Trends in maternal mortality at the University of Calabar Teaching Hospital, Nigeria, 1999-2009

BACKGROUND

Maternal mortality remains a major public health challenge, not only at the University of Calabar Teaching Hospital, but in the developing world in general.

OBJECTIVE

The objective of this study was to assess trends in maternal mortality in a tertiary health facility, the maternal mortality ratio, the impact of sociodemographic factors in the deaths, and common medical and social causes of these deaths at the hospital.

METHODOLOGY

This was a retrospective review of obstetric service delivery records of all maternal deaths over an 11-year period (01 January 1999 to 31 December 2009). All pregnancy-related deaths of patients managed at the hospital were included in the study.

RESULTS

A total of 15,264 live births and 231 maternal deaths were recorded during the period under review, giving a maternal mortality ratio of 1513.4 per 100,000 live births. In the last two years, there was a downward trend in maternal deaths of about 69.0% from the 1999 value. Most (63.3%) of the deaths were in women aged 20-34 years, 33.33% had completed at least primary education, and about 55.41% were unemployed. Eight had tertiary education. Two-thirds of the women were married. Obstetric hemorrhage was the leading cause of death (32.23%), followed by hypertensive disorders of pregnancy. Type III delay accounted for 48.48% of the deaths, followed by Type I delay (35.5%). About 69.26% of these women had no antenatal care. The majority (61.04%) died within the first 48 hours of admission.

CONCLUSION

Although there was a downward trend in maternal mortality over the study period, the extent of the reduction is deemed inadequate. The medical and social causes of maternal deaths identified in this study are preventable, especially Type III delay. Efforts must be put in place by government, hospital management, and society to reduce these figures further. Above all, there must be an attitudinal change towards obstetric emergencies by health care providers.

Complications of pregnancy and foetal outcomes in pregnant diabetic patients managed in a tertiary hospital in Saudi Arabia

OBJECTIVE

To compare the pregnancy complications and fetal outcomes in pregnancies complicated by diabetes mellitus.

DESIGN

A retrospective cohort study. Setting- Abha Maternity Hospital, Abha, Saudi Arabia.

MATERIALS AND METHODS

One hundred and eighty five diabetic pregnant patients who delivered at the Abha Maternity Hospital during the 3-year-period from April 2000-March 2003 formed the subjects of this study. There were 27(14.6%) (type 1) - insulin dependent diabetics, group 1, 19 (10.2%)(type 2), non insulin dependent diabetic patients who constituted group 2 and 139(75.2%) gestational diabetic patients who made up group 3. Data extracted from the case files included maternal age, gravidity, parity, number of abortions, gestational age at booking, time of diagnosis of diabetes mellitus, complications during pregnancy, birth weight, placental weight.

RESULTS

There were no statistically significant differences in the three groups regarding the mean gravidity, parity, birth weight and placental weight (p > 0.05). However, statistically significant differences were found with respect to the mean maternal age, gestation at booking, fasting blood sugar, and gestation at delivery (p < 0.05). Out of 139 gestational diabetics, 23(16.5%) were diagnosed by the 141 week of pregnancy while 24(17.2%) were diagnosed between the 15- 27 weeks of gestation. The control of blood sugar was adjudged to be poor in 32% of gestational diabetics, 50% of type 2 diabetics and 69% of type l diabetics, with statistically significant difference between the groups, (p < 0.05). Although there was statistically significant difference between the groups regarding one of the pregnancy complications (polyhydramnios) (p < 0.05), none were found in other complications (p > 0.05). The overall caesarean section rate was 48%. The overall perinatal mortality was 5.7%, all the deaths occurred in babies born to patients with gestational diabetes.

CONCLUSION

Gestational diabetes accounted for all the fetal losses in this study, while polyhydramnios was the most common antenatal complication which was significantly higher in type 1 diabetics.

Elective hysterectomy: a clinicopathological review from Abha catchment area of Saudi Arabia

OBJECTIVE

To review the major indications, types and clinicopathological features of elective hysterectomy managed in our locality.

MATERIAL AND METHODS

A retrospective study of 317 consecutive patients who had elective hysterectomy performed for various indications during the study period from January 1994-December 2001,(96 months) was conducted. The patients were divided into 3 groups: Group 1, total abdominal hysterectomy(TAH) 165 (52%); Group 2: subtotal abdominal hysterectomy(STAH) 59(18.6%) and Group 3: vaginal hysterectomy (VH),93 (28.4%). Data extracted from the case files included age, parity, presenting symptoms and indication for hysterectomy. Others included relevant investigation results, type of hysterectomy, and histopathological diagnosis of the specimens

SETTING

Abha Maternity Hospital, Abha, Saudi Arabia.

RESULTS

No statistically significant trend was found in the annual number of hysterectomies performed during the study period (p > 0.05). There was statistically significant difference in the mean age in the 3 groups of patients (p < 0.05), but none in the parity (p > 0.05). Menorrhagia and abnormal vaginal bleeding was the indication for hysterectomy in 123(38.8%) patients, followed by uterine prolapse in 91(28.7%), abdominopelvic mass, 48 (15.1%) and pelvic mass in 46 (14.8%). Histopathology of hysterectomy specimens and appendages were reported as abnormal in 179 (56.4%), with uterine fibroids the most common pathology in 82 specimens (25.8%) followed by adenomyosis in 72 specimens(22.7%).

CONCLUSION

Uterine fibroids and adenomyosis were the most common benign conditions in hysterectomy specimens in our community with peak incidence at 41-50 years, while endometrial and ovarian cancers peaked at the same age group. At the same time, vaginal hysterectomy was performed exclusively for utero-vaginal prolapse.

Reduced liquor drainage at delivery: an unusual presentation of uterine rupture

A 27-year old unbooked G(5)P(3) + 1 woman with a history of previous caesarean section is reported. She had an apparent normal vaginal delivery at term with very scanty liquor drainage. She then developed severe persistent abdominal pain with stable vital signs. A laparotomy confirmed a ruptured uterus. We therefore conclude that any woman with a scarred uterus presenting with very scanty liquor drainage at delivery, if she develops persistent abdominal pain, should raise a suspicion of uterine rupture.

Primary caesarean section in nulliparous and grandmultiparous Saudi women from the Abha region: indications and outcomes

OBJECTIVE

To assess the indications for and outcomes of primary caesarean section (PCS) perfomed in nulliparous and grandmultiparous women in the Abha region of Saudi Arabia.

METHODS

A retrospective cohort study.

MATERIALS

393 nulliparous women (para 0) (NPG) and 432 grandmultiparous women (parity>5) (GMPG) who had PCS at the Abha Maternity Hospital (AMH) over a 3-year period, (1997-1999) formed the basis of the study.

RESULTS

The PCS rates in NPG and GMPG were 19.4% and 18.3% respectively with no statistically significant difference. (p>0.05). There were statistically significant differences between the two groups regarding the mean age, blood loss during surgery, post operative haemoglobin, and birth weight were compared, p<0.05. There was no statistically significant differences in the mean gestation at delivery, p>0.05. The most common indication for surgery in the two groups of patients was fetal distress (NPG=28%, GMPG=25%: p=NS), followed by failure of progress in labour. (NPG=22.7%, GMPG =21.6%, p=NS). Antepartum haemorrhage (APH) was the indication for PCS in 6.8% of the NPG and 13.9% of the GMPG, (p<0.05). Multivariate linear regression analysis indicated that maternal age and booking status significantly affected birth weight (p=0.004,p=0.022 respectively). However, neither birth weight nor low Apgar score was affected by the indications for CS or parity. While there were no perinatal deaths in the series, no statistically significant difference was found between the two groups with regards to low Apgar score (<7 at 5 mins), p>0.05.

CONCLUSION

The major indications for PCS were the same in the NPG and GMPG in our study while the CS rates were similar in both groups. However, APH and its inherent complications occured more commonly in the GMPG. Neonatal morbidity was similar in both groups of women, but the mean birth weight was significantly higher in the GMPG. However, in order to reduce the high CS rate in these groups of patients, and in our obstetric population in general, it is suggested that CTG be used appropriately in high risk women and that intermittent auscultation is recognized as a valid form of management for most low risk cases.

Antenatal intrauterine fetal death: a prospective study in a tertiary hospital in south-western Saudi Arabia

This study was conducted to determine the frequency of antenatal intrauterine fetal death (IUFD) and the associated maternal and fetal risk factors in women who presented at a regional tertiary hospital in Saudi Arabia. Over a 5-year period, 191 consecutive cases of IUFD presented and were studied prospectively. Relevant maternal and fetal data were obtained. The stillbirth rate during the period was 10 per 1000 deliveries. In 41% of the cases, the associated causal factors could not be determined. There was a significant (P = 0.00122) linear trend showing an increased risk of IUFD above the age of 20 years and, similarly, a significant (P = 0.00047) linear trend after the first pregnancy. Lack of antenatal care (88.5%), hypertensive diseases in pregnancy (12%) and diabetes mellitus (8%) were associated risk factors while 'major congenital malformation' (14%) was an outstanding fetal factor. The risk factors of antenatal stillbirth in our community seem to be avoidable. Health education to encourage the utilisation of the available antenatal care services, family planning and genetic counselling are being advocated strongly as possible preventive measures.

Induction of labour using low and high dose regimens of prostaglandin E2 vaginal tablets

OBJECTIVE

To compare the efficacy of low dose prostaglandin E2 vaginal tablets with that of high dose in induction of labour.

DESIGN

A retrospective study.

SETTING

Abha Maternity Hospital, a teaching hospital in the southern region of Saudia Arabia.

PATIENTS

The outcome of induction of labour in 73 women induced with 1.5 mg prostaglandin E2 vaginal tablets was compared with those in 168 women induced with 3 mg vaginal tablets.

RESULTS

There were no statistical significant differences in the success rate, induction-delivery interval, caesarean section rate and Apgar scores between the two groups. There were two incidences of uterine hyperstimulation and two of uterine rupture in the high dose group. These were not statistically significant. Logistic regression analysis showed that the success rate of induction of labour was dependent only on maternal age (P=0.0025) and Bishop score (P=-0.0403) and not on parity, gestational age, birthweight or dose of prostaglandin.

CONCLUSION

The low dose regimen of 1.5 mg is as efficacious as the high dose regimen of 3 mg prostaglandin E2 vaginal tablets in inducing labour. This implies that using the low dose regimen reduces the cost of induction of labour effectively. Larger prospective randomized studies are needed to confirm this finding.

Changing patterns in the management and outcome of breech presentation over a 7-year period. Review from a referral hospital in Saudi Arabia

A retrospective study that was conducted on 755 singleton breech deliveries over a 7-year period between January 1994 and December 2000 at a referral hospital in Saudi Arabia showed that it represented 3.35% of all deliveries. There was a statistically significant trend in caesarean section (P = 0.001) accompanied by a modest linear trend in perinatal mortality (P = 0.049). There were no statistically significant differences in the mean age, parity and birth weight when the women delivered during each year were compared (P > 0.05), but there were statistically significant differences in the gestation at delivery (P < 0.05). Furthermore, statistically significant differences were found in the trends of the preterm breech deliveries and booking status over the period of study (P > 0.05). However, there was no statistically significant linear trend in the birth trauma (P > 0.05). Nineteen cases of the fetal birth trauma (67.8%) were associated with vaginal breech delivery while nine cases (32.2%) were reported from caesarean section. This was statistically significant (P = 0.00074). The role of selective external cephalic version as a way of reducing the caesarean section rate and also trauma during vaginal breech delivery at term in our community is discussed.

Pregnancy outcome in asthmatic patients from high altitudes

OBJECTIVE

To compare pregnancy outcome in asthmatic and non-asthmatic patients from high altitudes.

METHOD

A prospective case-control study over a 4-year period. The setting was: Abha Maternity Hospital, south-west region of Saudi Arabia. Eighty-eight asthmatic pregnant patients were followed up on during their pregnancies and deliveries (cases). The control subjects were 106 non-asthmatic patients who delivered during the same period.

RESULTS

There were no statistically significant differences in the mean age, parity and gestation at delivery between the cases and control subjects (P>0.05), while there were statistically significant differences in the mean birth weight, placental weight and number of abortions between the two groups (P<0.05). Antenatal complications occurred in 12.5% of the asthmatic patients and 1.9% of the control subjects. Pre-eclampsia was diagnosed in 7.9% of the asthmatic group but in none of the control subjects. Induction of labor, cesarean section rate, perinatal mortality, congenital malformations and Apgar score <7 at 5 min were significantly higher in the asthmatic patients.

CONCLUSION

Asthma occurring in pregnancy was associated with increased antenatal complications, increased perinatal loss and congenital malformations in our study population.

A clinico-epidemiological review of cervical cerclage from the Assir region of Saudi Arabia

A retrospective review was conducted on patients who had cervical cerclage performed because of suspected cervical incompetence over a 7-year period to assess the outcome of pregnancy and complications resulting from the cerclage. Other factors that could affect the outcome and complications were also assessed. Out of 196 patients who had the operation, 154 patients had adequate records available and therefore comprised the study population. There were 139 (90%) live births of which 76.6% weighed more than 2000 g. The outcome was not influenced by the experience of the surgeon, type of cerclage or the use of prophylactic antibiotics. There were no complications in 138 (90%) of the cases, and no cases of ruptured uterus, cervical lacerations and severe infections were encountered. The complications were seen more in multiple-order pregnancy and when the operation was performed as an emergency. The future role of cervical cerclage in the management of cervical incompetence in our community is discussed.

A comparison of spontaneous labor with induced vaginal tablets prostaglandin E2 in grand multiparae

OBJECTIVE

To compare the outcome of labor in grandmultiparous patients (para >5) who had induction of labor with prostaglandin E2 vaginal tablets with grandmultiparous patients in spontaneous labor, and to observe the complications during induction of labor.

METHODS

A retrospective case control study was carried out at King Faisal Military Hospital, Khamis Mushayt between January 1993 through until December 1994. This included 64 grandmultiparous patients that were induced with prostaglandin E2 vaginal tablets. Ninety grandmultiparous patients who went into labor spontaneously served as controls. Maternal and fetal data extracted from their hospital record files included age, parity, indication for induction, Bishop score at induction, total dose of prostaglandin used and complications of induction of labor. Other information were length of labor, need for syntocinon augmentation, blood loss during the 3rd stage of labor, mode of delivery, birth weight, sex and Apgar score at 10 minutes.

RESULTS

No serious complication of induction of labor such as rupture of the uterus was noted in the subjects studied. There were no significant differences when the mean age and parity of patients in the 2 groups were compared (P>0.05) but there was difference in the gestational age at delivery (p=0.00). There was no significant difference in the mean length of first and 2nd stages of labor. The cesarean section rate was 11% and 8% in the cases and controls, while the need for syntocinon augmentation was twice in the cases than controls, 27% vs 14%. These were not statistically significant.

CONCLUSION

We conclude that induction of labor with prostaglandin E2 vaginal tablets may not have adverse effect on the outcome of labor compared with patients in spontaneous labor. It may be safe to use prostaglandin E2 vaginal tablets for induction of labor in the grand- multiparae. We recommend a randomized prospective trial to validate these observations.

Teenagers obstetric performance

OBJECTIVE

To study the pregnancy outcome in teenage primigravida women admitted and delivered in our unit between April 1997 and March 1998, and to compare the outcome with other primigravida above 20 years old.

METHODS

Data was collected from primigravidae in respect of age, last menstrual period, history of booking at Primary Health Center and complications of pregnancies were identified. The process of labor and delivery were monitored and the outcome recorded.

RESULTS

During the period of study, 2,650 women delivered in the unit, 171 (6%) were primigravida, out of which 116 (68%) were teenagers, ages between 13 and 19 years old, 55 (32%) were above 20 years of age. All the primigravidas were married and therefore had their husband and parental support. Forty three percent of the teenagers plan to return to school after delivery. The length of the 2nd stage of labor (67.7 minutes) in the young teenagers aged 13 to 15 years was significantly longer than of the older teenagers 16 to 19 years old and that of the control group ages above 20 years old, P<0.0001. The mean birth weight (2.45 kgm) in the younger teenagers were also lower than that of the older teenagers and the control group (3 kgm and 3.25 kgm) P<0.0001. There was no significant difference between the teenagers ages 13 to 19 years old and the control group regarding normal vagina delivery, lower segment cesarean, ventouse delivery, number of anemic patients and the mean birth weight as shown by the P-values. There was no significant difference in the numbers and types of medical complications identified between the teenagers and the control group.

CONCLUSION

The younger teenage group (13 to 15 years) has been identfied as the high-risk group in this study but there was no significant difference in the pregnancy outcome of the teenagers (13 to 19 years old) in general compared with the control group. Attention must therefore be turned to the young teenagers pregnancy, labor and delivery. To avoid poor outcome in this age group, age at first pregnancy should be encouraged from 16 years and above.

The changing pattern of malignant neoplasms among females in Asir region of Saudi Arabia

OBJECTIVE

The study was undertaken to compare the frequencies of the various types of malignant neoplasms affecting females in the Asir Region of Saudi Arabia during the years 1996-1998, to the experience of a previous report (1987 to 1989) in the same population with rapid advancing health care services.

METHODS

A retrospective descriptive approach was adopted. Histopathological records of Asir Central Hospital were reviewed to extract data on female malignant neoplasms seen in the years January 1996-December 1998. The cancer from various sites were ranked based on their percentage (crude relative) frequencies, and compared with the previous report (1987-1989).

RESULTS

Of the 274 cases of histologically confirmed female malignant diseases, the breast (22%), skin (9%) and thyroid (7%) were the leading sites. This ranking contrasts with the previous finding (1987-1989) which involved the skin, breast and non-Hodgkin's lymphoma, in descending order of frequencies. The frequency of gynecological malignancies was relatively higher than in the previous report.

CONCLUSION

There may be a need to review the pattern of malignancies in the female population in this region from time to time in order to concurrently update planning on preventive and treatment measures.

Ectopic pregnancy in Abha, Saudi Arabia. A continuing conundrum

OBJECTIVE

To determine the incidence of ectopic pregnancy in Abha, in the south-western region of Saudi Arabia and to evaluate the relevance of the known risk factors.

METHODS

Eighty-two women with histologically confirmed ectopic pregnancies, managed in Abha Maternity Hospital over a three-and-a-half year period, were retrospectively studied.

RESULTS

The incidence of ectopic pregnancy was 0.74 per 100 live births. Most (56%) of our patients were within the 21-30 age group. Parous women constituted 56% and nulliparous patients constituted 21% of the study group. No previous history of abortion was found in 60% of the patients. Fourteen (17%) had used the intra uterine contraceptive device and 5% had a history of previous ectopic pregnancy. There were 3 cases of heterotopic pregnancies in the series. The right and left fallopian tubes were equally affected. Salpingectomy (90%) was the most frequent definitive surgical procedure performed, and 15% of the patients required blood transfusion. There was no obvious seasonal variation and no maternal death was reported.

CONCLUSION

The incidence of ectopic pregnancy appears to be comparatively low in our community and the risk factors do not seem to be clearly defined. A nation-wide multicenter survey to determine the effect of climatic factors and to check, as routine, Chlamydia trachomatis serology in suspected cases of ectopic pregnancy, may be desirable. Without these determinations, ectopic pregnancy and possible preventive measures may continue to remain a conundrum.

Efficacy and acceptability of depo-medroxyprogesterone acetate injection. As a method of contraception in Saudi Arabia

OBJECTIVE

To determine the efficacy and acceptability of Depo-Medroxyprogesterone acetate (depo-provera) among the women using that method of contraception at King Faisal Military Hospital in the south-west region of Saudi Arabia.

METHODS

A preliminary retrospective and questionnaire analysis of 165 Saudi women who had depo-provera as a method of contraception at the contraception clinic of King Faisal Military Hospital over a period of 2 months.

RESULTS

The mean age of the women was 31.21 years and the mean parity 6.77. There was no pregnancy reported during the period of use of the contraceptive method which ranged from 3 months to 7.25 years. The side effects were mainly irregular spotting (69%), continuous bleeding per vaginam (7%), amenorrhoea (8%) and menorrhagia (1%). The rest reported normal menstrual pattern. Irregular spotting was common in women who had used the method for less than 2 years while amenorrhoea was the most common menstrual abnormality after 3 years of use. The other complaints included weight gain, loss of hair, abdominal pain and backache. The side effects were not acceptable to 4% of the women and they tried other methods of contraception. Thirteen percent of the women became pregnant after stopping the injections within intervals varying between 6 months to 2 years. Seventeen percent were using the method for the 2nd time.

CONCLUSION

Depo-provera is a very effective form of contraception in our community. While a few of the patients (4%) in our series would try other methods if not happy with the side effects, the majority were prepared to cope with the side effects as long as the desired prevention of pregnancy was guaranteed. Further studies are needed to validate these findings.

Diabetes and perinatal loss. A continuing problem

OBJECTIVE

To determine the fetal outcome in diabetic pregnant patients managed exclusively by the obstetrician at King Faisal Military Hospital in the south-west region of Saudi Arabia, and to compare this with the non-diabetic control group in the same hospital.

METHODS

Case-control study of 83 diabetic and non-diabetic pregnant patients who delivered at King Faisal Military Hospital over a 2 year period.

RESULTS

The perinatal mortality rate in diabetic patients was 6.02% while that in the non-diabetic control group was 1.2%. However, the difference was not statistically significant, p>0.05. There was a difference in the mean birth weight between the cases and controls; p = 0.001 and the cesarean section rate was 5 times higher in the cases than in controls [corrected]. This was statistically significant; OR=5.22 (1.90-16.48).

CONCLUSION

Diabetes in pregnancy is still a major cause of perinatal loss in our community. The increase in cesarean section in diabetic pregnant patients also indicates a drain in the financial resources. It is recommended that emphasis should be placed on health education in order to reduce the cost of child birth as this condition may be prevented.

Biophysical profile score in late pregnancy and timing of delivery

OBJECTIVE

To determine if the Biophysical Profile Score (BPS) as a screening procedure on patients without antenatal care (unbooked patients), seen in late pregnancy, is of value in providing an insight into the mode of delivery and fetal outcome.

DESIGN

Prospective case study of pregnant mothers, data collection and analysis over 2 years at Abha Maternity Hospital, Saudi Arabia.

SUBJECTS

Unbooked patients with abnormal BPS (Group I), and patients with normal BPS (Group II) used as control subjects, delivered in the hospital from January 1996 through December 1997.

RESULTS

The number of normal deliveries was significantly higher (P < 0.01) in the control group than in the study group patients. Cesarean section rate was significantly higher in the study group than in the control group (P < 0.01, OR = 4.48). There was a significant increase in the number of asphyxiated and meconium aspirated babies in the study group than in the control group. Neonates that needed mechanical ventilation were significantly higher in the study group than in the control group (P < 0.01, OR = 10.38).

CONCLUSION

These findings suggest that abnormal BPS is invaluable in effecting delivery, particularly in women without antenatal care, who present in late pregnancy to an obstetric unit. Patients with abnormal BPS are four times more likely to be delivered by cesarean section than those with normal BPS.

Ventilatory function in Nigerian asbestos factory workers

Ventilatory function indices; forced vital capacity (FVC), forced expiratory volume in one second (FEV1), the percentage of vital capacity in one second (FEV1%) and peak expiratory flow rate (PEFR) were measured to find the effect of asbestos fiber on lung function in 95 male Nigerian asbestos factory workers (aged 25-55 years). The results were compared with a control group of age and sex-matched Nigerians from the same area that were not exposed to asbestos fiber or any known air pollutant. The results were also compared with expected values calculated from linear regression equations worked out for healthy Nigerians. The mean values of FVC, FEV1 and PEFR were significantly lower in the asbestos factory workers than in the control group (P less than 0.01, 0.05 and 0.001 respectively). FEV1 in asbestos factory workers showed a statistically significant negative correlation with the duration of service (P less than 0.05). The reduced FVC and FEV1 and normal FEV1% in asbestos factory workers is indicative of restrictive lung defect and may be attributed to asbestos fiber exposure. Frequent monitoring of the health of these factory workers and control measures should be stepped up in the factory.

Illegal induced abortion--a continuing problem in Nigeria

Illegal induced abortion is still a major contributing factor to maternal morbidity and mortality in Nigeria. It is very common among school girls who are still ignorant of contraception. A good percentage of the abortions are procured by nonmedically qualified personnel. The author has not only advocated the introduction of sex education into the school curriculum as a redeeming measure, but also the provision of contraception in schools and the liberalization of the abortion law.