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Articles

NORPLANT: AN UNMET CONTRACEPTIVE NEED IN ENUGU, SOUTHEAST, NIGEIRA

Dr Ibekwe, Perpetus Chudi(FWACS)
Department Of Obstetrics & Gynaecology Ebonyi State University Teaching Hospital - Abakaliki, Nigeria.
(Formerly -Department Of Obstetrics/Gynaecology University Of Nigeria Teaching Hospital Enugu, Nige
ria)

Nigeria has one of the highest maternal mortality rates in the world1 and ranks lowest in terms of contraceptive prevalence rates in Africa2. The contraceptive prevalence in Nigeria ranges between  7-14.8% 3-5. This high maternal mortality rate coupled with the very high total fertility rate (above 6.0 in the area of study)6 has led to a renewed vigour in effecting solutions through a pervasive family planning programme, not only in Nigeria but in other developing countries. It has been opined that if family planning services were more widely available, up to 42% of maternal deaths could be averted in developing countries7. This same survey revealed that approximately 300 million couples in the reproductive age range did not want more children, but were not using any method of contraception.

One of the factors that have contributed to this low contraceptive prevalence and high birth rate is that a large percentage of the population lives in rural areas, where family planning services may not be available. In addition, the low socio-economic status of the people combined with high rate of infant and child mortality, religious and cultural factors and changing pattern of social organization may all negatively influence motivation8-10. In another study, male opposition, low availability and accessibility were reported as commonest reasons for non-use of contraception11.

It has been accepted that reproductive health of women can only be enhanced if they are provided with an opportunity to plan their reproductive lives through provision of various contraceptive methods that are relatively safe, available, accessible and affordable7-11. Norplant, as a family planning method, became available for use at the University of Nigeria Teaching Hospital (UNTH), Enugu in 199212. Hitherto, clients had relied on intrauterine contraceptive device (IUCD), depots of norethistherone enanthate and medroxyprogestrone acetate (Depo-Provera), oral contraceptives, tubal ligations and other non-prescriptive methods like condoms and foams.

At the family planning clinic of the UNTH, clients receive group counseling on all methods of contraception from the health nurses. Private counseling is thereafter provided by the doctors before a decision on the most appropriate method is reached. Norplant acceptors are informed about the benefits and side effects of the implant. They are physically examined to rule out medical contraindications before insertion. Norplant implant, consisting of six silastic capsules of levonorgestrel, is inserted by doctors in the upper non-dominant arm, about four- finger breath above elbow.

An eight-year review of Norplant use at the Family planning clinic of the UNTH, Enugu (January 1996 -  December 2003) showed that Norplant was in sporadic supply throughout 1997 and major parts of 1998, and totally out of stock for eleven months in 2000. From 2001, high financial commitment was requested from clients desiring Norplant, thus creating problem of affordability. Also, the product was in short supply between 2001 and 2003. All other products mentioned above were available throughout the review period.

In spite of these problems of availability and affordability, Norplant enjoyed an acceptance rate of 8.5%. Were the products more readily available, it would have compared favorably with an acceptance rate of 12.4% recorded in Lagos, Nigeria13. Experience from other parts of the World has also demonstrated a high acceptance rate of norplant14, 15. This method of family planning may therefore be fulfilling an unmet need for a long term, efficient, reversible form of hormonal contraception for women who have achieved their desired family size, but for fear of the unknown, do not want the permanence of sterilization16.

With the, continuation rate of 95% at one year and 89% at three years, lowest observed failure rate of 0.04%17, effective life of five years18, Norplant is one of the most effective reversible contraceptive methods. It is also a suitable option for lactating women when effective non-hormonal methods are contraindicated or not acceptable19. Sexually transmitted diseases are prevalent in Nigeria20 and in many sub-Saharan African countries and this may make Norplant a more appropriate contraceptive method than IUCD for clients with high risk of acquiring sexually transmitted diseases such as teenagers and sex workers.

There is a great need therefore for strong advocacy for regular and efficient supply of Norplant, all year round in all family planning units. It is known that successful implementation of any family planning programme depends on the ease of access of contraceptive services and the availability and affordability of the products21. Thus, availability and accessibility of Norplant are very important as it was observed, very obviously, that the sporadic nature of the availability of Norplant and the cost constraint imposed on the product at a time, adversely affected it as a contraceptive method and its acceptance rate. Government and donor agencies are called upon to formulate appropriate strategies to meet this very important contraceptive need of women.

 

REFERENCES

  1. High Rate of Maternal Deaths in Nigeria is a cause for Alarm. Communiqués from the 38th Annual Scientific Conference of the Society of Gynaecology and Obstetrics of Nigeria (SOGON), Makurdi, Benue State, Nigeria, November, 2004. Trop J obstet Gynaecol.2005; 22: 100.

  2. Federal Office of Statistics. Nigeria Demographic and Health Survey 1990. IRD/Macro International: Columbia, M.O., 1992.

  3. Oye-Adeniran BA, Adewole IF, Odeyemi KA, Ekanem EE, Umoh AV. Contraceptive Prevalence among young women in Nigeria. Journal of Obstetrics and Gynaecology 2005; 25: 182-185.

  4. Population Reference Bureau. World Population Data Sheet. Demographic data and estimate for the countries and regions of the world. 2005. ww.prb.org

  5. Oye-Adeniran BA, Adewole IF, Umoh AV, etal. Sources of Contraceptive commodities for users in Nigeria. PLoS Med 2(11): 306.

  6. Egwuatu VE Child bearing among the Igbos of Nigeria. Int J. Obstet Gynaecol 1986; 24: 103  111.

  7. WHO. Community Based Distribution of Contraceptive, A Guide for programme Managers. WHO: Geneva, ix, 19915.

  8. Ladipo OA. Socio-cultural barriers to Contraception. Trop J Obstet Gynaecol 1998, 13: 1-4.

  9. Ojo OA. A history of the development of family planning in Nigeria. Trop J. Obstet Gynaecdol 1995; 1: 48  56.

  10. Susu B, Ransjo-Aarvidson AB. Family Planning Practices before and after childbirth in Lusaka, Zambia. East African Med J 1996; 73: 208-213.

  11. Fakeye O, Babaniyi O. Reasons for non-use of family planning methods in Ilorin, Nigeria: male opposition and fear of methods. Tropical Doctor 1989; 19: 114-117.

  12. Ozumba B, Chukudebelu W. Snow R Norplant as a contraceptive device in Enugu, Eastern Nigeria. Advances in Contraception 1998; 14:109  119.

  13. Ogedengbe OK, Giwa  Osagie OF, Adeboye M, Usiofoh CA. The Acceptability and Role of Norplant as a Long-acting Contraceptive in Lagos, Nigeria. Trop J Obstet Gynaecol 1997; 14: 28  33.

  14. Martey JO, Turkson SO. Clinical Evaluation of Norplant in Kumasi, Ghana.  East African Med J 1995; 72: 385.

  15. Davie J, Hirematu K, Glasier A. The introduction of a new contraceptive: Two years experience with Norplant. Health Bull. Edin 1996; 54: 314  22.

  16. Ozumba BC, Ibekwe PC. Contraceptive use at the family planning clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria. Public Health 2001; 115: 5153.

  17. Contraceptive Method Characteristics. Outlook 1992; 100 : 1

  18. Fraser IS, Tiitinen A, Affandi B. et al. Norplant consensus statement and background review. Contraception 1988, 57: 1  9.

  19. Soledad Diaz. IPPF Medical Bulletin 2001, 35 (2) : 1.

  20. Osoba AO. Sexually transmitted diseases in Nigeria: a review of the present situation. West African J Med 1989; 8: 42  51.

  21. Elstein M. Training in Family Planning. Br Med Bul 1993; 49: 273  274.

UPDATES ON CONTRACEPTION

Kigbu, J H,   Daniyan, A B C.
Department of Obstetrics & Gynecology, Jos University Teaching Hospital Jos, Nigeria.

Introduction
Contraception, which is the prevention of conception or impregnation by methods other than abstinence from coitus1, has become an important subject the world over and in particular the Sub-Saharan African which has one of the highest fertility rates in the world.2

In the past, a high conception rate was counteracted by high fetal and maternal death rates as well as reduced life expectancy occasioned by disease, violence and war hence stabilizing the size of the family and community3,4.  However with the advancements made in medicine and relatively improved socio-political environment, there has been increased survival rates and increased life expectancy with consequent increase in population.  Hence contraception which until recently was, a very sensitive subject among Africans given our moral, religious and cultural beliefs, is now being increasingly accepted as a necessary ingredient of socio-economic development.

This contraceptive evolution was heralded by the introduction of 'the pill' in the 1960s4.  Despite this, the fertility rate and population have continued to increase, as shown by a fertility rate of 6.1 in Nigeria3,4.  In the light of the above, a discussion of the updates on contraception is therefore imperative in order to add to information already available on the provision of safe, acceptable, affordable and effective methods of contraception.

Rationale for advances in contraception
The world population is expected to increase by 2.6 billion to 9.1 billion in 20502,3.  This will occur, if fertility decreases from today's 2.6 children to about 2 children per woman.  If fertility were to remain at the present level, 34 million persons would be added annually by mid-century and thus the world population would reach 10.6 billion by 20502,3.  The most notable increase in the world population will occur in third world countries.  Therefore immense investments are being made to develop safe, reliable and easy to use contraceptive methods. 

On the local scene, the population of Nigeria was put at 140 million as at March 2006 by the National Population Commission giving a 63% increase over the 1991 figure and an annual population growth rate of 3.2%.  If unchecked a figure of 281 million has been projected by 2015 by expects giving a doubling time of less than 10 years compared to a doubling time of 42 years for the entire world population2,3.  The implications of  the above trend are enormous  increasing poverty, unemployment and a high dependency ratio among others.

Apart from the rapidly increasing population, there is a global need for new contraceptive methods because the currently available methods are not adequate to meet the diverse interest of millions of users.  Several concerns have made the current array of contraceptives grossly inadequate to meet the growing worldwide needs.
The concerns that have been raised include safety particularly the risk of long-term use such as malignancy and thromboembolism.  There are also concerns about side effects such as headache, nausea, weight gain, menstrual disorders such as menorrhagia, irregular menstruation and amenorrhoea.  The fear of conditions associated with changing lifestyles such as HIV/AIDS and infertility as well as the problem of litigation further strengthens the need for development of new methods.

Hence research must continue so that women can have a variety of 'ideal methods' to meet their ever growing needs.  The methods should be very effective, safe, free of side effects, convenient to use and not provider dependent.  They should also be long acting, independent of coitus, easily available and affordable. The contraceptive methods newly developed cut across the various categories of contraceptives. 

The  new  methods
The combine oral contraceptive pills
The combine oral contraceptive pills which has become the most used pharmacological agent since it was first marketed in 19604 has undergone several modifications in order to reduce the side effects associated with its use.  Both the oestrogen and progestin components have been modified without compromising its effectiveness.  Aside from the second generation progestogens like the norethisterone and levonogestrel, new compounds are now widely used namely norgestinate, gestodene and desogestrel.  These are the third generation progestogens.  The combined oral contraceptives containing these progestins have shown almost no adverse changes in carbohydrate and lipid metabolism and on the haemostatic system4,9.

Yasmin®)
This is a combined pill containing 30mcg ethinyloestradiol and 3mg of a new progestogen, drospirenone.  Drospirenone appears to have an inyloestradiol which tends to cause water retention, and some women do complain of bloating when they take the pill.  Drospirenone, which is related to spironolactone, counteracts this by having a natriuretic effect.  Trials suggest Yasmin may be as effective as Dianette for mild to moderate acne, and it may be particularly suitable for those who suffer bloating, weight gain and breast tenderness on other pills.

The progestogen-only pills
CerazetteR
This is new Progesterone-only pills (POP) (75mcg of desogestrel daily) is designed to inhibit ovulation.  A study comparing Cerazette with Microval (Levonogestrel 30mcg/day) showed that only 1.7% of cycles were ovulatory in Cerazette users, compared to 40% in Microval users15.  In a randomized trial of Cerazette vs Microval, the Pearl Index was 0.17 (method failure) and 0.5 (user failure) for Cerezette compared with 1.4 (method failure) and 1.9 (user failure) for Microval in non-breast-feeding women15.  Although the bleeding pattern in Cerazette users is more variable than with Microval, there is a greater tendency towards infrequent bleeding and amenorrhea by the end of the first year.  It would also appear reasonable, in view of the ovulation inhibition, that there could be 12 hour pill taking safety margin rather than the three hours normally advised for conventional POPs and Cerazette now officially has a 12 hour missed pill rule15.  This, combined with its higher efficacy, should make it a much more attractive proposition for many women.
   
The Injectable hormonal contraceptives
The injectable hormonal contraceptives depot medroxyprogestrone acetate (DMPA) and norethisterone enanthate are highly effective, long acting, safe and reversible agents.  However, continuation rates with these agents are unsatisfactory menstrual irregularities being the most frequent reason for discontinuation.

Recent developments have shown that the addition of a short or medium-acting oestrogens improves the endometrial bleeding pattern8,12,15.  Two of such combined injectable contraceptives are cyclofem which contains low doses of medroxyprogesterone acetate (25mg) combined with 5mg oestradiol cypionate and mesygina which contains low doses (50mg) of norethisterone enanthate combined with 5mg oestradiol valerate.  Other progestogen derivatives under trial include cyclobutyl carboxylate (HPP-001), butanoate (HRP-002) and cyclopentylcarboxylate (HPP-003) of levonogestrel.  Their main advantage is that they allow a single and predictable bleeding episode every month with an extremely high efficacy1,6,8,15.  However they are given monthly as against the conventional two or three-monthly injectables. The option of self injection is being explored.

The subdermal implants
The observation that steroid hormones can be released at a constant rate from silicone rubber for long periods of time led to the development of the subdermal implants.  The Norplant which has been available since 1993 with six silastic capsules each containing 36mg levonogestrel and which lasts for five years was very effective but relatively expensive6,7,11.  Also many women complained about the menstrual pattern among other side effects and it has now been withdrawn6,11. 

Jadelle
The Jadelle is an improved version of the norplant, comprising two silicone rods each containing 75mg levonogestrel.

Implanon
Many of the problems associated with Norplant were related to the insertion and removal of the six implants.  Implanon has an advantage in that it consists of a single, semi-rigid rod, measuring 40mm by 2mm.  It releases 30-40 mcg of etonorgestrel (3 keto-desogestrel) per day and lasts for three years.  This hormone level is designed to achieve complete inhibition of ovulation and so far, in the worldwide phase III clinical trials, there has not been a single pregnancy10,11.    The implant comes preloaded in a disposable inserter which is about the same size as a blood transfusion needle, and the insertion procedure is very simple, not requiring a skin incision.  Insertion takes, on average, two minutes.  Removal, using a 'pop-out' technique, is facilitated by the rigidity of the capsule and takes three minutes. Amenorrhoea is more common in implanon users than with Norplant (21% vs 10% respectively).  However, there is no evidence that hypo-oestrogenicity is a problem in implanon users.  Etonorgestrel appears to inhibit LH, but not FSH, so follicles, and therefore oestradiol, are still produced.  The incidence of acne appears to be slightly lower than with the levonorgestrel implants.  However, irregular bleeding can be a problem, as with all progestogen-only methods.

The biodegradeable implants
These are a new generation of implants designed to eliminate the need for removal of the capsules.  An example is the capronor II which consists of two implants, each is a 4cm capsule of polymer caprolactone filled with 19mg levonogestrel.  It is effective for one year.  Another example is the capronor III which is a single implant consisting of 4cm capsule containing 32mg levonogestrel.  It is effective for one year.  The capsule is a copolymer which releases the drug more readily and also biodegrades more quickly than the simple polymer used in capronor II.  There is also the annuelle which comprises 4-5 pellets each about 8mm, made of norethidrone (90%) and cholesterol (10%).  Each pellet contains 35mg norethidrone.  It is effective for one year.

The vaginal rings
This is a long-acting method of contraception that does not require daily intervention and is entirely under the user's control.  Most steroid hormones are absorbed effectively through the vaginal wall and can be released from a silastic ring.  The ring can be easily inserted into the vagina, checked, removed and replaced by the woman herself.  It offers several advantages.  It can be worn continuously for a number of weeks, its use is unrelated to coitus, it causes fewer side effects, and daily intake of hormones and the hepatic first pass phenomenon seen with the oral contraceptive pills are avoided.  Also, there is a rapid return to fertility on removal.
There are two types of formulations of the vaginal ring.  There are vaginal rings that contain only progestogen (progestogen only rings).  Examples are the levonogestrel ring which delivers 70mcg per day and the nestorone ring which delivers an average of 100mcg nestorone10,11,20.  There is also the progesterone ring which delivers progesterone and can be used for up to 90 days.  It is suitable for lactating women because it prolongs lactational amenorrhoea and it uses a natural progestogen  progesterone to which the fetus is exposed to in-utero.  The new type of formulation is the combined ring which contains both oestrogen and progestin.  An example is the Nuvaring.

The Nuvaring
This is a vaginal ring containing 15 micrograms of ethinyloestradiol and 120 micrograms of etonogestrel (3-ketodesogestrel).  The ring is flexible and transparent; it is made of ethylene vinylacetate (EVA) copolymers, with an outer diameter of 54mm and a cross-sectional diameter of 4mm.  Each ring is to be used for three weeks, followed by a one-week ring-free interval.  Like the EVRA patch, Nuvaring can be inserted and removed by the woman herself.  In a large multicentre trial the method failure was 0.77 per hundred women years, and the user failure rate was 1.18 per hundred women years10,11.  Nuvaring has good cycle control and is well tolerated.

The transdermal patches
These are another group of recently introduced contraceptives.  They contain both oestrogens and progestogens that are easily absorbed through the skin.  An example is the EVRA.

The EVRAR
The EVRA is a contraceptive patch containing 20 micrograms of ethinyloestradiol and 150 micrograms of norgestimate, was launched in the UK in 20035,6.  Each patch is worn for a week, and can be placed on the buttocks, abdomen, the back or the upper arm.  Showering, bathing and swimming do not appear to affect adherence.  In the clinical trials, approximately 20% of women experienced mild to moderate application site reactions, although only 2% discontinued the method for this reason.  Efficacy was high, with a failure rate of only 0.7  1.2 per hundred women years overall. Cycle control was good and comparable to that of Mercilon (approximately 10-15% having spotting or bleeding in the third cycle).  The main side effect was transient breast tenderness in the first couple of months, experienced by 18% of users6,12.

The intrauterine contraceptive device (IUCD).
The IUCD has undergone a lot of development from the first generation or non-medicated devices of the 1960's such as the Lippe's loop and Saf-T-coil which were large plastic inert devices and the Dalkon shield made of polyvinyl acetate.  These were large inert devices which often caused heavy and painful menstrual periods.  They are not common anymore although some women may still have them in-situ because once fitted, they could be left in place until the menopause.  From these we have the second generation devices of the 1970s and 1980s that had copper added to them such as the Nova-T (Noncord) and multiload 250.  The third generation intrauterine contraceptive devices are copper-containing devices such as the copper T-380A which caused less menstrual disruption.  They are effective with failure rate of 1 per 100 or less.  They however still cause the problems of bleeding and pain2,3,11.

Researchers have been working to design copper intrauterine contraceptive devices that are highly effective, have minimal pain and bleeding associated with their use, can be provided to nulliparous women, are easy to insert and remove, have lower accidental expulsion rates and have higher continuation rates.  The new intrauterine devices are discussed below.

The Progestasert
Protestasert is a device made of a semi-permeable membrane of ethylene vinyl acetate which releases progesterone at a rate of 65mcg per 24 hours for one year.  It causes a dramatic reduction in menstrual blood loss.
The Mirena (Levonorgestrel-releasing intrauterine system)
This is based on the the well-established Nova T, on the vertical limb of which has been added a silastic capsule containing levonorgestrel.  The device releases 20 micrograms of levonogestrel per day and is now licensed for five years.  This mechanism of action has been associated mainly with atrophy of the endometrium, and the majority of women will ovulate only occasionally after the first year of use1,12,15.

In contrast to other IUDs, it has a failure rate of around 0.2 per hundred women years, and, unlike its progesterone-releasing predecessor, is therefore associated with a reduced risk of ectopic pregnancy.  In addition, its use results in a major reduction in menstrual flow and dysmenorrhoea, prompting suggestions that it is a viable alternative to hysterectomy and endometrial ablation in women with menorrhagia (for which it now has a license).  It does not appear to increase the risk of PID.  Its major disadvantage is the width of the stem, making fitting more difficult in nulliparous women.  The use of local anaesthetic in such women may be desirable.  Irregular, though light, bleeding also occurs, particularly in the first few months of use.  Only about 10 of women become amenorrhoeic. It should be noted that the Mirena is not licensed for post-coital use and there is evidence that it is not suitable for such cases.

The Mirena is already proving invaluable for perimenopausal women who still need contraception, as it also provides the progestogen part of Hormone Replacement Therapy (HRT).  It is hoped that a licence for use solely in HRT will be obtained in the near future.  A smaller device, especially for use in post-menopausal women, is also being developed.  A new inserter, which facilitates single-handed fitting, was introduced in 2000.

The Gyne-Fix
This is a frameless IUD.  Six copper tubes are threaded onto a nylon thread, which is knotted at one end and anchored in the muscle of the uterine fundus.  Studies show that the Gyne-Fix has a failure rate of less than 1% up to five years of use.  Gyne-Fix does not appear to increase the incidence of dysmenorrhoea in multiparous women and it is hoped that it will therefore be suitable for nulliparous women.  The fitting technique is very different to other IUDs and training is strongly recommended.

Nova T 380
The Ortho Gynae T 380 has been withdrawn for commercial reasons10.  The Nova T 380 contains the same amount of copper.  Early studies show the efficacy to be comparable, though slightly lower (1.6 vs 0.4 at two years and 2.0 vs 1.6 at 5 years)11.  Currently the Nova T 380 has a five year license, but it is hoped this will be extended10.

Natural family planning
New developments in this area include the use of the standard day method and the persona.

The Standard day method(Cycle beads)
This is a new system assisting women to understand their menstrual cycles thereby helping a couple to avoid unplanned pregnancy by knowing which days they should not have unprotected intercourse.  It identifies days 8-19 of the cycle as fertile and it is for women with menstrual cycle between 26 and 32 days long.  A client can use a colour-coded string of beads to help her keep track of where she is in her cycle and know when she is fertile.  Women are provided with Cycle beads as a visual aid to help them identify there cycle length, the first day of the cycle and the fertile days.  There are three different colour beads.  Red beads represent the first day of the cycle, brown beads represent the days when pregnancy is unlikely and white beads represent the fertile days.  The Cycle beads have a moveable rubber ring to mark the days of the cycle1,11,17.

The persona
Natural family planning has entered the age of technology.  This is basically a micro-computer attached to a microlaboratory.  The woman is required to insert test sticks dipped in her early morning urine: the device measures the levels of Luteinising hormone and oestrogen breakdown products, calculating the likely date of ovulation well in advance and allowing for sperm survival.  She is thus shown 'green' days, when conception is unlikely and 'red' days when conception may well occur.  With perfect use, failure rates are in the region of 6 per hundred women years.  However, more typical user failure rates are much higher11,13.

The barrier methods
Newly introduced barrier methods include the non-latex male condoms, the leas shield and the panty condom.

Non-latex male condoms
The non-latex male condoms are male condoms made from materials other than the natural latex.  These include condoms made of polyurethane, plastic and other synthetics.  They are stronger and better able to withstand storage conditions in developing countries.

The Leas shield
The Leas shield is a reusable cervical barrier made up of the same shape as the cervical cap.  It contains a value in the centre and a loop at the anterior end to facilitate removal.  It acts by preventing spermatozoa from entering the cervix.  For maximum effectiveness it should be inserted into the vagina anytime before intercourse and should be left in-situ for 8 hours after intercourse13.

The panty condom
The panty condom consists of a sensual, sexy cotton or nylon panty with an aperture in the front lower section where an interior membrane (much like a feminine day pad) contains a self adhesive condom that develops during coitus.  It is manufactured from a polyethylene resin, a material that is thinner and stronger than latex.  Unlike latex, it is anti-allergic.  It is lubricated, discreet, safe, easy to use and can be worn all day.  It is protected inside a membrane until used.  The panty is reusable and the condom is replaceable13,15.

Emergency contraceptives
Recent improvements in emergency contraceptives include the development of a single dose regimen of levonogestrel 1.5mg instead of two doses of 750mcg 12 hours apart.  It is easy and it has safety and efficacy comparable to the two-done regimen12,13,14.  The possibility of increasing the 12 hours interval to 24 hours is also being considered.  The use of mifepristone, an antipregestogen, both at 10mg and 25mg doses has been shown to be safe and effective.  The use of gestrinone, a 19-nortestosterone derivative is also being considered as a method of emergency contraceptive.

Female sterilization The Essure
A new method of female sterilization is the Essure that use the transcervical approach for sterilization.  The essure microinsert consists of a stainless steel inner coil, a nitinol superrelastic outer coil, and prolyethylene fibres.  The coil is placed into the uterine end of the fallopian tubes using a hysteroscope.  In clinical trials, essure was 99.8% effective after two years of follow-up.  Essure comes with a disposable delivery system.  When released, the outer coil expands to 1.5 to 2.0mm in diameter to anchor the microinsert in the varied diameters and shapes of the fallopian tube.  This results in tubal occlusion by the polyethylene fibres, eliciting a tissue in growth.  The rest of the tubes remain normal.
The advantages of the Essure includes the fact that it does not require any incision on the skin and there is no scar, no general anaesthesia is required for the procedure which can be carried out in the outpatient setting.  The procedure can be completed in 30 minutes and the client can go home 4-5minutes after the procedure.  About 99% of the women experienced satisfaction up to 2 years after insertion5,16,17.
   
Contraceptive vaccines
Contraceptive vaccines (CV) may provide viable and valuable alternatives to the presently available methods of contraception. The molecules that are being explored for CV development either target gamete production (luteinizing hormone-releasing hormone (LHRH)/GnRH, FSH), gamete function (sperm antigens and oocyte zona pellucida (ZP)), and gamete outcome (HCG)16,19,20.  CV targeting gamete production have shown varied degrees of efficacy; however, they either affect sex steroids causing impotency and/or show only a partial rather than a complete effect in inhibiting gametogenesis.  However, vaccines based on LHRH/GnRH are being developed by several pharmaceutical companies as substitutes for castration of domestic pets, farm and wild animals, and for therapeutic anticancer purposes such as in prostatic hypertrophy and carcinoma. These vaccines may also find applications in clinical situations that require the inhibition of increased secretions of sex steroids, such as in uterine fibroids, polycystic ovary syndrome, endometriosis and precocious puberty.  CV targeting molecules involved in gamete function such as sperm antigens and ZP proteins are exciting choices.  Sperm constitute the most promising and exciting target for CV.  Several sperm-specific antigens have been delineated in several laboratories and are being actively explored for CV development. Studies are focused on delineating appropriate sperm-specific epitopes, and increasing the immunogenicity (specifically in the local genital tract) and efficacy on the vaccines.  Anti-sperm antibody (ASA)-mediated immunoinfertility provides a naturally occurring model to indicate how a vaccine might work in humans.

Male contraceptives
The provision of safe, effective and reversible methods of contraception for men remains a challenge to scientists and clinicians alike.  Researches are still ongoing on many aspects of male contraception.

Vas occlusion
Vas occlusion using the no-scapel vasectomy was developed in China many years ago and is rapidly gaining acceptance.  Also, vas occlusion by percutaneous intravasal injection of sclerosants such as carbolic acid and n-butyl-cyanoacrylate is very effective but like surgical contraception, it does not offer increased chances of reversibility5,17,18,20.

Hormonal male contraception
Hormones inhibit fertility in men by suppressing sperm production.  Testosterone-enanthate induced azoospermia has proven to provide optimal contraceptive protection.  Preliminary studies have shown that testosterone alone or androgen-progestin combinations induce profound sperm suppression in the Eastern and white populations, respectively17,20. Thus, these regimens may represent viable options for male contraception.  New long-acting androgen formulations represent a major advancement in this field, allowing for the development of more acceptable and effective regimens.

Conclusion
The provision of effective contraception has undergone enormous developments.  Family planning clients however are still limited as to their choice of contraceptive methods because of myriads of side effects.  Hence a continuous research is needed in this area to provide clients with an array of contraceptive options with minimal or no side effects without compromising efficacy.

REFERENCES

  1. Tindall, VR: Contraception In: Jeffcoate's principles of Gynaecology.5th Ed.1987, 40:598-616.Butterworth, London.
  2. Adekunle AO.  Recent advances in contraceptive development.  In: Okonofua F. and Odunsi K. (Ed), Contemporary Obstetrics and Gynaecology for Developing Countries. Benin-City: WHARC. 2003; 110-127.
  3. Internet: World population data sheet. Population reference bureau,2006; http://www.prb/pdf 06/06 world data sheet.pdf, (Accessed 8 July,2008)
  4. Emuveyan, EE: Advances in Contraception   In: Kwawukume EY, Emuveyan EE, eds. Comprehensive Gynaecology in the Tropics. Vol.1.Accra, Graphic packaging. 2005:233-241.
  5. Nnatu, S.: Female Sterilization Techniques  Update. In: J. Obst. Gyn. East Cent. Afr. 1984, 4: 187-191.
  6. Audet M, Moreau M, Koltun WD, Waldbarn AS, Shangold G, Fisher AC, et al. Evaluation of contractive efficacy and cycle control of a transdermal contraceptive patch vs and oral contraceptive.  JAMA 2001; 2347-54.
  7. Arkutu, A: Family planning in Sub-Saharan Africa: Present status and future strategies. In: Int. J. Gyn. East Cent.Afr.1984, 4: 187-191.
  8. Towobola, OA, Otubu, J A M: Injectable Contraception In: Nigerian Med. J. 1988, 18:3.426-429.
  9. Cundy T, Evans M, Roberts H, Wattie D, Ames R, Reid I.  Bone density in women receiving depot medroxyprogesterone acetate for contraception.  BMJ 1991; 303: 13-16
  10. Dieben TOM, Roumen F. Apter D. Efficacy, cycle control and user acceptability of a noval combined contraceptive vaginal ring.  Human Reproduction 2002; 10 (3): 585-93.
  11. Erkkola R. Recent advances in contraception.  Minerva Ginecol 2006; 58 (4) 295-305.
  12. Gbolade BA.  Depo Provera and bone density.  J Fam Plann & Reprod Health Care 2002; 28 (1): 711.
  13. Hoesl CE, Saad F, Poppel M, Altwein Je.  Reversible, non-barrier male contraception: status and prospects. Eur Urol 2005 Nov; 48 (5): 712-22.
  14. Korver T for collaborative group. A double blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75mcg/day or levonorgestrel 30mcg/day.  Europ J Contraception and Reprod Health Care 1998; 3: 169-178.
  15. Meriggiola MC, Costantino A, Cerpolini S.  Recent advances in hormonal male contraception.  Contraception 2002; 65 (4): 269-272.
  16. Naz RK, Gupta SK, Gupta JC, Vyas HK, Talwar AG.  Recent Advances in contraceptive vaccine development: a mini-review. Hum Reprod 2005 20 (12): 327183.
  17. Practice committee of the American Society for Reproductive Medicine.  Hormonal contraception: recent advances and controversies.  Fertile Steril 2006 Nov; 86 (5 Suppl): S229-35
  18. Rice C et al.  A comparison of the inhibition of ovulation achieved by desogestrel 75mg and levonorgestrel 30mcg daily.  Human Reprod 1999; 14 (4): 982-985
  19. Smallwood GH, Meador M. Lenihan JP, Shangold GA, Fisher AC, Creasy GW, Efficacy and safety of a transdermal contraceptive system.  Obstet Gynecol 2001; 98: 799-805.
  20. Szarewski A.  Hormonal contraception: recent advances.  J Fam Health Care  2006; 16 (2): 35-6. 

CARDIOTHORACIC SURGICAL EMERGENCIES IN A NIGER DELTA TERTIARY HEALTH INSTITUTION: A 12 MONTH APPRAISAL.

E. E. Ekpe FWACS, T. Nottidge FWACS,  O. E. Akaiso FWACS
Department of Surgery,University of Uyo Teaching Hospital,  Uyo,  NIGERIA.

Abstract 

BACKGROUND: Many cardiothoracic surgical emergencies maybe life threatening. More than 70% of these are caused by thoracic trauma. Fortunately about 85% of thoracic trauma may be optimally treated with closed tube thoracostomy drainage (CTTD) or lesser procedures. A well dedicated trauma / cardiothoracic surgical unit is needed to significantly reduce the death toll from thoracic trauma.

OBJECTIVE: This study aimed to audit the cases of cardiothoracic surgical emergencies that presented to, and were managed in the University of Uyo Teaching Hospital over a one-year period in order to provide a database prior to a formal setup of a cardiothoracic surgery unit.

STUDY DESIGN: Clinical records of all patients with cardiothoracic surgical emergencies who presented during the period under review were analyzed.

RESULTS: There were 54 patients with cardiothoracic surgical emergencies during the period with male: female ratio of 2:1, and mean age of 30 years. Eighty-five per cent had thoracic trauma and 15% had major peripheral vascular injury. Thirty-five (64.8%) of the patients were treated in our hospital with medications and additional closed tube thoracostomy drainage in 51.9%. The remaining 35.2% of the patients were referred to cardiothoracic centre / units in other states over a range of 80 to 300 km away from Uyo, Nigeria.

CONCLUSION: Our findings conform to the known epidemiological pattern of cardiothoracic surgical emergencies, and emphasize the urgent need for a functional / well equipped cardiothoracic surgical unit in our hospital.

KEYWORDS: Cardiothoracic emergencies, need for a cardiothoracic unit INTRODUCTION:
Many cardiothoracic surgical emergencies are life  threatening. About 70% are caused by trauma, and about 50% of trauma  related deaths have thoracic components. About 85% of thoracic injuries are optimally treated by closed tube thoracostomy drainage (CTTD) or lesser procedures.1

Uyo is the capital of Akwa Ibom State, in the Niger Delta region of South-South geographical zone of Nigeria with a high patronage of commercial motorcycles as means of both inter- and intra- city transportation. This increases the risk of road traffic accident (RTA).

This study aimed at auditing cardiothoracic surgical emergencies in the hospital in the previous one year to serve as database for the proposed cardiothoracic surgical unit.

MATERIALS AND METHODS
This is a retrospective study that covered the period October 2005 to September 2006. Case notes of all patients who presented with cardiothoracic surgical emergencies were retrieved. Their demographic data, mode of presentation, clinical features, investigations, treatment, and outcome were reviewed. The information was entered into a proforma and analyzed using EPI  INFO version 2000.

RESULTS
In the 12 month period, October 2005  September 2006, a total of 54 patients were seen with cardiothoracic surgical emergencies distributed as 35 males and 19 females (male: female ratio 2: 1). The mean age of the patients was 30 years with a range of 12 to 57 years (fig. 1). There was no patient in the

first decade of life and none beyond the fifth decade of life. Motorcyclists accounted for 13 (24.1%) of the patients, while drivers accounted for 7 (13.0%). Civil servants were 7 (13.0%), business people 9 (16.7%), motor boys or conductors 5 (9.3%). Others included pupils, students, politicians, touts, clergies, and craftsmen who accounted for the remaining 13 (24.1%) (fig. 2).

Road traffic accidents including vehicular-pedestrian injuries were the mechanisms of the injury in 31 (57.4%) patients, assaults including gunshot by police, armed robbers, cultists and assassins, and machete cut, and blow with various objects like stick and concrete block, were responsible for injury in 14 (25.9%) of the patients with chest penetration in 5 patients (9.3%), soft tissue lodgement of bullet or pellets in 6 (11.1%) patients, and limb vascular injury in 2 (3.7%) patients. Other mechanisms of injury were fall from height in 3 (5.6%), hit by falling object 1 (1.9%), iatrogenic injury to the femoral vessels during femoral herniorrhaphy and groin dissection in two (3.7%) patients (fig. 3).

Most patients 40 (74.1%) presented primarily while 14 (25.9%) presented on referral after initial presentation to private or general hospital(s). All patients who presented after 24 hours of injury had been taken to another hospital before presentation in our hospital. The majority of patients 35 (64.8%) were stable at presentation while the unstable ones

 





who needed intensive resuscitation were 19 (35.2%). Blunt or closed injury was the type of injury in 32 (59.3%) of the patients, while penetrating chest injury and a combination of both blunt and penetrating chest injuries occurred in 11 (20.4%) and 3 (5.6%) of the patients respectively. Major vascular injury needing revascularization operation occurred in 8 (14.8%) of the patients (fig. 4).

Table 1 shows that 40 (74.1%) of the patients sustained their injury within 35 miles (56 km) from the hospital, 10 (18.5%) between 35 to 70 miles (56-112 km) and 4 (7.4%) beyond 70 miles (112 km). Only 24 (44.4%) of the patients presented within one hour of their injury, 17 (31.5%) between one to six hours, 6 (11.1%) between six and 24 hours, and 7 (13.0%) presented beyond 24 hours (table II).

Lung parenchymal injury resulting in haemothorax or haemo-pneumothorax was the commonest type of injury (59.3%), followed by rib fracture (40.7%). Mediastinal injury and major airway injury occurred in 3.7% of the patients each. Extra-thoracic vascular injuries including major arterial injury demanding immediate revascularization operation for limb salvage, and minor arterial, venous, and veno-arterial injuries occurred in 27.8% of the patients as a whole (table III). Figure 5 shows that 17 (31.5%) of the patients sustained injuries classified amongst immediate treatable causes of death which need immediate diagnosis and prompt / proper treatment to prevent death; cardiac tamponade in 1 (1.9%), open pneumothorax in 1 (1.9%) tension pneumothorax in 2 (3.7%), flail chest in 2 (3.7%), major airway injury in 2 (3.7%) and massive haemothorax in 5 (9.3%). Massive haemothorax means initial drainage of blood through chest tube of greater than 1500 mL or continuous drainage of greater than 250 mL per hour for three consecutive hours following insertion of thoracostomy tube. Others were four (7.4%) patients with haemorrhagic shock from gunshot wound and vascular injury.

Chest radiogram was the commonest diagnostic investigation as it was used in 43 (79.6%) patients, while 10 (18.5%) had other investigations including limb radiogram, toe pulse oximetry, abdominal ultrasound scanning, and diagnostic thoracocentesis. One patient (1.9%) who had cardiac tamponade did not have any specific investigation done before he died in the emergency room.

Forty (74.1%) of the patients with cardiothoracic surgical emergencies had associated injuries in one or more other organ systems. Such injuries included head injury, spinal injury, abdominal injury, skeletal fractures, dislocation, abdominal injury, genito-urinary and soft tissue lacerations. Fourteen (25.9%) of the patients were free from associated injury.
The definitive treatment offered to 28 (51.9%) of the patients was closed tube thoracostomy drainage (CTTD). Seven (13.0%) of the patients had other forms of treatment such as arrest of bleeding, wound care, antibiotic and analgesic therapy. Nineteen (35.2%) of the patients were referred to other centres with cardiothoracic surgical service outside Akwa Ibom State.


Of the thirty five (64.8%) of the patients treated here, 30 (55.6%) had good outcome defined as satisfactory functional recovery, three (5.6%) absconded before the end of treatment and two (3.7%) died in hospital. Nineteen patients (35.2%) were referred out for revascularization operation for limb salvage, emergency thoracotomy for treatment of massive haemothorax, and elective thoracotomy for treatment of clotted haemothorax (fig.6).

DISCUSSION
Cardiothoracic surgical emergencies are fairly common life-threatening surgical emergencies. This can occur as chest injury and/or extra-thoracic vascular injury involving intra-abdominal vessel(s), neck vessel(s) or peripheral vessel(s). In United States of America, chest injury is estimated to occur in 12 persons per million populations per day1. The same study pointed out that about 33% of these injuries would demand hospitalization and that chest injury contributed to about 50% of all trauma related deaths1.

This study reveals a total of 54 cardiothoracic surgical emergencies in our centre during the 12-month period under review. This is a significant number and much higher than the nine cases noted in Ilorin by Solagberu et al2. We also noted male: female ratio of 2: 1 and predominant involvement of young adult (65%). This is an active age group that is predominantly involved in a lot of activities like motorcycle riding, vehicle driving, and traveling, touting and even crime. In our culture, men are expected to be the bread winners for their homes, and are therefore expected to engage more in those activities, and therefore more at risk of injury than women. This pattern is seen in other similar studies.2,3,4,5.

This study also reveals that road traffic accident (RTA) alone was responsible for the greater proportion of cardiothoracic surgical emergencies (57.4%). RTA is also noted in another related study to be a major cause of surgical emergencies2. Assault and armed robbery attacks were the mechanisms of injury in 25.9% of cases. Various weapons were used to cause various types of injuries including blunt and penetrating chest injuries to the chest wall and intra-thoracic organs. Gunshot injury and knife stab were the mechanisms of injury in all penetrating chest injury and some peripheral vascular injury. There was no case of gunshot injury to the neck involving neck vessels in this study. However this type of injury appears to be common in Enugu, Nigeria resulting in traumatic carotid-jugular fistula6. There was also no case of penetrating chest injury caused by fall from height and impalement injury, a mechanism reported by Eze and Aghaji7. In a study from Calabar analyzing gunshot injuries, cardiothoracic involvement was 16%, necessitating limb amputation in 4% of the patients3.

Rare mechanisms of injury in this study were fall from height, hit by falling object, and iatrogenic femoral vessels injury during groin dissection and another one during femoral herniorrhaphy.
    Motorcyclists constituted 24.1% of the patients in this study. This was not a surprising finding because of the over-patronage of motorcycles as means of both intra- and inter-city transportation in Akwa Ibom State where this centre caters for primarily. Commercial motorcycling provides an immediate source of income thereby luring the teaming population of un-employed youths, apprentices, traders, military men and even low salary-earning civil servants to this business popularly called “aka uke?” in the local dialect. The reckless attitude and conveyance of more than one passenger at a time by most commercial motorcyclists are the risk factors exponentially increasing their risk of RTA8. Drivers, business people and driver's assistants (conductors or motor boys) are also exposed to a high risk of motor vehicular accident; because of high level of traveling involved in these groups of occupations2. The heterogeneous group represented as others in this study consisted of pupils, students, clergies, applicants, etc.

Most (74.1%) of the patients in this study presented primarily while only 25.9% presented as referral after an initial presentation to other hospital(s). This is probably because our centre was the only tertiary health care institution in this state with 31 local government areas, as at the time of this study. No similar studies elsewhere reviewed included mode of presentation in their analysis.

The majority (64.8%) of the patients in this study were haemodynamically stable on presentation. This was also observed in a previous study by Madziga5. The remaining (35.2%) of the patients were unstable at presentation and these were the patients with haemorrhagic shock, tension pneumothorax, open pneumothorax, massive haemothorax or cardiac tamponade who needed an aggressive cascade of resuscitatory measures to live. This high level of unstable presentation compared with the four percent in the Solagberu study is thought to be as a result of the vital nature of the cardio-pulmonary organ system which was injured in the present study. The Solagberu study reviewed injuries to all organs systems in the body2.

Chest injury comprised the majority (85.2%) of injuries in this study with blunt or closed chest injury accounting for 59.3%, penetrating chest injury 20.4% and combined in 5.6%. These findings agree with findings of other workers9,10,11.  Major vascular injury which was the type of injury in the remaining 14.8% of patients consisted mainly of peripheral vascular injuries, caused by RTA, gunshot injury, stab wound and iatrogenic injury to femoral vessel during groin dissection and femoral herniorrhaphy in two patients. There was no case of injury to abdominal vessels or neck vessels caused by gunshot injury in our study. Ezemba et al in Enugu, Nigeria reported two patients with traumatic carotid - jugular fistula resulting from gunshot injury to the neck6.

This study reveals that majority (74.1%) of the injuries occurred within a distance of 35 miles (56 km) from the hospital, 18.5% between 35 and 70 miles (56-112 km), and 7.4% beyond 70 miles (112 km). These findings call for establishment of land ambulance service which is more suitable and effective for transporting casualties within distances of 35 miles than air ambulance12. However, the use of air ambulance to transport cardiothoracic surgical emergencies from site of injury to trauma centres beyond 35 miles is more effective and efficient than land ambulance12. This greatly enhances presentation at the trauma centre within the golden hour, which is consistent with prompt resuscitation, timely treatment and good outcome. Other Nigerian studies on similar subject have been silent on distance from site of injury to trauma centre. Early presentation is positively correlated with good outcome, assuming constancy of all other prognostic factors. This was also revealed by the study on paediatric blunt abdominal trauma in Zaria, Nigeria, by Ameh and Nmadu13. The delay in presentation in this study is blamed on the inherent risk in, and problems associated with taking accident victims to hospital in some parts of Nigeria. Drugs including those used for resuscitation, and other consumable items in most Nigerian hospitals are dispensed on 'cash and carry' basis. This means that any good 'Samaritan' taking accident victims to the hospital should be willing and able to pay for the treatment of the patient(s) in addition. The police investigating the cause of the injury would also regard the good 'Samaritan' as being connected to the injury thereby discouraging people from helping to take accident victims to hospital.  

Haemothorax or haemo-pneumothorax was the commonest type of injury (59.3%) recorded in this study. This is probably because of the large surface areas of the parietal pleura, lungs and other intra-thoracic contents, which when injured could produce haemothorax, haemo-pneumothorax or pneumothorax. This type of injury can result from blunt or penetrating chest injury. This correlates well with the findings in Lagos, Nigeria by Thomas and Ogunleye14. Rib fracture occurred in 40.7% of the patients. Most cases of rib fractures were as a result of blunt rather than penetrating chest injury.

Major airway injury and mediastinal injury occurred in two patients (3.7%) respectively. The major airway injuries were blunt injury to cervical trachea in one patient, and machete cut into the cervical trachea in another patient who was assaulted by his neighbour. Injury to the major airway is a life threatening injury and therefore should be diagnosed early and properly treated to avert mortality15. The mediastinal injury noted in this study was one case each of haemo-pericardium and oesophageal perforation caused by blunt and penetrating injury respectively. There was no case of diaphragmatic rupture in this study. Although this injury is generally uncommon, its non existent here may be as a result of missed-diagnosis in those who would later present as acquired diaphragmatic hernia4,16,17. Other types of injury in this study included major vascular injuries (14.8%) resulting from RTA, gunshot injury, stab wound and iatrogenic injuries during surgical operations in the groin. Two patients presented late with gangrene of leg and were treated by limb amputation. Others were referred for revascularization operation in cardiothoracic centres outside Akwa Ibom State.

The incidence of immediate treatable causes of death in this study was rather high at 31.5%. These included massive haemothorax which usually indicate bleeding from a major vessel and not the lung parenchyma and therefore not likely to stop on conservative management of pleural drainage and volume replacement. It constitutes one of the indications for emergency thoracotomy in chest injury18. Major airway injury, flail chest and tension pneumothorax occurred in two patients each, while open pneumothorax and cardiac tamponade occurred in one patient each. The presence of any of these entities should be urgently identified, and treated to avert the high mortality that is associated with them9,11,12.

Forty-three (79.6%) of the patients had plain chest radiogram as the sole diagnostic investigatory tool, 18.5% had other investigations as ultrasound scanning, pulse oximetry, limb radiography and diagnostic thoracentesis. These investigations were grossly inadequate and cannot make precise diagnosis of chest injury19. As our centre is planning to set up a cardiothoracic surgery unit, echocardiography with both trans-thoracic and trans-oesophageal probes, computed tomographic scan (CTS), fluoroscopic screening, angiography, video-assisted thoracoscopic surgery (VATS), magnetic resonance imaging (MRI), bronchoscopy, and oesophagoscopy should be planned alongside. The role of serum level of cardiac enzymes like cardiac troponin I and creatine kinase MB isoenzyme is widely recognized and should be utilized by all centres20,21.

Extra thoracic injury was present in up to 74.1% of the patients. This was a high figure and did increase morbidity and mortality. The injuries included musculo-skeletal, abdominal, neurological, and genito-urinary injuries. This calls for an holistic approach in evaluation of all trauma patients. This same spectrum was noted by other workers5,9,10,11,22.

The specific treatment given to about 51.9% of the patients in this study was closed tube thoracostomy drainage. This means of treatment is known to be sufficient for the treatment of up to 80-85% of patients with chest injury whereas the remaining 15% would demand a more invasive operation like thoracotomy, median sternotomy, and laparotomy11,14. The remaining patients were referred to cardiothoracic centres outside Akwa Ibom State (35.2%), treated with limb amputation (3.7%) or treated with analgesic, antibiotic and other supportive measures (9.2%).

The majority (55.5%) of the patients had good outcome determined by good functional recovery, 35.2% who were referred could not be determined, same as the 5.6% that absconded, with 3.7% mortality. The referral level was rather high but is not unexpected in a centre with no functional cardiothoracic unit like ours.

CONCLUSION:
This study showed the big morbidity burden associated with cardiothoracic surgical emergencies, which are fairly common in Uyo, Nigeria. Improving the transportation system in the state whereby motocycles would be replaced with cars and buses can reduce this burden. Establishment of a well-equipped functional cardiothoracic surgery unit is urgently needed in this healthcare institution to reduce the referral, morbidity and mortality level experienced during the short period under review.

 

REFERENCES:

  1. LoCicero J 3rd, Mattox KL: Epidemiology of chest trauma. Surg Clin North Am 1989 Feb; 69(1): 15-9

  2. Solagberu BA, Duze AT, Kuranga SA, Adekanye AO, Ofoegbu CKP, Odelowo EOO: Surgical Emergencies in a Nigerian University Hospital. Nigerian Postgraduate Medical J 2003 Sept; 10 (3): 140-3

  3. Udosen AM, Etiuma AU, Ugare GA, Bassey OO. Gunshot injuries in Calabar, Nigeria: indication of increasing societal violence and police brutality. African Health Sciences 2006; 6 (3): 15 - 9

  4. Jamabo RS, Eke N: Traumatic rupture of the diaphragm. Sahel Medical J 2005; 8 (1): 45 - 52

  5. Madziga AG: Arrow injuries in North East Nigeria. West African J M 2003; 22 (2): 34 - 9

  6. Ezemba N, Ekpe EE, Ezike HA, Anyanwu CH. Traumatic Common Carotid-Jugular Fistula. Texas Heart Institute J 2006; 33 (1): 81-3.

  7. Eze JC, Aghaji MAC. Experience with the Management of unusual Penetrating Chest Injury. Journal of College of Medicine 2002; 7 (1): 7 - 11

  8. Udosen AM, Ngim  NE. Commercial motorcyclists: Do they care about road safety? Nigerian Medical Practitioner 2007; 51 (6): 23 - 7

  9. Feliciano DV, Rozycki GS: Advances in the diagnosis and treatment of thoracic trauma. Surg Clin North Am 1999 Dec; 79(6): 1417-29

  10. Campbell DB: Trauma to the chest wall, lung, and major airways. Semin Thorac Cardiovasc Surg 1992 Jul; 4(3): 234-40

  11. Mandal AK, Sanusi M: Penetrating chest wounds: 24 years experience. World J Surg 2001 Sep; 25(9): 1145-9

  12. Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 1989 Jun; 209(6): 698-705; discussion 706-7

  13. Ameh AM, Nmadu PT. Gastrointestinal injuries from blunt abdominal trauma in children. East African Medical Journal 2004; 81 (4): 220 - 7

  14. Thomas MO; Ogunleye EO. Penetrating chest trauma in Nigeria. Asian Cardiovasc Thorac Ann.  2005; 13(2):103-6

  15. Balci AE; Eren N; Eren S; Ulkü R. Surgical treatment of post-traumatic tracheobronchial injuries: 14-year experience. Eur J Cardiothorac Surg.  2002; 22(6): 984-9

  16. Mamman M, Raymond B, Sani A. Traumatic Diaphragmatic Hernia: A Case Report. Highland Medical Research Journal 2004 2 (2): 72 - 6

  17. Nursal TZ; Ugurlu M; Kologlu M; Hamaloglu E. Traumatic diaphragmatic hernias: a report of 26 cases. Hernia 2001; 5(1): 25-9.

    Karmy-Jones R; Jurkovich GJ; Nathens AB; Shatz DV; Brundage S; Wall MJ; Engelhardt S; Hoyt DB; Holcroft J; Knudson MM. Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study. Arch Surg.  2001; 136(5):513-8


19.    Peytel E; Menegaux F; Cluzel P; Langeron O; Coriat P; Riou B. Initial imaging assessment of severe blunt trauma. Intensive Care Med.  2001; 27(11):1756-61

20.    Adams JE; Dávila-Román VG; Bessey PQ;         Blake DP; Ladenson JH; Jaffe AS. Improved         detection of cardiac contusion with cardiac         troponin I. Am Heart J.  1996; 131(2):308-12
 

21.    Salim A; Velmahos GC; Jindal A; Chan L; Vassiliu P; Belzberg H; Asensio J; Demetriades  D. Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings. J Trauma.  2001; 50(2):237-43

22.    Ceran S; Sunam GS; Aribas OK; Gormus N; Solak H. Chest trauma in children. Eur J Cardiothorac Surg.  2002; 21(1):57-9

ENTEROCUTANEOUS FISTULA: A REVIEW OF LITERATURE

*Udo I A FWACS, ** Umoh M S FWACS

*Department of Surgery, University of Uyo Teaching Hospital, Uyo
**Department of Surgery, University of Calabar Teaching Hospital, Calabar

Abstract
Enterocutaneous fistula carries a high morbidity and mortality; it is preventable with good surgical decision making. It is common with emergency abdominal procedures but could arise from trauma or spontaneously. Complicated hernias still cause this condition in tropical Africa.
The management requires early recognition and control of ongoing metabolic and nutritional abnormalities. Enteral nutrition is adequate in distal fistulas. Surgery is not considered a priority in management; it is reserved for complex fistulas.
Key words: Enterocutaneous fistula, high morbidity, emergency procedure.

Introduction
Enterocutaneous fistula is an abnormal communication between the intestinal tract and the skin. Most arise as a complication of difficult and/or emergency abdominal surgery. This ailment remains a challenge to the abdominal surgeon and could cause extreme distress to the patients, relations and the attending surgeon.1-3 The morbidity and mortality remain high due to the associated malnutrition, sepsis, fluid and electrolyte  abnormalities.4-6
Increasingly though, and with a better understanding of the ongoing anatomic, physiologic and metabolic abnormalities in these patients, hope of successfully managing fistulas conservatively leading to spontaneous closure is rising. Most fistulas will close spontaneously if there is no distal obstruction, epitheliazation of the tract, abscess cavity or malignancy. High output fistulas often require surgical intervention after the initial conservative approach.
Post-operative fistulas account for as much as 90% of fistulas3; perhaps higher in tropical Africa because of poor health care access and scarce qualified manpower7. Unfortunately, the era of complicated abdominal hernias with resultant faecal discharge from the abdominal wall and scrotum is yet to be history in much of rural Africa8. This is a great challenge to the health profession on the continent.
Prompt and adequate management with prevention of the associated malnutrition, sepsis and metabolic abnormalities, as well as carefully planned surgical intervention where necessary, can significantly reduce the morbidity and mortality from enterocutaneous fistulas.
This review is an attempt to highlight trends in managing enterocutaneous fistulas and provides practitioners with information on a subject fast disappearing from recent publications.

Historical perspective
Enterocutaneous fistula has a long and disturbing history separated into eras based on advances attained in its management1. The first era (1945 - 60) coincided with the introduction of antibiotics into medical practice. The reported mortality at that time was 45%. The second era (1960 -70) emphasized respiratory and nutritional support as well as intensive care. This caused the mortality to drop to 15%. The third era (1970 -75) was the deployment of parenteral nutrition in management of fistulas. This increased the spontaneous closure rate to 25% (from 15% previously) but without a change in mortality.
Currently, octreotide, a long acting somatostatin analogue is widely used in conservative management of fistulas. It reduces fistula output thus accelerating closure. Other experimental therapies include the use of fibrin glue to seal the tract, wound Vacuum-Assisted Closure (VAC) and vascularized muscle flap closure for large abdominal wall defects.

Aetiology
The aetiology of enterocutaneous fistula is varied. Approximately 50%- 95% are iatrogenic, arising secondary to difficult abdominal surgical procedures such as anastomosis failure and accidental bowel injuries. They are commonly encountered with intestinal inflammation such as perforated typhoid ileitis and extensive adhesiolysis especially under emergency conditions with sub-optimal preparation of the patient.1,3,4,8
 In developing countries strangulated abdominal hernias (inguinal, femoral and umbilical), criminal abortions, poorly executed appendicectomy, herniorrhaphy, and anastomosis are common causes of post operative fistulas.
 Chronic granulomatous infections,  especially caused by tuberculosis and schistosomiasis are rare causes of fistulas. Traditional interventions for groin swellings by puncture may lead to complex fistulas8. Spontaneous fistulas are due to intra-abdominal malignancies, diverticulitis, radiation enteritis and Crohn's disease. These are rare in the tropics. Persistent vitello- intestinal duct causes a congenital fistula.

Classification
Fistulas are classified based on anatomical site, character of the tract (simple, complex), physiology (high or low output), or aetiology. They could further be described as end fistula (the entire bowel diameter is involved) or lateral fistula (involving the sides).

The modified Sitges- Serra classification of post operative fistula proposed by Schein and Decker9 has four types:
    -Type I- involves the abdominal oesophagus, stomach and duodenum
    -Type II- involves the small intestines
    -Type III- involves the large intestines
    -Type IV- involves any of the above with a large abdominal wall defect.
A high output fistula produces an effluent greater than 500 ml in 24 hours and likely originates from the small intestines with marked physiological derangements, while a low output fistula produces less than 500 ml in 24 hours and often originates in the large bowel.   

Diagnosis
The diagnosis of enterocutaneous fistulas is made clinically based on history and physical findings. There is discharge of intestinal content externally through the abdominal wall post-operatively. In circumstances of doubt, excretion of an orally administered dye such as Congo red, methylene blue or charcoal through the fistula easily gives away the diagnosis by the bedside.
 A predictable sequence of events occurs in post-operative fistulas: post-operative fever, wound infection and resolution of fever on draining the wound. Serosanguinous wound discharge and pus precedes the egress of intestinal contents through the wound on the 7th to 10th post-operative day; usually on removal of skin sutures.
Complex fistulas present with large abdominal wall defects, intra-abdominal abscesses and multiple internal and external drainage channels; these are particularly difficult to manage and call for ingenuity and experience on the part of the surgeon4.

A fistulogram with water-soluble contrast is invaluable in managing fistulas; it maps out the tracts, demonstrates an abscess cavity and may determine the management protocol. When adequately done, it may exclude the need for other gastro-intestinal tract investigations5. Other radiological investigations like barium series, CT and MRI scans are employed when the diagnosis is difficult or to outline intra-abdominal abscess cavities. Serum electrolyte, complete blood count and serum protein assessment are also required and may be of prognostic value1.


Treatment
Treatment of intestinal fistulas is divided for convenience into phases; with priorities clearly spelt out in each phase. The treatment options depend on the number of complicating factors. Prevention remains the best treatment.

Phase I (Stabilization phase):- Priorities in this phase are to correct ongoing metabolic derangements and skin care to prevent skin contact with effluent which could be corrosive in high output fistulas. Aggressive fluid and electrolyte therapy is required especially in high output fistulas because of the enormous fluid loss and lack of absorptive surface because of the high location of fistula.5 Controlled drainage of the effluent preferably with a sump drain allows for accurate measurement of fluid loss and precise fluid replacement.  Blood is transfused to correct severe anaemia which is invariably present; albumin alone is transfused where hypoalbuminaemia is the problem1.
Enteral nutrition, through a tube or oral, is preferred to parenteral by some authors; it is trophic to the gut and does not prevent spontaneous closure. It is particularly indicated in distal fistulas1. Where full enteral nutrition is not practicable, a portion of the nutrient may still be given enterally5. Total parenteral nutrition is employed if there is practically no absorptive surface in the gut.
Skin care requires a stoma bag and karaya gum to collect the effluent.  However, dressings changed at regular intervals have also been successfully used in distal fistulas. Applying zinc oxide paste protects the exposed skin from excoriation by acid and enzymes.1

Phase II (Investigation and Diagnosis): This phase seeks to delineate the character and aetiology of fistula as well as formulate a management plan. It identifies factors which preclude spontaneous closure such as distal obstruction, foreign body, malignancy and a large opening greater than 1cm in diameter10. Presence of these factors are  indications for surgery. Specific imaging modalities include plain abdominal x-ray and fistulogram.

Phase III (Conservative management): This phase aims at devising ways to close fistula and re-establish continuity of the gastro-intestinal tract. Spontaneous closure is often desired though not feasible with high output fistulas5. Conservative management allows time for adequate nutritional rehabilitation, correction of metabolic derangements and skin sepsis, and may optimize the patient for surgery or spontaneous fistula closure. Ihekwaba and Shittu11  however do not recommend conservative management in poorly equipped hospitals with limited resources because of its uncertain outcome; they favour operative closure while patient condition is still near optimal.

Phase IV (Definitive therapy): Surgical intervention is not a priority in managing fistulas; it is reserved for fistulas that fail to close spontaneously4. It requires meticulous attention to technique, and in the presence of adhesions or radiation enteritis the risk of further injuries at surgery must be considered.
Drainage of abscess cavity is done in the stabilization phase after injecting water soluble contrast into the cavity to provide a better anatomic image of the cavity and tracts. Drainage is advised under antibiotic cover because of associated bacteremia. 5
Resection with end -to-end anastomosis carries the best prognosis of restoring anatomical continuity. By-pass procedures are done but not recommended in radiation induced injuries because of the difficulty in predicting the extent of injuries leading to high failure rates, high mortality and creation of blind loop syndrome5,10.
 Cases with large abdominal wall defects are rare and difficult to manage. Such may require vascularized muscle or omental flaps to close the defects.4,12

New Therapies
Octreotide: A long acting somatostatin analogue used in conservative management of fistulas along with other treatment modalities. It is reported in some studies to rapidly reduce fistula output within 24 hours and accelerate spontaneous closure of fistula13-15.  It is administered at a dose of 100 micrograms eight hourly, no glucose intolerance was observed during treatment.1,15

Adhesives: Fibrin glue has been used to seal the fistula tract with very limited success; it is not widely employed in the management of fistulas13.

Wound VAC: The wound VAC system improves skin care; the vacuum sucks the effluent into a receptacle away from skin.13

Conclusion 
Enterocutaneous fistula remains a challenge to the abdominal surgeon, with a high morbidity and mortality. It can be prevented by good surgical decision making and execution as well as provision of adequate health facilities with qualified manpower.
A conservative approach emphasizing correction of the associated metabolic and nutritional abnormalities will lead to spontaneous closure in most instances. Few will come to surgery.

 

REFERENCES

  1. Ajao O G, Shehri M Y. Enterocutaneous Fistula. Saudi J Gastroenterology. 2001;7(2)51-54
  2. Shelton AA, Schrock TR, Welton ML. Small Intestine. In: Way L, Dohert G. Current Surgical Diagnosis and Treatment. 11th Ed. McGraw Hill. 2003:696-7
  3. Ohanaka CE, Momoh IM, Osime U. Management of Enterocutaneous Fistula in Benin City Nigeria. Tropical Doctor. 2001, Apr;31(2):104-6
  4. Chang P, Chun J T, Bell J L. Complex Enterocutaneous Fistula: Closure with Rectus Abdominis Muscle Flap. South Med. J. 2000;93(6):599-602
  5. Durdick SJ,Maharaj AR, Mckelvey AA. Artificial Nutritional Support in Patients with Gastrointestinal Fistulas. World Journal of Surgery. 1999 Jun;23(6):570-6
  6. Adotey JM. External intestinal fistulas in Port Harcourt. West Afr J of Med. 1995 Apr-Jun; 14(2):97-100
  7. Kumar P. Providing the Providers-Remedying Africa's Shortage of  Health Care Providers. New England Journal of Medicine. 2007 Jun; 25(356):2564-2567
  8. Udofot SU.Multiple Faecal and Urinary Fistulas as a Complication of Native Treatment of Inguinal Hernia. Trop Geo Med. 1991 Jan-Apr; 43(1-2):105-7
  9. Schein M, Decker G A. Postoperative External Alimentary Tract Fistulas. Am. J. Surg. 1991;16(4):435-8
  10. Chintamani, Rohini Badran, Daniel RK, Vinay Singhal, Dinesh Bhatnagar. Spontaneous Enterocutaneous Fistula 27-years following Radiotherapy in a patient of carcinoma of the Penis. World Journal of Surgical Oncology. 2003, 1:23
  11. Ihekwaba FN, Shittu AB.Perforated Typhoid Enteritis-The problem of intestinal fistula. Trop Geogr Med. 1991Oct; 43(4):370-4
  12. Alagumuthu M, Das Bhupati, Pattanaya Siba, Rasanada Mangual. The Omentum: A unique organ of exceptional versatility. Indian J of Surg. 2006;68:136-141
  13. Draus DM, Huss SA, Harty NJ, Cheadle WG, Larson GM. Enterocutaneous fistula:   are treatments improving? Surgery. 2006;140(4):570-6
  14. Spiliotis J, Briand D, Gouttebel M C, Astre C, Louer B, Saint-Aubert et al. Treatment of fistulas of the gastro-intestinal tract with total parenteral nutrition and octreotide in patients with carcinoma. Surg Gynecol Obst. 1993 Jun; 176(6):557-80
  15. Nubiola Badia J M, Martinez-Rodenas F, Gill M J, Segura M, Sancho J et al. Treatment of 27 post-operative enterocutaneous fistula with long half-life somatostatin analogue SMS 201-995. Ann Surg. 1989 July;210(1):56-8

MATERNAL BLOOD LOSS BY MODE OF UTERINE INCISION AT CAESAREAN SECTION: A COMPARISON BETWEEN SHARP AND BLUNT TECHNIQUES

Dr. E.O. Orji, MBBS, FMCOG, FWACS  Dr. O.A. Olaleye MBBS,
Department of Obstetrics, Gynaecology and Perinatology, Obafemi Awolowo University, Ile-Ife, Nigeria

ABSTRACT

Objective: To evaluate the effect of two techniques of uterine incision expansion   at caesarean section on the maternal blood loss, inadvertent extension of incisions and the feto-maternal outcome .

Methods: A quasi-experimental study with convenient sampling involving two groups of women who underwent lower segment transverse caesarean section. Both groups were studied for their demographic characteristics and clinical data. Standard surgical techniques were used in both groups except the technique of uterine incision either by blunt or sharp method. Finally a comparison of the two groups was made regarding blood loss, changes in haemotocrit, blood transfusion and uterine tears. The study was conducted at the obstetric unit of Obafemi Awolowo University teaching Hospital Ile-Ife, Nigeria from January to December 2006.

Result:    Seventy-two women were studied (36 into either method).  Blunt method of uterine expansion was significantly associated with in creased risk for blood loss, fall in haematocrit (P=0.001), need for blood transfusion (P<0.05) and uterine, vaginal and cervical tears due to  inadvertent extension compared to sharp expansion group.
Conclusion: The sharp expansion method is recommended because it is associated with reduced maternal morbidity in term of blood loss and uterine tears.

INTRODUCTION
Although caesarean section is much safer today due to improved techniques, antibiotics, anaesthetic procedures and blood transfusion1-3, it is still a major cause of intra-operative and post-operative complications worldwide4. Its morbidity remains high as compared to vaginal delivery5,6.

Attention has therefore been focused on reducing morbidity associated with the procedure through refinements of the surgical techniques7-9. A variety of surgical techniques have been employed to restrict blood loss during caesarean section. These include; spontaneous versus manual removal of placenta10, in situ repair of uterine incision versus uterine exteriorization10. T and J extension in low transverse births11 and comparison of modified Joel-Cohen technique for Caesarean Section with Pfannenstiel technique12 among others.  One of the techniques that remains debatable is the blunt versus sharp expansion of uterine incisions in low transverse caesarean section13,14. Different surgeons based on their own experience have advocated each method. Very few prospective studies have demonstrated any merit or demerit associated with either of these methods

This prospective study tries to compare which technique of extending the uterine incision that is associated with less morbidity in terms of less intra- operative blood loss, need for blood transfusion and uterine tears. This is particularly important in our environment where there is scarcity of compatible blood during emergency obstetric conditions and great aversion towards caesarean section.

METHODS
All the patients requiring caesarean section at the obstetric unit of Obafemi Awolowo University Teaching hospital Ile-Ife, Nigeria from January to December 2006 who fulfilled the inclusion criteria were recruited into the study after obtaining informed consent. A quasi experimental study with convenience sampling involving two groups of women who underwent caesarean section was studied.

 


The sample size for the comparison of independent means was used15:
N= S² ( Q-¹ A + Q-¹ ß (Zx+ Zp)²
                       Ų²
Where S²= pooled estimate of the common variance of the two samples; QA= the proportion of the total sample in sample A; Qß= the proportion of the total sample in sample B; Ų= the difference detected between the means of the two samples.

 

Using the computer system CPEA (computer programme for epidemiologic analysis) to calculate the sample, it gave a minimum sample size of 22 patients for each group. However seventy two women were recruited in the study to increase the statistical significance. 36 of them were assigned to group 1 (in these patients uterine extension was done bluntly (digital extension). The other half (36) were designated group 11 (in which uterine extension was made by sharp incision). Distribution of patients in either group was made on the basis of non-randomized (convenience) sampling. General anaesthesia was  administered to all patients. Packed cell volume, blood group and cross matching were performed in all patients. Pre-operative preparations and techniques were same in both groups except the procedure for expanding the uterine incision. A sub-umbilical midline incision was made for all the patients, followed by a low transverse uterine incision. After making an incision of 2cm in the uterine walls with a scalpel, the incision was extended either by blunt or sharp method. The blunt method involves the introduction of fore fingers into the initial uterine incision, followed by forcefully splitting the uterine musculature laterally and superiorly16. In sharp method, using curved dissecting scissors, the initial uterine incision was extended lateral and superiorly to avoid the lateral angles of the cervix.

 


After delivery of the fetus, the placenta was delivered by controlled cord traction. Intravenous oxytocics were given alongside uterine incision and abdominal incision was closed in layers. The intraoperative blood loss was estimated by measuring the amount of blood in the suction apparatus and weighing the pre-weighed sponges. Haemotocrit was repeated after 48 hours of surgery. A record of blood transfusion was kept along with the number and extent of tears. An extension of tear was defined in this study as an inadvertent extension of uterine incision beyond normal limits.
Inclusion criteria comprised of all singleton pregnancies with gestational age 37-42 weeks. Exclusion criteria were all pregnant women with multiple pregnancies, polyhydramnious, ante partum haemorrhage, previous history of post partum haemorrhage and uterine fibroids all of which are risk factors for increased blood loss during and after surgery. All data pertaining to the age of patients, Parity, gestational age, indication for surgery, and birth weight of the baby were recorded in a proforma and a comparison made. All the data were fed into statistical package for social sciences (SPSS) version 11. Data were analyzed using the chi-square test and student t-test. Level of significance was placed at P<0.05

RESULTS
Seventy-two patients who fulfilled the inclusion criteria were assigned into each group (36 women per group). Table I shows the selected demographic characteristics of the blunt and sharp group. There were no statistical significant difference between the two groups in the mean age, mean parity, mean gestational age at delivery, type of surgery, and the stage of labor when the surgery was performed (P>0.05).
Table II shows the haematological profiles of the comparison group. While there was no difference between both groups in their mean pre-operative packed cell volume (P>0.05), there was significant reduction in postoperative packed cell volume (PCV) among patients who had blunt dissection compared to those with sharp dissection (29.89 versus 33.66) P=0.001.Similar findings were seen in the mean fall of haematocrit (P=0.001) and in the estimated blood loss (P=0.001). One patient among the blunt group had a pint of blood transfused post -operative.
Table III shows further maternal and neonatal outcome among both groups. Patients who had blunt dissection had more inadvertent tears (50%) compared to 16.7% among the sharp group (P<0.05). There was no significant difference in the risk for fetal injury, mean Apgar scores at 1 and at 5 minutes and in the mean birth weight (P>0.05).
Table IV shows that indications for surgery were similar among both groups. These indications include; obstructed labour, cephalopelvic disproportion, breech presentation, fetal distress, failure to progress, pre-eclampsia/eclampsia, transverse lie, bad obstetric history and two previous caesarean sections.

DISCUSSION
Surgical techniques to perform caesarean sections have evolved over the passage of time7. In this study we compared the technique of extension of uterine incision by blunt versus sharp methods. There were no significant difference between the study groups in terms of maternal age, gestational age at delivery, and neonatal Apgar scores. Our results showed that the blunt dissection group had significantly increased risk for blood loss, and fall in post -operative haematocrit compared to the sharp group. While this is similar to the findings of other authors13, it contrasts with others who in their study observed more blood loss in the sharp group14. However, both our study and theirs reported more tears in the blunt group compared with the sharp group. The increased risk for tears observed in the blunt group had been attributed to the fact that the force required to expand the incision in the blunt group cannot always be calculated or controlled and therefore may result in inadvertent extension of the incision laterally into the broad ligament which may damage major vessels thus leading to more blood loss16 as was observed in our study. There were also extension of the tears into the vagina, and the cervix which further increased blood loss and the repair may actually increase the duration of surgery. In comparison, the sharp grouped had less tears and blood loss probably because the expansion of the incision with curved scissors was well controlled and precise hence reducing the risk of inadvertent extension.

However, in contrast to our findings, Magann et al conducted a comparative study between the two techniques and found that blood loss and uterine tears were more in sharp group14  than in the blunt group. These differing findings call for more research into the various techniques so that the morbidity arising from blood loss and tears would be reduced with concomitant reduction in hospital costs and duration of hospital stay.

The reduced mean blood loss and the less need for blood transfusion observed in our study among the sharp group is worthy of note. This technique should be encouraged in our locality where there is great aversion to caesarean section and blood transfusion18,19 .

It is further advantageous in our environment where there is scarcity of blood for transfusion during obstetric emergencies. Further more, many of our patients requiring caesarean section present late in labour when complications had set in and many may be in obstructed labor with the head deeply impacted in the pelvis20,21 .Careful expansion by sharp dissection in such conditions would be beneficial because any inadvertent extension to the vagina or broad ligament may be catastrophic if there is inadequate blood supplies.

In conclusion, our study showed that blunt expansion in uterine incision at caesarean section is associated with increased morbidity in terms of blood loss and inadvertent tears compared to the sharp method.

 

REFERENCES

  1. Malomo OO, Kuti O, Orji EO, Oguniyi SO, Sule SS. A randomized controlled study of non-closure of peritoneum at caesarean section in a Nigerian population. J. Obstet Gynaecol 2006, 26 (5): 429-432
  2. Hema KR, Johansson R.  Techniques for performing Caesarean Section.  Best Pract. Rec. Clin. Obstet. Gynaecol. 2001; 15:17-47.
  3. Paul RH, Milter D.A, Caesarean birth. How to reduce the rate. Am J Obstet Gynaecol 1995, 172:1903  1911
  4. ACOG educational bulletin Postpartum haemorrhage number 243. January 1998 (replaces No s143, July 1990). American college of Obstetrics Gynecologists int J Obstet Gynaecol 1998: 6 (1) 79  88
  5. Fikree FF, Midher F. Sadruddn S, Berendes HW, Maternal Mortality in different Pakistani sites: ratios, clinical cases and determinants. Acta Obstet Gynacol Scand 1997; 76 (7) : 637  645
  6. Jaferey SN, Maternal mortality in Pakistan compilation of available data. J. Pak Med Assoc 2002; 52 (12): 539-544
  7. Mathai M, Hofmeyr G.J.  Abdominal Surgical incision for Caesarean Section. Cochrane Database of Systematic Review 2007, Issue I.
  8. Higgins JFT, Green S, editors.  Cochrane Handbook for Systemic reviews of Interventions 4.2.5 (Updated May 2005). In the Cochrane Library Issue 2. 2005. Chichener UK. John, Wiley & Sons Ltd.
  9. Bergholi T, Standemp JK, Vedsted-Jakobsen A, Helen P, Lenstrup C. intra-operative surgical complications during caesarean section: an observational study of the incidence and risk factor. Acta Obstet Gynacol Scand 2003, 82 (3): 251-256
  10. Magann EF, Washburne JF, Harris RI, Bass JD, Duff WP, Morrison JC. Infections morbidity, operative blood loss, and length of the operative procedure after caesarean delivery by method of placental removal and site of uterine repair. J AM Coll Surg 1995, 181(16): 517-520
  11. Boyler JG, Gabbe SG. T and J vertical extensions in low transverse caesarean births: Obstet Gynaecol 1996, 87 (2): 238-243
  12. Wallin G, Fall O. Modified Joel-Cohen technique for caesarean delivery Br J Obstet Gynaecol 1999: 106 (3) 221-226
  13. Rodriguez AL, Forter KB, O'Brien WF Blunt versus sharp expansion of the uterine incision in low segment transverse caesarean section. Am J Obstet Gynaecol 1994: 171:1022  1025
  14. Magnan EF, Chauban SP, Bufkin, L, Field K, Roberts WE, Martin JN Jr. Intra-operative haemorrhage by blunt versus sharp expansion a randomized clinical trial. BJOG 2002; 109(4) 448-452.
  15. Galinger PM, Abramson JH, Sample size for comparison of proportion or means. In Computer Programme for Epidemiologic Analysis. Hawai. Makapuu, Medical Press 1993; 131-141.
  16. Hagen A, Schmed O, Runkel S, Wersil H, Hopp H.  A randomized trial of two surgical techniques for Caesarean Section. Euro. J. Obset Gynaecol Repro Biol 1999: 86: 581.
  17. Smith JF, Hernandes C, Wax JR. fetal laceration injury at caesarean delivery BJOG 2002: 109 (4):448-452
  18. Orji EO, Ogunniyi SO, Onwudiegwu U. Beliefs and perceptions of pregnant women at Ilesa about caesarean section. Trop J Obstet Gynacol 2003; 20: 141-143
  19. Fasubaa OB, Ogunniyi SO, Dare FO, Isawumi AL, Ezechi OC, Orji EO. Uncomplicated caesarean section: is prolonged hospital stay necessary? EAMJ 2000, 77 (8):448-451
  20. Fasubaa OB, Ezechi OC, Orji EO, Ogunniyi SO, Akindele ST, Loto OM, Okogbo F.O, Delivery of the impacted head of the fetus at caesarean section after prolonged obstructed labour a randomised comparative study of two methods J. Obstet Gynaecol 2002, 22 (4): 375-378
  21. Orji EO, Analysis of obstructed labour at Ife State Hospital, Ile-Ife, Nigeria. Sahel Medical Journal 2002, 5 (3): 143-148.

NEAR MISS MATERNAL MORTALITY IN JOS UNIVERSITY TEACHING HOSPITAL (JUTH), JOS, PLATEAU STATE NIGERIA.

Patrick H. Daru, Jonah Musa, Peter Achara, and Ishaya C. Pam
Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos, Plateau State.


Background: Near misses are incidents which might have resulted in a maternal death, but for prompt and effective treatment. Characterizing near-miss mortality is valuable for monitoring the quality of hospital based obstetric care, and for assessing the incidence of life threatening complications. It is the major indicator used to monitor maternal health in the developed world, and it is also being increasingly used in Africa. For every woman who dies; many suffer serious life threatening complications of pregnancy. The near miss case definition was based on five diagnostic categories: Hypertensive disorder in pregnancy, haemorrhage, infections, labour dystocia, and severe anaemia

Aim- To determine the incidence of near-miss obstetric mortality in Jos University Teaching Hospital (JUTH) over a 12 month period

Method: Retrospective analysis of near-miss maternal morbidity from 1st January 2006 to 31st December 2006 was carried out. Data on maternal age, parity, diagnosis, booking status, duration of admission and treatment were collected. Analysis was done with EPI-Info, version 6 statistical software packages.
Result: There were 2,972 deliveries, and 73 near-miss cases. The incidence of near misses in the year under review was 2.5%, or 2,500 per 100,000 deliveries. Forty of the 73 case files were retrieved .Hypertensive disorders constituted 32.5%, and were the leading event. It was followed by haemorrhage (27.5%), infections (22.5%), dystocia (15%), and severe anaemia (2.5%). Majority (60%) of the cases were unbooked, many (27.5%) booked elsewhere, and only a small minority (12.5%) booked in this center.

Conclusion: Hypertensive disorders, haemorrhage, and infections were the leading near miss events in this center, and efforts should be made to further allocate more resources for managing these cases, especially in unbooked patients.

INTRODUCTION
Near-miss events are defined as acute obstetric complications that immediately threaten a woman's survival, but do not result in her death, either by chance or because of hospital care she receives during pregnancy, labour or within 6 weeks after termination of pregnancy or delivery1-2.

Characterizing near-miss mortality is valuable for monitoring the quality of hospital based obstetric care, and for assessing the incidence of life threatening complications3. It is the major indicator used to monitor maternal health in the developed world3, and it is also being increasingly used in Africa4. For every woman who dies; many suffer serious life threatening complications of pregnancy3.

A Canadian study defined mortality of severe obstetric complication to be: the number of women, who had a life threatening condition for each 100, 000 live births, in any given place, at any given time5. Near miss cases in 6 African countries were discovered to be due to complications arising mainly between 28th weeks of gestation and 42 days after delivery, which would have been lethal or irreversibly devastating, if medical help was not available6.

More severe maternal morbidity is seen in women who do not attend antenatal care in a standard health unit, but are referred there when they develop life threatening complications4.

METHODOLOLGY
This is a retrospective study of near miss (severe maternal) mortality in JUTH, from 1st January  31st December 2006. The medical records of the patients were retrieved from the records department, theatre, gynaecological, antenatal and postnatal wards. Data on maternal age, parity, diagnosis, booking status, duration of admission and treatment were collected. Analysis was carried out using Epi-info, version 6 statistical software packages. Frequency tables, mean, and percentages were generated.

The near-miss mortality was grouped under 5 major diagnostic categories: 1. Hypertensive disorders of pregnancy which included severe pre-eclampsia and eclampsia; 2. Haemorrhage, which comprised both ante-partum and post-partum haemorrhage, 3. Infections which were cases of post-abortal sepsis and puerperal sepsis. 4. Dystocia which included prolonged obstructed labour and uterine rupture. 5. Severe anaemia.

The criteria for inclusion in the study were: ICU admission, transfusion of ≥3 units of blood, genital sepsis with systemic symptoms or clinical features of septic shock, severe or neglected dystocia and severe anaemia with heart failure.

RESULTS
 There were 2,972 deliveries and 73 near-miss cases during the one year period under review. The incidence of near-miss maternal mortality was 2.5% of deliveries. Forty, out of the 73 case files were retrieved for analysis. Hypertensive disorder was the leading near-miss event 13 (32.5%) (Fig.1). This included 12 cases of eclampsia and one case of severe pre-eclampsia with anarsarca and oliguria. Haemorrhage was the second most common event 11 (27.5%). This included 7 cases of abruptio placenta, either with coagulopathy or necessitating transfusion of ≥3 units of blood; and 4 cases of severe post partum haemorrhage. Infectious morbidity was the third most common near-miss event 9 (22.5%). It comprised 5 cases of septic abortions and 4 cases of puerperal sepsis with fever or septic shock. Dystocia accounted for 6 cases (15%), and there was a case of severe postpartum anaemia in a known sickler (2.5%). These are summarized in Table-1.

Most of the patients (60%) with life threatening morbidities were unbooked. Many others (27.5%) were booked elsewhere, while only a minority (12.5%) booked in this center.  These are shown in table 2.

Primiparae (45%) and grandmultiparae (32.5%) were the most common. Average parity was 3 with a range of 1-10.

Half (50%) of the near miss patients stayed a week or less on admission. Average duration of admission was 11 days, with a range of 1-51 days. Teenagers constituted 25% of cases of near miss events. The age range was 16-45years, with a mean of 28years.

DISCUSSION
Most studies on near miss maternal mortality utilized intensive care unit (ICU) admission as one of the criteria for inclusion in the studies7.  The indications for admission into ICU are different in various countries, and differ in different institutions within a country7. The criteria for regarding an obstetric morbidity as near miss also differ in various studies. The differences in definition and identification of cases are major limitations in comparison of near miss data8. Studies in industrialized countries commonly use ICU-admission or organ-system dysfunction/ failure as criteria for case selection9. Though organ  system based criteria are the most specific and least vulnerable to bias8; the case definition used in this study suits our own circumstances, and will allow comparison of local studies.

The incidence of near miss maternal morbidity of 2.5% in this institution is comparable to other studies in Africa, but much higher than in developed countries8. This disparity is due to differences in identification of cases. A hypertensive disorder in pregnancy was the most common near miss event, and haemorrhage, the second most common. This is similar to reports from Sagamu, Nigeria10.

Most patients with near miss morbidities were unbooked or were referred when they developed life threatening complications. This suggests that resources for handling emergency referral of cases of hypertension and haemorrhage need to be enhanced. Early referral of severe cases from primary care centers, and enlightening the populace on the importance of antenatal care will further decrease the mortality from severe maternal morbidity.
   
Primiparous and grandmultiparous women are at greatest risk of having a life threatening maternal morbidity, and booking these women at specialist clinics will decrease the morbidity and mortality in these groups.

This new measure of maternal care allows for an effective audit system, because it is clinically based, and the cases identified reflect the pattern of maternal death4. Near miss data also enhance the determination of fatality ratio, which is an objective indication for the quality of obstetric care. Fatality ratio is the ratio between the number of maternal deaths and all cases of women who experience life threatening complications7.

REFERENCES

  1. Campbell S, lees C. Maternal and pernatal mortality: The confidential enquiries. In: Campbell S, lee C (Eds). Obstetrics by Ten Teacher; 17th edition. ELST with Arnold, 2000; 3: 19-32.
  2. Ronsmans C, Fillip V: Reviewing severe maternal morbidity: learning from survivors life-threatening complications. In: Beyond the Numbers: Reviewing Deaths and complications to make pregnancy safer. Geneva: world Health organizations: 2004; 103-124.
  3. Geller S.E, Rosenberg D, Cox S.M, Kilpatrick S. Defining a conceptual framework for near miss maternal morbidity. J AM Med Women Assoc 2002; 57 (3): 13 5-9.
  4. Mantel G.P. Buchmann E, Rees H, Pattinson R.C. Severe acute maternal morbidity: a pilot study of a definition for “near miss” British J of Obstet. Gynaecol 1998; 105: 985-90.
  5. Canadian perinatal surveillance system steering committee and Health indicators for Canada, a resource manual. Severe maternal morbidity ratio.2000: 46-8. URL: http/ www.hc-se. gc.ca/pphb/rhs-ssg/phic-ispc.
  6. Kaye D, Mirembe F, Aziga F, Namulema B. Maternal mortality and associated near misses among emergency intrapartum obstetric referrals in Mulago Hospital Kampala, Uganda. East Afr med J.2003; 80 (3):144-9
  7. Minkauskiene M, Nadisauskiene R, Padaiga Z, Mankari S. Systemic review on the incidence and prevalence of severe maternal morbidity. Medicina 2004; 40 (4):1-11.http:// medicina.Kmu.It.
  8. Say L, Pattinson R.C, and Gulmezoglu A.M. WHO system review of maternal morbidity and mortality: The prevalence of severe acute maternal morbidity (near miss). Reprod. Health 2004, 1:3.  [http://www.Reproductive-health journal.Com/ content/1/1/3].
  9. Baskett T.F, Sternadel J. Maternal intensive care and near miss mortality in obstetrics. B.JOG 1998, 105:981-984
  10. Olufemi T.O, Adewale O.S, Adetola O.U, Olusoji D. “Near miss” Obstetric events and maternal deaths in Sagamu Nigeria, a retrospective study. Reproductive Health 2005, 2:9. http://www.reproductivejournal.com/content/2/1/9.