Mother-to-Child Transmission Outcomes of HIV-Exposed Infants Followed Up in Jos North-Central Nigeria

OBJECTIVE

Since 2010, Nigeria has adopted World Health Organization (WHO) 'Option B' which requires administration of triple antiretroviral prophylaxis or treatment (ART) to all HIVinfected pregnant women. We studied the transmission outcomes of HIV-exposed children up to 18 months of age.

DESIGN

This was a retrospective, observational study of HIV-infected pregnant women and their exposed infants who accessed prevention of mother to child transmission (PMTCT) services at Jos University Teaching Hospital, Jos, North-central Nigeria.

METHODS

HIV-infected women were enrolled during antenatal care or at labor/delivery between January 1, 2010 and December 31, 2012. Antiretroviral (ARV) prophylaxis/therapy was provided according to the 2010 Nigerian PMTCT guidelines (adapted WHO 2010 guidelines); Infant HIV diagnosis was performed at 6 weeks and at 6 months. HIV antibody diagnosis was used for exposed children at 18 months.

RESULTS

A total of 996 HIV-exposed children were followed up. Of those children, 140 (14.1%) were lost to follow up by 18 months of age. Twelve children (1.4%) died (all HIV negative) before 18 months of age and six infants (0.7%) were confirmed to be HIV-infected (4 by the age of 6 months and 2 thereafter) and were referred for treatment. A total of 838 (84.1%) children tested HIV negative at 18 months and were discharged. Mother-to-child transmission (MTCT) of HIV by 18 months was lower among women on ART before pregnancy compared to those women who started ART/Triple ARV prophylaxis during pregnancy/delivery. (0.4%; 3/700 vs 2.0%; 3/150 P=0.05). Home delivery was associated with higher transmission than facility delivery (p=0.03). Mode of delivery or method of infant feeding had no significant impact on vertical transmission by 18 months.

CONCLUSION

In North-central Nigeria where HIV is prevalent, ART started before pregnancy is enormously effective in preventing mother-to-child transmission. Adoption of WHO 'Option B+' deserves serious consideration in such settings.

Analysis of cases of rape as seen at the Jos University Teaching Hospital, Jos, North Central Nigeria

OBJECTIVE

Women are at a higher risk of being sexually harassed. There is a need to document the clinical findings of this crime and its outcome in order to improve the quality of care the victims receive.

MATERIALS AND METHODS

Case notes of patients who presented with alleged rape at Jos University Teaching Hospital between January 2001 and December 2003 were retrieved and analyzed.

RESULTS

During the study period, 2,135 patients were seen in the Gynaecological Emergency Unit. A total of 120 were for alleged rape, representing 5.6% of the total cases seen. However, only 105 case notes were available for analysis. Of these, 63.8% of the alleged rapes were in children, with the infantile age group accounting for 26.7%. 36.2% of the victims had experienced some form of sexual exposure prior to the rape. A previous relationship with the rapist was established in 77.4% of the cases. Most cases delayed in presenting to hospital. Thirty six percent of the cases did not have a human immunodeficiency virus screening test done. Candida albicans (13.3%) accounted for most of the infectious agents. Emergency contraception was administered to the victims when indicated.

CONCLUSION

Women under 16 years of age were at an increased risk of being raped, possibly because they are defenseless and vulnerable. Three quarters (3/4) of the assailants had some form of relationship with the victims, which may account for the delays in reporting. Children and young adolescents were more at risk than adults to be raped.

A 10-year audit of gynaecological surgeries performed in the paediatric age group at the Jos University Teaching Hospital

BACKGROUND

Surgeries performed for gynaecological conditions in children and adolescents are not common in our environment. Adequate facilities and the skill to perform the required procedures may also be lacking. We were interested in reviewing the practice of paediatric gynaecological surgery in our facility.

PATIENTS AND METHODS

A retrospective study of case files and theatre records of children below the age of 16 years who had surgeries at the Jos University Teaching Hospital over a 10 year period was undertaken.

RESULTS

A total of 89 surgeries were performed in this age group during the period under review. Twenty-eight (33.4%) of the patients were below the age of 11. The most common surgical procedure was for the management of septic abortion (21.3%). Correction of congenital malformations of the genital tract accounted for 21.4% (19) of the surgeries performed. Fourteen (15.7%) laparotomies were performed for ovarian cysts.

CONCLUSION

Though the number of surgeries performed on children for gynaecologic reasons may appear small, the skills required to manage them should be enhanced and the requisite facilities provided.

Underutilization of vaginal hysterectomy and its impact on residency training

BACKGROUND

The advantages of vaginal hysterectomy over abdominal hysterectomy include lower morbidity, shorter hospital stay, and reduced cost to the patient. It is, therefore, important to pass the required skill for vaginal hysterectomy unto trainees.

OBJECTIVE

To determine the proportion of vaginal hysterectomies done in a residency training institution in Nigeria and its possible impact on the proficiency of future gynaecologists in performing the procedure.

METHODS

A chart review was done on all documented cases of hysterectomies for benign gynaecological conditions done in Jos University Teaching Hospital, over a four-year period (January 2002 to December 2005). Case files of patients who had hysterectomy during the study period were retrieved and the relevant information obtained for analysis of frequencies and percentages.

RESULTS

A total of 94 hysterectomies for benign gynaecological conditions were done during the study period. Nine (10%) vaginal hysterectomies were done. All the vaginal hysterectomies performed were for uterovaginal prolapse by consultants. However, 45 (53%) of the abdominal hysterectomies were performed by consultants and 40 (47%) by residents.

CONCLUSION

This study suggests that residents exposure and training on the act of vaginal hysterectomy is inadequate. This has potential implications on future gynaecologist proficiency to perform this method of surgery that has documented advantages and better outcome for patients.

Cervical dysplasia in Nigerian women infected with HIV

OBJECTIVE

To determine the prevalence of and risk factors for cervical dysplasia in HIV-positive women receiving care at the Jos University Teaching Hospital in Nigeria.

METHODS

A total of 369 HIV-positive women had cervical cytology performed; HIV-1 RNA viral load and CD4 counts were measured.

RESULTS

Of 369 participants, cervical dysplasia was present in 107 (29.0%) women. However, cervical cytology was abnormal in 252 (68.3%). Among those with abnormal cytology, 145 (57.5%) women had ASCUS, 56 (22.2%) had LSIL, and 51 (20.2%) had HSIL. Median CD4 lymphocyte count was lower in women with dysplasia compared with those without (142 vs 170 cells/mm(3); P=0.04), while median HIV RNA viral load was higher in women with dysplasia (101781 vs 77479 copies/mL; P=0.002). Low CD4 count (<200 cells/mm(3)) and evidence of HPV infection were significantly associated with cervical dysplasia.

CONCLUSION

A high prevalence of cervical dysplasia was found among HIV-positive Nigerian women, which was associated with increased immune suppression.

Meigs' syndrome presenting as haemorrhagic pleural effusion

BACKGROUND

The association of a benign ovarian tumor with ascites and hydrothorax that resolve after tumor resection, known as Meigs syndrome is a rare clinical entity. Rarer still is the haemorrhagic form of the syndrome

OBJECTIVE

To describe a case of benign ovarian tumour associated with ascites and bloody pleural effusion.

METHODS

A thirty-seven year old woman was referred for the further management of a pleural effusion. A detailed clinical evaluation was carried out, including pleural fluid cytology, chest CT scan and laparatomy. Treatment included antituberculous therapy and finally ovariectomy.

RESULTS

The physical examination and a pelvic ultrasonographic scan revealed ascites in addition to a right sided ovarian mass. A chest CT-scan did not show any intrathoracic mass. Repeated pleural fluid cytology showed mesothelial cells but was negative for malignancy. An ovariectomy was performed and histological examination revealed a thecoma fibroma. The pleural effusion and ascites resolved spontaneously thus confirming the diagnosis of Meigs' syndrome.

CONCLUSION

Meigs' syndrome should be considered in the differential diagnosis in female patients with hemorrhagic pleural effusion.

Familial polycystic kidney disease in Nigeria: a report of two cases

A case of familial polycystic kidney disease is reported. Although isolated cases of adult polycystic kidney disease have been reported in our environment, no case to our knowledge has been reported with a familial link. Polycystic kidney disease is said to be rare in Africans. Although it commonly terminates in chronic renal failure, it hardly features in the aetiopathogenesis of end stage renal disease requiring some form of renal replacement therapy in African series. This, some workers believe may be due to misdiagnosis and under reporting. This report is to show that it may not be as rare as suspected, and that the familial link shown in the advanced countries is also applicable here. Case 1 was diagnosed in the course of evaluation of her clinical disease. Case 2, an aunt of Case 1, was diagnosed following investigation of a casual complaint of a painless abdominal mass in the wake of her senior brother's death from haemorrhagic stroke.

Partner disclosure of HIV status among HIV positive mothers in Northern Nigeria

Partner consent and support can substantially enhance adherence to PMTCT interventions. This study explores the issues concerning disclosure of HIV status to partners of HIV sero-positive mothers in a PMTCT programme in Jos, Northern Nigeria. Previously field-tested questionnaires were administered by trained counsellors to 570 consenting HIV positive mothers who were participating in the PMTCT programme at Jos University Teaching Hospital (JUTH), Jos. The findings were entered into Epi Info and analysed using frequencies. The median age of respondents was 29 years while that of their partners was 37 years. Five hundred and fifty-five (99.5%) of respondents were married. Majority of the women were Christians (82.9%) while 16.9% were Moslems. Seventy four percent (419/563) of the mothers were aware of their husband's HIV sero-status. Of these, 65.4% (274/419) of the partners were HIV positive while 34.6% were sero-negative. Eighty nine percent (500/560) of the women have disclosed their HIV status to their partners. Of these, 39.6% (199/502) required the assistance of health workers while 59.4% (298/502) did it by themselves. Following disclosure of HIV status, 86.9% (430/495) of the partners were supportive, 5.7% were indifferent, 6.7% were quarrelsome and abusive while 1.0% was violent. The reactions of partners of HIV positive mothers to disclosure of their wives' HIV status are predominantly supportive. This should strengthen strategies to promote partner disclosure.

Rapid HIV testing and counselling in labour in a northern Nigerian setting

Between April and August 2004, all pregnant women in labour at JUTH, were offered rapid HIV testing and counselling with opportunity to decline testing. HIV positive women were offered the standard nevirapine mono-therapy prophylaxis regimen (HIVNET 012). Four hundred and thirty (99.8%) of the 431 pregnant women who were offered rapid HIV testing and counselling, agreed to test. A sero-conversion rate of 2.1% (5 of 235) was found among women who had previously tested negative for HIV during the index pregnancy. A seroprevalence rate of 9.6% (16 of 166) was found among women with unknown HIV status. One patient who had an indeterminate HIV status prior to labour tested positive in labour. Rapid HIV testing and counselling in labour is a useful practice in high prevalence settings since it detects a substantial number of HIV-infected women and HIV-exposed babies that would otherwise have missed interventions to prevent MTCT.

An investigation of sociomedical risk factors associated with vaginal fistula in northern Nigeria

In some countries in Africa it is customary for early marriages involving young adolescent girls to be contracted prior to the commencement of their menses. This practice often results in premature pregnancies which in turn leads to devastating physical and social consequences such as vesico vaginal fistula (VVF). VVF is a severely demoralizing and disabling childbirth injury among women who become incontinent as a result of an opening created between the vagina and bladder. A case control study of 50 VVF patients and 50 non-VVF village women was undertaken in Katsina, Nigeria. Statistical analysis showed that VVF patients were smaller in stature, had less education and were of lower socioeconomic status. Also, the analysis showed that both groups of women married and commenced childbearing at an age too early for a safe delivery, thus placing them at risk of VVF. Predictive variables for the condition are: age at marriage, parity, husband's occupation and level of education.

An evaluation of the copper-T 380A IUD's safety and efficacy at three African centers

The use of intrauterine devices in Africa is low compared with other contraceptive methods such as oral contraceptives. This study, coordinated by Family Health International, evaluated the clinical performance (safety and efficacy) of the TCu 380A IUD in three African centers, respectively, in Cameroon, Egypt, and Nigeria from 1986-1989. The 12-month unintended pregnancy rates were low for all three centers, ranging from none to 1.6 per 100 women. The 12-month discontinuation rates for all reasons ranged from 8.8 to 26.9 per 100 women. Statistically significant differences were observed among clinics for discontinuation rates for bleeding and/or pain and for planned pregnancy. The overall performance of the TCu 380A IUDs was considered satisfactory. Thus, the limited use of IUD in Africa could be due to the lack of accessibility, lack of information about, and confidence in the method rather than to documented clinical performance.

Pregnancy associated alpha-glycoprotein (SP-III) in Nigerian pregnant women

Pregnancy associated protein (SP-III) was measured by rocket electroimmunoassay in the sera of Nigerian women with normal and abnormal singleton pregnancy. A tendency to increases of SP-III levels with advancing gestational age was observed. SP-III may contribute to immunosuppression in preventing anti-allograft responsiveness and levels may also reflect the effect of infections since SP-III is also leucocyte derived. Values in PET and anaemia in pregnancy were similar to values in normal pregnant women.

A simple mass-closure technique compared with layered technique in the closure of high-risk abdominal wounds

A retrospective comparison of the outcome of patients with ruptured gravid uterus following obstructed labour who had abdominal closure by a simple mass-closure technique (using non-absorbable Nylon suture) with their counterparts who had the more popularly used layered technique. The clinical features on admission, operation details and wound complications were compared. Thirty-one patients who had mass-closure were compared with 103 that had the layered technique. Nineteen percent of the former had wound infections or partial dehiscences while none had complete dehiscence or hernias. On the other hand these respective complications occurred in 32%, 9.7% and 1.9% of the layered group. This mass-closure technique has the advantages of low-cost, speed and safety. We advocate that it be used on all high-risk abdominal wounds.

A multicenter clinical trial in Nigeria with a low-dose oral contraceptive, Marvelon

The monophasic combination preparation, Marvelon, is a modern, technically improved oral contraceptive. It was tested for contraceptive reliability, cycle control and acceptability in 4 clinical centers in Nigeria for a period of one year. A total of 408 women was included in these studies, and 3102 cycles were monitored. The results showed a high contraceptive reliability and an excellent cycle-control. It was well tolerated. There were very few side-effects and the symptoms during medication were minor and hardly needed any treatment. At 12 months, 43.1% of the acceptors were still in the trial. Seventy-nine women (19.4%) discontinued before the end of the study for any reason. Drop-out reasons of these women were mainly non-medical. For the remainder of drop-outs no reason was given. This study suggests that this new oral contraceptive adequately satisfies the contraceptive needs of modern women.

A multicenter clinical trial in Nigeria with Multiload-Cu250 (MLCu250) and Multiload-Cu375 (MLCu375) intrauterine devices

A multicenter study was conducted in Nigeria, comparing the Multiload-Cu250 (MLCu250) with the Multiload-Cu375 (MLCu375). The two intrauterine devices were studied on aspects of effectiveness and acceptability. Parameters were observed and analyzed, using the life-table method of Tietze and Lewit. Continuation rates were excellent. Overall results were in line with studies done elsewhere in the world with Multiload devices, showing a slight superiority of the MLCu375 over the MLCu250.

Mycoplasmas among clients attending a family planning clinic in Zaria, Nigeria

The effect of contraception in the incidence of genital tract mycoplasma infection was studied in 150 women practicing contraception and another 50 women attending a gynecological clinic, using no contraception. Using the chi-squared method, there was no statistically significant difference between total mycoplasma recovery in family planning clients versus the controls. The only statistically significant difference was between total positive mycoplasma in the oral contraceptive group versus IUD users.

Sexually transmitted disease among women attending a family planning clinic in Zaria, Nigeria

Three types of sexually transmitted infections were investigated among 150 family planning clients using different methods of contraception and 50 controls. For oral contraception, intrauterine contraceptive device, medroxyprogesterone acetate (depo-provera) and controls, the incidence of trichomonas was 0%, 6%, 8% and 4%; for gonorrhoea it was 0%, 8%, 2% and 6%; for syphilis it was 4%, 34%, 16% and 12%. Only the difference in prevalence of syphilis among intrauterine contraceptive users and control was statistically significant (P less than 0.3).

Carcinoma of the cervix uteri in Zaria: etiological factors

The study conducted at Ahmadu Bello University Teaching Hospital, Zaria from January to December, 1984 showed that carcinoma of the cervix uteri occurred in 4.18% of new gynecological attendances; 68.9% of the cases occurred in the age range 40-55 years. Early age at marriage (80.0%), and at first pregnancy (77.8%) as well as multiple marriages (48.9%) and low contraceptive usage were identifiable associated factors. The parity of the patient did not seem to be of significance. The earliest presenting symptom was post-coital bleeding occurring 10.8 months prior to attendance for medical advice. However, late presentation (in Stages IIb-IV) in 86.7% of cases was due to illiteracy, shyness, male dominance and non-recognition of the importance of early warning symptoms.

Anaemia and iron status of pregnant and non-pregnant women in the guinea savanna of Nigeria

Haemoglobin concentration, serum iron, iron binding capacity, transferrin saturation, free erythrocyte protoporphyrin and serum ferritin (SF) were measured in 66 elite non-pregnant and 95 pregnant (27 elite and 68 non-elite) Nigerian women at Zaria, in the guinea savanna. Anaemia (as defined) was observed in 46% non-pregnant, 37% pregnant elite and 52% pregnant non-elite women. Iron deficiency (as defined) was diagnosed in 54, 30 and 25%, respectively. The mean SF in pregnant elite (28.9 micrograms l-1 was lower, but not significantly, than in pregnant non-elite women (33.6 micrograms l-1, either because of less inflammatory disease or because of more iron deficiency. The prevalence of anaemia tended to fall with increasing parity, being 52% in primigravidae and 40% in grande-multigravidae; this was probably due to greater risk of malaria-induced anaemia in primigravidae. In contrast, prevalence of iron deficiency increased with parity, being 18 and 35%, respectively, in primigravidae and grande-multigravidae. Anaemia and iron deficiency were seen most frequently in the third trimester. Pregnant women in the north of Nigeria require iron supplements irrespective of socioeconomic status or maternal parity.

Pregnancy-specific beta-glycoprotein (SP1) in normal pregnancy in Nigeria

The circulating levels of pregnancy-specific beta 1-glycoproteins (SP1) were measured in 71 normal pregnant women in Northern Nigeria by immunoelectrophoresis. The levels showed a steady rise up to 34 weeks as in Caucasians and then plateaued with a slight fall just before term. The mean individual values were lower than those found in Caucasians at comparable gestation periods. This was thought to be related to the lower mean fetal weight in the Nigerian women.

Microbial flora of the lower genital tract of women in labour in Zaria, Nigeria

Nine genera of microbes isolated from the lower genital tract of 187 women in labour in Zaria have been identified. The work was undertaken to establish the nature of microorganisms in the lower genital tract of women in labour as a basis for further study. The isolates in order of prevalence were: Candida albicans (20.9%), Klebsiella sp (15.0%), Escherichia coli (9.1%), Streptococcus faecalis (6.4%), haemolytic streptococci (other than Streptococcus pyogenes (2.7%), Streptococcus viridans (2.1%), Staphylococcus aureus (2.1%), Aeromonas hydrophila (2.1%), Proteus mirabilis (1.1%), Peptostreptococcus putridus (1.1%), Streptococcus pyogenes (0.5%), and Streptococcus pneumoniae (0.5%). Neisseria gonorrhoeae, Haemophilus sp, Lactobacillus sp, and Clostridium sp were sought but not found. Chlamydia, viruses, and T-strains of mycoplasma and trichomonas were not sought. It appears from this study that the lower genital tract of most women in Zaria at the time of labour is heavily colonised by pathogens. For this reason alone prolonged labour and trauma to the genital tract at the time of delivery should be avoided.

Postoperative morbidity of eclamptic patients delivered by cesarean section

Postoperative morbidity was investigated in 32 eclamptic patients and 12 normal well-matched controls who had been delivered by cesarean section. The incidence of wound and chest infection, genital sepsis and puerperal psychosis was higher among the eclamptics than the controls. The former also harbored more pathogens in the throat, rectum, abdominal wound and cervix than the controls. It is concluded that eclamptic patients are more prone to sepsis after surgery and should be nursed with special care.

Infection theory of eclampsia reevaluated

One hundred eclamptic patients and an equal number of carefully observed parturient controls were investigated clinically, radiologically, hematologically and bacteriologically for evidence of infection on admission. At that time, 77% of the eclamptics, but none of the other group, were febrile (temperature greater than 38 C). Sepsis was evidently greater among the eclamptics than the controls. Significantly more eclamptic patients with fever had infections as well, compared to those who were nonfebrile. The association of fever and infection with eclampsia was so striking that the author speculates on the possibility of a cause-and-effect relationship.

Continuation of abdominal pregnancy complicated by preeclampsia three weeks after birth of an intrauterine twin

A case of heterotopic pregnancy in a 22-year-old multigravida is presented. The extrauterine baby was delivered alive three weeks after the intrauterine pregnancy had ended at term in spite of an associated preeclampsia. The inhibition of lactation resulting from the continuation of the extrauterine pregnancy resulted in marasmus for the first baby. The implications and especially the etiology of preeclampsia occurring in extrauterine pregnancy are discussed.

Endometriosis among the Hausa/Fulani population of Nigeria

In three and half years at the Ahmadu Bello University Hospital, Zaria, Nigeria, endometriosis was found in 27 Nigerians (all negroid) and one Caucasian. Age and parity distribution were similar to what has been found in patients elsewhere. In other respects, there were striking differences. The frequency (8.2 percent) is one of the highest reported in the negro. Two fifths were menopausal, majority had associated pelvic inflammatory disease, and nearly all were in women of the lowest socio-economic status. The lesions were rare in the pouch of Douglas and were totally absent from the rectovaginal septum and in the extra peritoneal space.