Analgesic efficacy and safety of paracervical block versus conscious sedation in the surgical evacuation of the uterus following first-trimester incomplete miscarriages: A randomised controlled trial

Objective:

To compare the analgesic efficacy and safety of paracervical block and conscious sedation in the surgical evacuation of the uterus following a first-trimester miscarriage.

Methods:

This is an open-label, randomised control trial comparing pain relief by paracervical block versus conscious sedation during manual vacuum aspiration of first-trimester incomplete miscarriages. One-hundred and sixty-two women were equally randomised into two groups. Group A (paracervical group) received a paracervical block of 4 ml of lidocaine each at the 4 and 8 o’clock positions. Group B (conscious sedation group) received intravenous 30 mg pentazocine and 10 mg diazepam. Data obtained were presented using a frequency table, student t-test, chi-square and Mann–Whitney test and bar chart. A P-value of ⩽0.05 was taken to be statistically significant.

Results:

The mean pain score was lower in the paracervical block group compared to the conscious sedation group (P < 0.05); however, there was no significant difference in women’s satisfaction between the groups (P ⩾ 0.05). Conscious sedation had more negative side effects compared to paracervical block which was significant (P < 0.05).

Conclusion:

Paracervical block has better pain control compared with conscious sedation and has a good side effect profile.

Trial registration:

Pan African Clinical Trial Registry (registered trial no. PACTR202108841661192).

Synopsis

Paracervical block for manual vacuum aspiration (MVA) during first-trimester miscarriage is associated with less pain among women compared with conscious sedation.

Psychological Distress among Caregivers of Children Admitted into the Children Emergency Room of a Nigerian Tertiary Hospital

BACKGROUND

Many caregivers experience significant psychological burden which may impact on the management of a sick child.

OBJECTIVE

To determine the prevalence and associated factors of psychological distress among caregivers of children admitted at the Children Emergency Room.

METHODS

This was a descriptive cross-sectional study among caregivers of children who were hospitalized for at least 24 hours. The 28-item General Health Questionnaire (GHQ 28) was used to assess the psychological distress among the caregivers. GHQ scores were stated as means ± standard deviation (SD). Chi-square or Fisher's exact test was used to test for association between sociodemographic variables and psychological distress. Mean GHQ scores in the various domains of psychological dysfunction were compared among groups using the independent sample t-test; at p<0.05.

RESULTS

Of the 97 caregivers who participated in the study, 96 had their data analyzed. The caregivers were aged 19 to 63 (mean 34.25 (8.46)) years; 86 (89.7%) were females and 48 (50%) had tertiary education. The prevalence of psychological distress among the care givers was 69.8%. Caregivers had high levels of anxiety but low levels of depression. Those with lower educational attainment had higher scores on severe depression domain (p = 0.001). Unemployed caregivers had higher mean scores on the anxiety/insomnia (p = 0.039) and social dysfunction domains (p = 0.031). Those with large family sizes scored higher on the anxiety/insomnia domain (p = 0.03).

CONCLUSION

Psychological distress was high among caregivers of children admitted at the children emergency room.

Microbiological profile and antibiotic resistance pattern of empyema thoracis in Calabar, Nigeria

Targeted empirical antibiotic therapy based on local microbiology and antibiotic resistance patterns is essential for the treatment of empyema thoracis. Our retrospective review of 105 pleural empyema culture and sensitivity reports aimed at determining the causative microorganisms and their antimicrobial resistance pattern. Of 105 pleural aspirate samples, 46 (43.8%) were positive on culture. Gram-negative organisms (n = 43) were the predominant isolates, the commonest of which was Klebsiella pneumoniae. It was concluded that empyema thoracis is predominantly caused by Gram-negative organisms in our locality. This should guide protocols on the initiation of empirical therapy.

Comparison of age-based weight estimation with actual measured weight in children aged one to twelve years in Enugu

Aims

This study was carried out to evaluate the degree of accuracy of age-based weight estimation methods in assessing the weight of the Nigerian child.

Method

The weights of one thousand, four hundred and fifty-six (1,456) children were measured and compared with the updated Advanced Paediatric Life Support (APLS), Best guess, Nelson and Luscombe & Owen methods.

Result

The updated APLS, Nelson and Luscombe & Owen methods underestimated the weights in younger children while overestimating in older ones. Best guess overestimated the weights across all ages. The Nelson formula had the best agreement within 10% and 20% of the measured weights among all methods. A linear regression analysis produced an equation for weight estimation: weight (W) = 2.058 Y + 9.925, where W is weight in kilogram and Y is the age in years.

Conclusion

None of the weight estimation formulae assessed was entirely accurate in our study, though the Nelson method showed superior agreement.

The prevalence of allergic diseases among children with asthma: What is the impact on asthma control in South East Nigeria?

Background

Allergic diseases are known to occur in children with asthma and its coexistence with asthma may impact on asthma control in affected children living in a low-income country. The study is to determine the allergic profile of children with asthma and the association with asthma control and attendant social risk factors.

Materials and Methods

This was a cross-sectional study of consecutively enrolled children with physician diagnosed asthma, attending clinics in a tertiary center in Nigeria. The presence of asthma, allergy types, and asthma control levels were determined using the Gobal initiative on asthma (GINA), international study of asthma and allergy in childhood and asthma control test questionnaires, respectively.

Results

There were 207 children with asthma enrolled from the Pediatric Asthma Clinic at University of Nigeria Teaching Hospital, Enugu. The median age was 10 years and interquartile range of 7-11 years. There were 127 (61.4%) from middle and high socioeconomic class and 86.5% who lived in the urban areas. Of the study participants, 41.5% had one or more allergy symptoms; rhinitis (33.3%), conjunctivitis (29.0%), and dermatitis (7.2%). Allergy symptoms persisted from infancy in 55.9%. Children from large families had a lower prevalence of allergies. Having any allergy symptom and belonging to a small-sized family were both associated with asthma exacerbations. Most children studied, (69.1%) had their asthma under control. Allergy persistence from infancy and type of allergy were not significantly associated with the level of asthma control.

Conclusion

Allergic diseases are common in children with asthma in our environment, but did not significantly impact on asthma control. Socioeconomic factors such as urbanization and family size had effects on the achievement of asthma control but not on allergy status.

The preference and practice of Nigerian obstetricians regarding focused versus standard models of prenatal care

OBJECTIVE

To determine preferences, practices, and acceptance of focused versus standard prenatal-care models among Nigerian obstetricians.

METHODS

A cross-sectional survey was performed among clinicians who attended a conference held in Lagos, Nigeria, between November 27 and 29, 2013. The questionnaire assessed sociodemographic characteristics and opinions on prenatal care.

RESULTS

A total of 201 delegates returned complete questionnaires. All respondents were aware of both models of prenatal care. Although 70 (34.8%) respondents stated a preference for focused care, only 6 (3.0%) used this model in clinical practice. The main reason for their preference was the evidence base (23.4%). Overall, 185 (92.0%) respondents stated institutional protocol determined preference for and practice of standard care, 108 (53.7%) believed patients preferred standard care, and 89 (44.3%) felt standard care had health benefits. Preference for one model over the other was significantly associated with type and level of the healthcare practice (P=0.002 and P<0.001, respectively). Modification of the focused model to meet local, national, and cultural needs was recommended by 171 (85.1%) respondents.

CONCLUSION

Most obstetricians are skeptical about focused prenatal care and have not embraced this model owing to personal, institutional, and sociocultural factors.

Demographic, socio-economic and clinical characteristics: implications for time to presentation at a Nigerian tertiary ophthalmic outpatient population

OBJECTIVE

To investigate the associations between time to presentation, and sociodemographic and clinical characteristics of new adult ophthalmic outpatients at the University of Nigeria Teaching Hospital (UNTH), Enugu, between March and August 2010.

STUDY DESIGN

Hospital-based case-control study.

METHODS

Consecutive new ophthalmic outpatients at UNTH were categorized into controls (early presenters, i.e. <3 months after onset of current eye disease) and cases (late presenters, i.e. >3 months after onset of current eye disease). Relevant data were obtained from the participants' case notes and interviews. Descriptive statistics yielded frequency distributions; bivariate and multivariate comparisons were used to test the significance of associations. P < 0.05 was considered to indicate significance.

RESULTS

Eight hundred and twenty-four subjects [454 males and 370 females, mean age 39.2 (standard deviation 1.2) years, range 19-82 years] participated in this study. There were 370 early presenters and 454 late presenters. Multivariate analysis found that late presentation was significantly associated with age >50 years [odds ratio (OR) 1.34, 95% confidence interval (CI) 1.28-2.22; P < 0.01], female gender (OR 1.63, 95% CI 1.52-2.11; P < 0.01), residence >20 km from UNTH (OR 0.65, 95% CI 0.38-0.89; P = 0.0212), individual-level deprivation (OR 0.69, 95% CI 0.55-0.92; P = 0.0324) and subnormal visual acuity at presentation (OR 1.32, 95% CI 1.05-1.76; P = 0.0353).

CONCLUSIONS

At UNTH, most new adult ophthalmic outpatients present >3 months after onset of their current eye disease. Measures to overcome age-, gender- and distance-related causes of late presentation, grassroots economic empowerment of the feeder population and public education about eye health are required.

Obstetric analgesia for vaginal birth in contemporary obstetrics: a survey of the practice of obstetricians in Nigeria

Background

Contemporary obstetrics in sub-Saharan Africa is yet to meet the analgesic needs of most women during child birth for a satisfactory birth experience and expectedly, obstetricians have a major role to play in achieving this.

Methods

This was a questionnaire-based, cross-sectional study of 151 obstetricians and gynecologists that attended the 46th Annual General Meeting and Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) held in Abakaliki, southeast Nigeria in November, 2012. SOGON is the umbrella body that oversees the obstetric and gynecological practice in Nigeria. Data was collated and analyzed with Epi-info statistical software, and conclusions were drawn by means of simple percentages and inferential statistics using Odds Ratio, with P-value < 0.05 at 95% Confidence Interval (CI) taken to be statistically significant.

Results

Of the 151 participants, males predominated; 110 (72.9%) practiced in government-owned tertiary hospitals in urban locations. Only 74 (49%) offered obstetric analgesia. Among users, only 20 (13.3%) offered obstetric analgesia routinely to parturients, 44 (29.1%) sometimes and 10 (6.6%) on patients’ requests. The commonest analgesia was opioids (41.1%). Among non-users, the commonest reasons adduced were fear of respiratory distress (31.1%), cost (24.7%) and late presentation in labour (15.6%).

Conclusion

The routine prescription and utilization of obstetric analgesia by obstetricians in Nigeria is still low. Obstetricians are encouraged to step up its use to make childbirth a more fulfilling experience for parturients.

A six-year study of the clinical presentation of cervical cancer and the management challenges encountered at a state teaching hospital in southeast Nigeria

Cervical cancer is still a major contributor to cancer-related mortality amongst women living in poor, rural communities of developing countries. The objective of this study is to establish the clinical presentation of cervical cancer and the management challenges encountered in Abakaliki, southeast Nigeria, with a view to finding intervention strategies. This study is a retrospective descriptive assessment of cases of clinically diagnosed cervical cancer managed at a state teaching hospital over six years. Of 76 cases managed, 61 (80.3%) cases notes were available for study. The mean age and parity of patients were 53.8 years and 6.8 years, respectively. The majority (75.4%) were illiterate. All had been married, but 42.6% were widowed. The main occupations were farming or petty trading. One patient (1.6%) had had a single Pap smear in her life. The major presenting complaints were abnormal vaginal bleeding (86.9%), offensive vaginal discharge (41.0%), and weight loss. Twenty patients (32.8%) were lost to follow-up prior to staging. Of the remaining 41 patients, 16 (39.0%) had stage III disease and 17.1% stage IV. Fifteen patients (24.6%) with late stage disease accepted referral, and were referred for radiotherapy. Those who declined were discharged home on request, though 4 (9.8%) died in the hospital. There was no feedback from referred patients confirming that they went and benefitted from the referral. The presentation followed known trends. Illiteracy, poverty, early marriages, high parity, widowhood, non-use of screening methods, late presentation, non-acceptance of referral, and lack of communication after referral were some of the major challenges encountered. These underscore the needs for health education and awareness creation, women educational and economic empowerment, legislation against early marriages and in protection of widows, and creation of a well-staffed and well-equipped dedicated gynecologic oncology unit to forestall further referral.

Bilateral tubal ectopic pregnancies: a report of two cases

Bilateral tubal ectopic pregnancies are rare occurrences. Two recently managed cases are discussed. The first was a single, sexually active 23-year-old nullipara with family history of twinning who presented with eight weeks amenorrhea, positive pregnancy test, lower abdominal discomfort and other clinical and ultrasound findings suggestive of unruptured left tubal pregnancy. Intra-operatively, unruptured bilateral tubal pregnancies were found and bilateral salpingotomy performed with uneventful recovery. Histology of the specimens confirmed the intra-operative diagnosis. She was appropriately counseled. Case 2, a 30-year-old multiparous housewife who had been on clomid for secondary infertility, presented with signs and symptoms of ruptured tubal ectopic. Intra-operatively, ruptured left and unruptured right tubal pregnancies were found and salpingectomy and salpingotomy were done respectively, with uneventful recovery. The diagnosis was also confirmed histologically and counseling given as in case 1. Bilateral tubal ectopic pregnancies appear to be increasing with twin proneness and use of fertility drugs as risk factors. Whether spontaneous or induced, the hallmarks of good management include early presentation, high index of suspicion, meticulous ultrasound scanning, good case selection, judicious intra-operative inspection of the contralateral tube, histology of specimens and appropriate patient counseling.

The incidence, pattern and management outcomes of early pregnancy losses at the Ebonyi State University Teaching Hospital, Abakaliki

BACKGROUND

Early pregnancy losses are a source of deep emotional trauma to any woman, her family and the attttending Gynaecologist. This study evaluated the prelence, pattern and management outcomes of such losses at a tertiary Health Institution.

METHODS

Data of all women who suffered early pregnancy losses between 1st January, 2002 and 31st December, 2004, were reviewed in a descriptive study. Information obtained from their case notes which related to the early pregnancy event, their socio demographics, obstetric history and management outcomes were collated. Univariate analysis was performed and frequency tables and figures were constructed where appropriate.

RESULTS

Early pregnancy losses comprised miscarriages, molar pregnancy and ectopic gestations accounted for 32.1% of all gynaecological admissions during the period. Miscarriages were the commonest diagnosis and incomplete abortion constituted the bulk of this. Women of all parities were involved but rate of loss increased down the socio economic class strata. Majority were unbooked. A maternal mortality rate of 1.8% attended all forms of early pregnancy losses during the period.

CONCLUSION

Early pregnancy loss constitutes a major gynaecological problem in our centre. Health care providers must institute prompt and appropriate clinical management for a good clinical outcome.

Uterine rupture at a secondary hospital in Afikpo, Southeast Nigeria

INTRODUCTION

Uterine rupture is an obstetric catastrophe that is associated with high maternal and perinatal mortality rates. Its incidence is high in developing countries. In Nigeria, the incidence of uterine rupture continues to increase due to poverty, illiteracy, ignorance, the lack of quality obstetric care and bad governance.

METHODS

A retrospective review was conducted of all cases of ruptured uterus seen at the Mater Misericordiae Hospital in Afikpo, Nigeria between January 2001 and December 2007.

RESULTS

There were a total of 51 ruptured uteri out of 4,361 deliveries, yielding a ratio of one in 86. A total of 19 (37.3 percent) patients had a scarred uterus, while 32 (62.7 percent) had an intact uterus, yielding a scarred to unscarred uterus ratio of one in 1.7. The mean maternal age was 32.0 years, and the mean parity was 3.4. Patients with a scarred uterus had a lower mean age and parity. 29 (56.9 percent) cases were unbooked, out of which seven (24.1 percent) had a scarred uterus. Obstructed labour (88.2 percent), grandmultiparity (27.5 percent) and abnormal lie (9.8 percent) were the main causes of rupture. 39 (76.5 percent) patients had their labour managed at home or by traditional birth attendants before presentation. 45 (88.2 percent) patients underwent uterine repair alone, five (9.8 percent) had uterine repair with bilateral tubal ligation and one (two percent) had a hysterectomy. Three maternal deaths occurred, yielding a case fatality rate of 5.9 percent. The perinatal mortality rate was 84.6 percent.

CONCLUSION

Health education, the provision of quality obstetric care, improved governance and monitoring of the activities of traditional birth attendants may help to reduce the menace of uterine rupture.

Avulsion of the perineal body in a single nulliparous woman following a motorcycle accident: a case report

Miss OO was seen at the gynaecology clinic in April 2008 with history of a road traffic accident three years earlier. She was thrown off a motorcycle and fell astride a culvert, sustaining perineal injury. She was treated at a private hospital, but subsequently developed faecal incontinence and was usually soiled with faecal matter during coitus. Examination revealed loss of perineal body and reconstruction was done, with success. With increase in motorcycle accidents on our roads, many more gynaecologically-related traumas are bound to occur. Proper and timely referral will lead to improved management with reduced psychosocial trauma. Organized awareness creation programmes will reduce these accidents in the long-term.

Successful intrauterine pregnancy following salpingostomy; case report

BACKGROUND

Ectopic pregnancy occurs more in young women who still desire children. Because of tubal rupture, salpingectomy which leads to tubal loss and reduced reproductive potentials is the commonest management option. This is a case report of a primipara who had ruptured left tubal ectopic pregnancy managed by salpingectomy and later had unruptured heterotopic pregnancy involving the contralateral tube and managed by salpingostomy, after which she had spontaneous abortion of the associated intrauterine pregnancy.

RESULT

Initial marital disharmony, followed by an uneventful intrauterine pregnancy carried to term with caesarean delivery of a live female baby.

CONCLUSION

In well-selected cases, conservative tubal surgeries should be encouraged in preference to radical surgeries in the management of unruptured tubal pregnancies.

Nigerian male sexual activity during pregnancy

OBJECTIVES

To determine the prevalence of extra-marital sexual affairs as well as other aspects of male sexual behavior during pregnancy in Nigeria.

METHODS

A questionnaire survey of the husbands of consecutive women who delivered in three tertiary care centers in south-eastern Nigeria within an 8-week period. The data were analyzed by means of simple percentages and descriptive and inferential statistics, using t-tests, chi-square tests and regression equations at the 95% confidence level.

RESULTS

279 (88.3%) of the 316 eligible husbands responded to the questionnaire. A total of 78 (28.0%) of the respondents engaged in extra-marital sexual relationships during pregnancy. Of the respondents, 36.6% and 32.3% experienced a decrease in achievement of erection and orgasm, respectively. While libido decreased in 41.9%, coital frequency declined in 72.4% of the respondents. On univariate analysis, respondent's age > or = 40 years, duration of marriage > or = 5 years, having an extra-marital sexual partner and beliefs that coitus during pregnancy should be less frequent or can cause miscarriage were significant predictors of reduced coital frequency while a belief that coitus enhances fetal well-being was a significant predictor of increased coital frequency during pregnancy (P<0.05 for each variable). On multivariate logistic regression, three factors were statistically significant predictors of reduced coital frequency - age > or = 40 years (OR=2.3; 95% C.I., 1.9-2.3) and beliefs that coitus during pregnancy can cause miscarriage (OR=1.9; 95% C.I., 1.5-2.3) and should be less frequent (OR=1.9; 95% C.I., 1.8-2.5).

CONCLUSIONS

Personal beliefs significantly affect sexual relationships between Nigerian husbands and their pregnant wives, making approximately one-third of husbands engage in extra-marital relationships as a way to satisfy their unmet sexual need during pregnancy. There is a need to educate husbands and their pregnant wives on sexual matters during pregnancy.

Abdominal versus vaginal hysterectomy: Appraisal of indications and complications in a Nigerian Federal Medical Centre

Aims: To compare hysterectomies performed via the abdominal and vaginal routes in terms of indicationsand associated complications.Methods: Review of retrospective data on all cases of hysterectomies performed at the Federal MedicalCentre Abakaliki over a six-year period (January 2000 to December 2005).Results: There were a total of 62 hysterectomies. Of these, 33 (52.2%) were abdominal hysterectomies while29 (46. 8%) were vaginal hysterectomies. Hysterectomy was carried out predominantly for grand multiparouswomen [21 (72.4%) and 21 (63.7%) were abdominal and vaginal hysterectomies respectively]. The meanages of the patients were 48.8 years and 55.5 years for the abdominal and vaginal operations respectively.The only indication for vaginal hysterectomy in this study was uterovaginal prolapse while uterine fibroid wasthe commonest indication for abdominal hysterectomy. Complications and duration of hospital stay weremore following abdominal hysterectomy.Conclusion: There is need for training and retraining of specialist gynaecologists and trainee residents onprocedures of hysterectomies, especially vaginal hysterectomy to expand the indications for the vaginalsurgery which is attended with less postoperative morbidity.Key words: indications; complications; route; pyrexia; wound; AbakalikiDOI: 10.3126/njog.v4i1.3328Nepal Journal of Obstetrics and Gynaecology June-July 2009; 4(1): 25-29