSH and prolactin compared to women with TSH ≤2.5 mIU/L, respectively.

Background: Early pregnancy loss is a challenging experience for both the patient and the physician; it is unfortunately a common complication of human gestation. Early pregnancy loss is defined as the termination of pregnancy before 20 weeks of gestation or with a fetal weight of <500 g. Immunological disorders have been attributed to early pregnancy loss in addition to chromosomal abnormalities. Thyroid autoimmunity is one of the immunological causes of early pregnancy loss that has been poorly studied in sub-Saharan Africa. Objective: This study was aimed at determining the relationship between early pregnancy loss and thyroid autoimmunity in Jos, North-Central Nigeria. Patients and Methods: This was a case-control study involving 44 women with a current history of miscarriage at an average gestational age of 11.57 ± 4.3 weeks (cases) and 44 pregnant women with previous history of delivery with no history of miscarriage(s) at a mean gestational age of 17.9 ± 4.9 weeks (controls). Serum thyroglobulin antibody (TgAb) and thyroid peroxidase antibody (TPOAb) were assayed by Electro-chemiluminescence immunoassay (ECLIA) using Cobas e411 auto analyzer (by Roche). The data obtained were analyzed using SPSS version 16.0. Results: TgAb was neither present in the cases nor in the control group. The prevalence for TPOAb was 11.4% for the cases and 4.5% for the controls. The difference in proportion was not statistically significant (P = 0.434). Conclusion: There was no statistically significant relationship between thyroid autoimmunity and early pregnancy loss.

Background: Postpartum hemorrhage (PPH) is a major cause of maternal mortality globally. Tranexamic acid, an anti-fibrinolytic agent, is a novel approach to prevent this dreadful complication. This study aims to document the efficacy of intravenous (IV) tranexamic acid in reducing blood loss during and after cesarean section (CS). Materials and Methods: In this prospective, randomized, placebo-controlled, open-label study, 100 mothers scheduled for elective CS were randomly selected and divided into two groups (study and control) of 50 each. The study group received 1 g IV tranexamic acid and the control group received IV placebo. Following delivery, all mothers received 10 units of oxytocin in 500 mL of normal saline. Results: The mean intraoperative and postpartum blood loss were significantly lower in the study group than the control group: 499.11 ± 111.2 ml and 59.93 ± 12.5 ml versus 690.85 ± 198.41 ml and 110.06 ± 13.47ml, respectively (P < 0.001). Total blood loss was 30% less in the study group (P < 0.001). Six mothers had PPH in the control group while none in the study group had PPH. The difference between the preoperative and postoperative hemoglobin values was significantly less in the study group than the control group, 0.26 ± 0.22 g% versus 0.99 ± 0.48 g% (P < 0.001).There was no significant difference with respect to other hematologic parameters. There was no added adverse effect or need for NICU admission in the study group. Conclusion: Preoperative IV tranexamic acid significantly reduced blood loss during elective CS without any significant adverse effects.

Background: Antenatal care has an important role in identifying high-risk pregnancies and improving the chances of safe motherhood particularly in developing countries where obstetric indicators are still poor. The objective of this study was to determine the choices women of reproductive age in Vom, a semirural town at the outskirts of Jos the capital of Plateau State Nigeria made to have antenatal care. Materials and Methods: This was a cross-sectional study carried out between January and March 2015 in Vom, a semirural area about 30 km from Jos the capital of Plateau State among 2,641 (Two thousand six hundred and forty one) women of reproductive age. Results: Fifty-eight percent of the respondents opted for antenatal care in government-owned hospitals while 29% chose faith-based institution which was in their vicinity, 11% favored private hospitals for antenatal care, while 1% chose traditional birth attendants (TBAs) and prayer houses to receive antenatal care. The majority of the respondents (32%) were females between the ages of 40 and 44 years while 22% were aged between 25 and 29 years of age. They were predominantly farmers of the Berom ethnic group and 47% of them had completed primary level of education. Conclusion: Females in the reproductive age in this rural setting in northcentral Nigeria favored government-owned hospitals as places to receive antenatal care. Their choices were not affected by their educational status varied according to the age ranges of the respondents.

Purpose: The purpose of this study was to assess the adverse maternal outcome and its assocoation with gestational diabetes among mothers who gave birth at selected public hospitals in Eastern Ethiopia. Patients and Methods: This study conducted from December 2015 to April 2017. We recruited a total of 1834 delivering mothers, and took equal number of mothers in both hospitals. Structured and pretested questionnaires were used to collect the sociodemographic, obstetrics history, and maternal outcome data during the study. Mothers who have a risk factor for gestational diabetes mellitus underwent oral glucose tolerance test to confirm the diagnosis. The collected data was entered into EPI-info version 3.5.1 and then exported to SPSS version 20.0 software for analysis. Results: Pre-eclampsia was the major 169 (9.2%) adverse pregnancy outcome observed among the study participants, which was followed by obstetric hemorhhage 107 (5.8%). Premature rupture of membrane and preeclampsia were found to have an association with gestational diabetes with AOR=3.44 [95% CI = 1.69–6.97] and AOR = 4.15 [95% CI = 2.16–7.95], respectively. Conclusion: In our study, we found that the major adverse outcome among women who delivered in Hiwot Fana and Dilchora hospitals were preecalampsia and obstetrics heamorhage which are the major causes of maternal mortality in developing countries. Among different adverse maternal outcomes observed PROM and preeclampsia were found to have a significant association with gestational diabetes.

Background and Objective: The accurate gestational age (GA) is critically important for pregnancy management, particularly for determining viability and growth in premature labor. The aim of this study was to evaluate the usefulness of occipitofrontal diameter (OFD) in estimation of GA in the second and third trimester of pregnancy. Materials and Methods: In this cross-sectional prospective study, a total of 483 Sudanese pregnant women underwent the routine sonographic examination at different antenatal care centers in Khartoum state using curvilinear transducers 3.5 MHz. The fetal OFD, biparietal diameter (BPD), and femoral length (FL) were measured and correlated with GA. Equations were obtained from regression models to estimate the GA. Results: In total, 384 singleton fetuses ranging between 12 and 40 weeks of gestation were enrolled. A statistically significant and strong relationship was found between OFD and GA, R² = 0.85. The model regression of OFD, BPD, and FL produced together with an accurate equation to estimate GA in second and third trimester with the equation; GA (weeks) = 4.474 + 100 × BPD + 0.118 × OFD + 0.128 FL (r = 0.909, n = 384, SE = 2.271). The equation of GA from OFD alone was GA = 3.663+.286 × OFD with SE = 2.882. The OFD can be used as a single lone parameter in the estimation of GA to give an accuracy of SE ± 2.882 days, but when used in combination with the other two parameters, the accuracy increased to SE ± 2.770 days. Conclusion: Fetal OFD assessed by sonography may serve as a useful parameter in determining GA and evaluating fetal growth in the second and third trimesters of pregnancy.

Background: Multiple pregnancy remains a significant determinant of perinatal outcome and a contributor to neonatal morbidity and mortality. Aim: To determine the prevalence, trend, and fetomaternal outcome of multiple births at Federal Medical Centre, Bida. Materials and Methods: This was a retrospective study of multiple births at Federal Medical Centre, Bida, Nigeria from 1^st January 2010 to 31^st December 2013. Data was collected using a pro-forma and then analyzed. Results: The period prevalence of multiple births was 28.4/1000 births and it ranged from 28.6/1000 births in 2010 to 27.4/1000 births in 2013. Associated with multiple births were prematurity, low birth weight, birth asphyxia, high perinatal mortality, and caesarean section. There was correlation between multiple births and increased maternal age which reached its peak at 25–29 years as well as maternal hypertensive disorders. There was no associated maternal death. Conclusion: The prevalence of multiple births was 28.4/1000 births and it was associated with prematurity, low birth weight, birth asphyxia, and admission to special care baby unit as well as increased cesarean section rate and maternal hypertensive disorders.

Background: Intermittent preventive treatment of malaria in pregnancy with sulphadoxine–pyrimethamine (SP) is recommended for prevention of malaria in pregnancy. However, chemoprophylaxis with proguanil (PG) is being used in pregnancy for preventing malaria in selected cases. Objective: To compare the efficacy of daily PG and intermittent monthly SP in preventing malaria and its complications during pregnancy. Patients and Methods: This was a prospective comparative study conducted among 270 consenting pregnant women with parity ≤2 at gestational age of 18–24 weeks. Participants were enrolled and randomized to PG or SP group following a baseline hemoglobin estimation and blood film negative for malaria parasite. At 36 weeks of gestation, maternal blood sample was checked for hemoglobin concentration and malaria parasitaemia, and the infant birth weight was assessed at delivery. Statistical Analysis: Appropriate univariate, and bivariate analysis employed and level of significance set at P < 0.05. Results: One hundred and thirty-five participants in each group (246) completed the study. Ten (8.5%) had malaria parasitaemia in the PG group at 36 weeks compared to 15 (11.7%) in the SP group (P = 0.40); 5 (4.3%) in the PG compared with 6 in SP group (4.7%) had anemia (Hb <10 g/dl) at 36 weeks (P = 0.86). In addition, 6 (5.1%) participants in the PG group developed clinical malaria compared to 3 (2.3%) in the SP group (P = 0.25). The mean infant birth weight in the PG and SP groups were 3.05 kg and 3.00 kg, respectively (P = 0.24). Conclusion: PG and SP were comparable in efficacy and outcome for malaria prevention during pregnancy. IPT-SP is recommended for prevention of malaria in pregnancy. However, PG is beneficial in selected patients with known adverse reactions to sulphonamide.

Context: Instrumental vaginal delivery is one of the lifesaving functions of emergency obstetric care to reduce perinatal and maternal morbidity and mortality. Objective: To determine the instrumental vaginal delivery rate, the trends, and the status of their operators in Jos University Teaching Hospital, Nigeria (JUTH) over a 7-year period (1997–2003). Study Design: A 7-year cross-sectional study of obstetric service data from 1^st January 1997 to 31^st December 2003. Patients and Methods: A register was kept for all cases of instrumental deliveries at JUTH from 1^st January 1997 to 31^st December 2003. This register with the patient case notes and neonatal ward records was used to conduct this study. Results: During the study period, there were a total of 17,888 deliveries and 349 instrumental vaginal deliveries, giving a rate of 1.95%. Out of these, 238 (68.2%) were vacuum extraction and 111 (31.8%) were forceps delivery. There was a 67% decline in the use of these instruments from 84 (3.18%) in 1997 to 34 (1.05%) in 2003. Majority 313 (90%) of the procedures were performed by residents (Registrars 49%, Senior Registrars 41%). Consultants performed 10%, and all were in the first four years of the study. Forceps delivery rate 0.62% and vacuum delivery rate was 1.33%. There was a strong negative correlation with the performance of IVD in JUTH. At the current trend, no forceps delivery (R = −0.93008) will be performed in JUTH in 2005 while only 4 vacuum deliveries (R = −0.80015) will be conducted in in the same period. Discussion: There is a low instrumental vaginal delivery rate in JUTH with a strong negative correlation in the performance of these procedures. Most procedures are performed by residents, and vacuum is the preferred procedure. Conclusions: Instrumental vaginal delivery in JUTH is a dying art. Training and re-training of resident doctors on this lifesaving function is recommended.

Peptic ulcer disease is a rare cause of rapidly progressing anaemia in pregnancy, especially during the second trimester of pregnancy. Making a definitive diagnosis in this group of patients is usually very tasking, especially when the common causes of anemia in pregnancy such as Malaria, Sickle Cell Disease, Upper respiratory tract infection, nutritional anemia, e.g., iron and folate deficiency anemia and ruptured ectopic gestation are excluded. We present a rare cause of rapidly progressing mid-trimester severe anemia in pregnancy secondary to peptic ulcer disease in pregnancy, along with the diagnostic challenges, multidisciplinary management, literature review, and the follow-up care.

Obstetric fistula accounts for most genital tract fistulae seen in the developing countries and poses significant psychosocial stress on the woman. It is a cause of marital disharmony, stigmatization, and infertility. Thus, women with unrepaired vesicovaginal fistula (VVF) rarely present with coexisting pregnancy. We present a rare case of a 29-year-old unbooked G3P2 (1A) with unrepaired VVF who presented with an advanced second stage of labor of a preterm fetus at 32 weeks of gestation. She was referred from a primary health center in labor. She had ruptured her fetal membranes about 3 days before presentation. She had been experiencing continuous involuntary leakage of urine about 2 weeks after vaginal delivery of a macerated male stillbirth following prolonged labor at a traditional birth home about 13 months earlier. She had not sought any specialized care for her condition due to financial challenges. She had regular unprotected coitus despite urinary soiling; her menstrual cycle was regular and she achieved conception. At presentation, she was in intermittent painful distress with bearing down efforts and had ammoniacal fetor. Fundal height was 34 cm and a singleton fetus was palpated in longitudinal lie and cephalic presentation with a normal fetal heart rate. The fetal head was visible at the introitus without parting the labia, and amnii liquor was foul smelling with ammoniacal dermatitis of the vulva and upper thigh. She delivered a live male baby with poor APGAR scores and birth weight of 1.96 kg. A 4 cm × 4 cm mid-vaginal defect was noticed on the anterior vaginal wall accommodating an inflated balloon of urethral catheter. She subsequently had VVF repair and rehabilitation. Financial challenge is an impediment to adequate care of VVF. This report establishes the possibility of regular coitus leading to conception and a live birth despite ongoing urinary soilage. Enhancement of social support services is advocated.

Data about the occurrence of primary carcinoma in ectopic breast tissue are rare and limited to small case series. Nowadays, its diagnosis and management are not definitively established. We report the case of a 61-year-old woman with primary carcinoma originating from the left axillary ectopic breast which was treated surgically by ectopic breast mastectomy with axillary lymph node dissection.

To describe an atypical presentation of subserous uterine fibroid. We report a case of pseudo-Meig's syndrome from subserous uterine fibroid in a 31-year-old para 0⁺⁰ woman who had myomectomy, appendectomy, and bilateral wedge resection of both ovaries. Histopathological examination confirmed uterine leiomyoma, appendicitis, and normal ovaries. Pseudo-Meig's syndrome is a condition which describes the association of any ovarian tumour (other than ovarian fibroma) or any other pelvic tumor such as leiomyoma with ascites and pleural effusion. Very few studies have reported the association of this entity with leiomyoma. It becomes highly important to identify this condition as it is a curable condition mimicking malignancy and can avoid unnecessary interventions. Subserous fibroid presenting with pseudo-Meig's syndrome is a rarely reported entity, especially in Nigeria, which can mimic malignant condition; hence, it is important to consider it as a differential in patients within the reproductive age presenting with ascites.