Management of uterine fibroids in Enugu, Nigeria

Of Elephants and Other Mammals: A Comparative Review of Reproductive Tumors and Potential Impact on Conservation

Reproductive tumors can impact conception, pregnancy, and birth in mammals. These impacts are well documented in humans, while data in other mammals are limited. An urgent need exists to understand the reproductive impact of these lesions in endangered species, because some endangered species have a documented high prevalence of reproductive tumors. This article documents that the prevalence of both benign and malignant neoplasia differs between African and Asian elephants, with Asian elephants more frequently diagnosed and negatively affected by both. The prevalence of these tumors across mammalian species is compared, and impact plus treatment options in human medicine are reviewed to inform decision making in elephants. Evidence suggests that reproductive tumors can negatively impact elephant conservation. Future studies that document reproductive outcomes, including the success of various treatment approaches in elephants with tumors will benefit conservation efforts.

A clinical audit of the patterns of presentations and complications of abdominal myomectomy at the University College Hospital, Ibadan, Nigeria

Abdominal myomectomy is a common modality of treatment for large and symptomatic uterine fibroids in women who wish to retain their fertility. Black women have higher rates and larger sizes of uterine fibroids. We aimed to determine the presentation patterns, peri-operative complications, and determinants of complications in patients who underwent abdominal myomectomy. This was a retrospective review of women who had abdominal myomectomy between July 2016 and June 2019. There were intra-operative complications and post-operative complications in 25% and 29.3% of patients respectively. There were higher odds for developing intra-operative complications among those who had general anaesthesia [OR = 3.514, 95%CI (1.951-6.331)], more than 10 fibroid nodules enucleated [OR = 4.917, 95%CI (2.600-9.298)], pre-operative Packed cell volume (PCV) < 30% [OR = 4.831, 95%CI (2.370-9.880)], presence of adhesions [OR = 2.680, 95%CI (1.510-4.730)], fibroids larger than 10 centimetres [OR = 1.98, 95%CI (1.13-3.49)], previous pelvic surgery [OR = 2.68, 95%CI (1.52-4.63)]. Post-operative complications were higher in those who had general anaesthesia or pre-existing medical conditions.IMPACT STATEMENTWhat is already known on this subject? Abdominal myomectomy is a major surgical procedure globally with a significant morbidity rate. Sufficient evidence relating to the determinants of peri-operative complications are lacking.What do the results of this study add? Our results highlight the factors associated with increased odds of developing complications following abdominal myomectomy.What are the implications of these findings for clinical practice and/or further research? Our study complements existing data on the peri-operative complications following abdominal myomectomy. It also reflects the possibility of mortality albeit a rarerity. A retrospective multivariate analysis like this, while classifying morbidities into intra-operative and post-operative complications, is required to start an audit cycle. Knowing these determinants will help improve patient optimisation for surgery, identify high risk women and enhance more directed counselling. The results from this pilot study will also be used to design a prospective study to be undertaken by the authors.

Burden of Uterine Fibroids: An African Perspective, A Call for Action and Opportunity for Intervention

Black women carry the burden of uterine fibroids, (AKA uterine leiomyomas), at a much higher rate than their racial counterparts. Thus, increasing awareness and discovering a solution to an endemic problem that plagues Sub-Saharan Africa is of critical importance, not only for the region itself, but also for the medical community globally. A collaborative, patient oriented, cost effective, and culturally sensitive approach must be at the forefront of this endeavor. While the exact pathogenesis of uterine fibroid development remains elusive, the racial disparity is well documented. Moreover, in the developed world, women are able to seek treatment through surgical and non-surgical means; however, sub-Saharan regions face their own challenges that, if not addressed, can ultimately extinguish the lives of many suffering women. Unfortunately, the literature is scarce on how to prevent fibroid development, which may be critical for women who do not have access to effective interventions. Recent research from our group and others has shown that vitamin D deficiency plays an important role in fibroid development and may be a preventable risk factor. Daily vitamin D supplementation is a low cost, effective intervention that could be implemented throughout the Sub-Saharan region. Similarly, education and increased awareness as to the nature and symptoms of uterine fibroids could improve the quality of life, remove negative social stigma, and reduce morbidity and mortality rates in women who seek medical care with advanced uterine fibroids.

The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis

There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research.

The benefit of myomectomy in women aged 40 years and above: Experience in an urban teaching hospital in Nigeria

Background:

Abdominal myomectomy remains the mainstay of surgical management of uterine fibroids in our environment. However, its benefit in women aged 40 years and above remains debatable.

Materials and Methods:

An 11-year prospective study was conducted involving 98 women, aged 40 years and above, who had abdominal myomectomy for the treatment of uterine fibroid at the University of Maiduguri Teaching Hospital, Maiduguri. They were followed up regularly for 1–6 years to detect conception, resolution of symptoms and obstetrics performance. Data were analyzed using SPSS version 13.

Results:

The mean age of the patients was 42.6±2.9 years and 77 (78.6%) of them were nulliparous. Lower abdominal swelling was the commonest clinical presentation and the mean uterine size was 18.6±8.5 weeks. Infertility with uterine fibroids was the indication for myomectomy in majority of the cases [48 (48.9%)], while pregnancy complications accounted for 11.2% (11) of the cases Fertility restoration was 10.4% among the infertile patients. There was complete resolution of symptoms in 35.9% of those who required symptomatic relief, and term pregnancies were recorded in 72.7% of patients with pregnancy complications.

Conclusion:

Myomectomy is the recommended treatment of uterine fibroids in women aged 40 years and above with infertility and who wish to become pregnant. If there is no need for further fertility preservation, hysterectomy should be offered.

Surgical management of uterine fibroids at aminu kano teaching hospital

Objective. To determine the influence of age and parity on the surgical management of uterine fibroids, clinical presentation, presence of pelvic adhesions, cadre of surgeons, and postoperative complications at the Aminu Kano Teaching Hospital, Kano, Nigeria. Methods. A retrospective analysis of 105 cases of uterine fibroids that were managed between 1st January 2003 and 31st December 2007. Results. The period prevalence of uterine fibroids was 24.7% of all major gynecological operations. The mean age was 35.8 ± 7.6 and mean parity 4.7 ± 2.8. Abdominal hysterectomy accounted for 58.1% of the cases and myomectomy 41.9%. The odd of using abdominal hysterectomy was about twice that of myomectomy. Pelvic adhesions were found in 67.6% of the cases. Menorrhagia (86.7%) was the commonest symptom, while post operative anemia and pyrexia showed significant association with myomectomy. There was no maternal mortality. Conclusion. Surgical operations for uterine fibroids are safe and common kind of gynecological operations at the Aminu Kano Teaching Hospital. Uterine fibroid is associated more with high parity and dominance of abdominal hysterectomy over myomectomy, because early girl marriage is common in our community.

Uterine fibroids: risk of recurrence after myomectomy in a Nigerian population

PURPOSE

To determine the recurrence rate and risk factors for recurrence following myomectomy.

METHODS

Two hundred and thirty-two women who had open myomectomy were followed up for 3-10 years. Clinical features as well as pelvic ultrasound scan were used to evaluate the patients for recurrence. Recurrence rate was computed and the risk factors for recurrence were determined using Odd ratio comparing the Sociodemographic characteristics, preoperative symptoms, surgical and pathologic findings in the two groups of patients.

RESULTS

The mean age and parity of the patients were 29.3 ± 3.8 years and 1.2 ± 1.1, respectively. The desire for procreation after surgery was noted in 183 (78.9%) of the patients while the rest desired resolution of symptoms. More than half of the patients had multiple symptoms. Intraoperatively, 63 (7.2%) had single fibroid removed while the rest were multiple varying from 2 to 67 pieces. The overall recurrence rate during the follow-up period was 20.7% (48/232) at 10 years and this increases with time. Positive family history of uterine fibroids, multiple uterine fibroids, and persistence or recurrence of three or more of the pre-myomectomy symptoms were significantly associated with the recurrence of uterine fibroids (OR = 21.83, 3.14, and 3.49, respectively) while pregnancy after myomectomy and the use of oral contraceptive pills (OCP) were protective.

CONCLUSION

There is a high recurrence of uterine fibroid after myomectomy in our environment. The risk is higher among women with positive family history, multiple uterine fibroids, and in those with multiple symptoms. Pregnancy and use of OCP are protective.

Pattern of mental ill health morbidities following hysterectomy for benign gynaecological disorders among Nigerian women

Objective

to compare the pre and post hysterectomy mental ill health (MIH) status and also, to determine whether there is any association with the surgical indication.

Methodology

An observational study, conducted among women scheduled for hysterectomy at the University College Hospital, Ibadan from January till June 2005. The MIH morbidities were assessed using a validated general health questionnaire (GHQ) before and after the surgery by trained research assistant. The score of 4 and above was used as the cut off. Cross tabulations were performed to detect any association and also to compare pre and post hysterectomy mental health status. The level of statistical significance was set at P < 0.05.

Results

Of the 50 women recruited, 45 participated in the study. The age range of the participants was 35 to 63 years with a mean of 48.6 (SD = 0.6) years. Anxiety related disorder was present in 20 (44.4%), and depression in 3 (6.7%) before hysterectomy. Post surgery, there was significant increase in those with anxiety by 6.8% and a reduction in the proportion of depressive illness by 2.3%. Uterine fibroid as a preoperative diagnosis, had significant association among those with anxiety related disorder (68.4%) and depression (10.5%).

Conclusion

This study suggests that mental ill health may complicates hysterectomy for benign uterine pathology among Nigerian women, and that anxiety related disorders increases after operation with the highest proportion in those with clinical diagnosis of Uterine Fibroid. We recommend adequate preoperative counseling using properly trained psychologists when affordable to minimize these morbidities.