The burden of caesarean section refusal in a developing country setting

Objective  To investigate the prevalence, aetiology and outcomes of caesarean section refusal in pregnant women.
Design  A prospective controlled study.
Setting  University of Nigeria Teaching Hospital and Aghaeze Hospital, Enugu, Nigeria.
Population  A total of 62 Nigerian women who declined elective caesarean section.
Method  Interviewer-administered questionnaires at the time of caesarean section refusal and postdelivery. The delivery outcomes of the subjects were compared with that of a matched control group of women who accepted caesarean section.
Main outcome measures  Prevalence, maternal reasons for caesarean section refusal and the resultant maternal and perinatal mortality.
Results  The prevalence of caesarean section refusal was 11.6% of all caesarean deliveries. Maternal reasons for refusing caesarean section include fear of death, economic reasons, desire to experience vaginal delivery and inadequate counselling. Outcomes were significantly worse among women who refused elective caesarean section than in the controls with a maternal mortality of 15% (versus 2%, P = 0.008) and a perinatal mortality of 34% (versus 5%, P < 0.001).
Conclusion  There is a high prevalence of caesarean section refusal in south-eastern Nigeria. Women declining caesareans have very poor maternal and perinatal outcomes and need extra support.     

Automated Algorithm for GI Spike Burst Detection and Demonstration of Efficacy in Ischemic Small Intestine

We present a novel, fully-automated gastrointestinal spike burst detection algorithm. Following pre-processing with SALPA (Wagenaar and Potter, J. Neurosci. Methods 120:113–120, 2002) and a Savitzky–Golay filter to remove unwanted low and high frequency components, candidate spike waveforms are detected utilizing the non-linear energy operator. Candidate waveforms are classified as spikes or artifact by a support vector machine. The new method achieves highly satisfactory performance with >90% sensitivity and positive prediction value. We also demonstrate an application of the new method to detect changes in spike rate and spatial propagation patterns upon induction of mesenteric ischemia in the small intestine. Spike rates were observed to transiently increase 10–20 fold for a duration of ≈600 s, relative to baseline conditions. In ischemic conditions, spike activity propagation patterns included retrograde-longitudinal wavefronts with occasional spontaneous conduction blocks, as well as self-terminating concentric-circumferential wavefronts. Longitudinal and circumferential velocities were 6.8–8.0 cm/s and 18.7 cm/s, respectively.     

Implications of incorrect determination of fetal sex by ultrasound

Objective: To assess the experiences of women following incorrect determination of fetal sex by ultrasound. Method: A 3-year prospective cohort study of 102 women with discordance between fetal sex determined by ultrasound scan and birth sex. Participants were interviewed using 2 structured pretested questionnaires. The first questionnaire was undertaken within 24 h of delivery. The women were followed up with a second questionnaire 6–9 months later. In-depth interviews were also carried out at this time. Results: Women who had received an incorrect determination of fetal sex by ultrasound experienced marital conflicts, domestic violence, negative perceptions of ultrasound, and a desire for reversal of tubal ligation. Conclusion: Incorrect determination of fetal sex by ultrasound has implications that can affect the mental and psychological health of the mother and the upbringing of the newborn.     

Juxtacervical vesicovaginal fistulae: outcome by route of repair.

Vesicovaginal fistula is a major public health problem in Nigeria with diverse medical, psychological and social consequences for the patient. This study compared the outcome of vaginal vs abdominal repair of juxtacervical vesicovaginal fistulae. It was a retrospective review undertaken at the University of Nigeria Teaching Hospital, Aghaeze Hospital and Mbanefo Hospital, all in Enugu, Nigeria, from 1 January 1992 to 31 December 2004. The outcome measures were primary repair success rate, blood transfusion, postoperative urinary tract infection rate and duration of hospital stay. Abdominal repair of juxtacervical vesicovaginal fistula was associated with a significantly higher need for blood transfusion when compared with vaginal repair. Both routes of repair had similar primary repair success rates, postoperative urinary tract infection rates and duration of hospital stay. It was concluded that the route of repair of juxtacervical vesicovaginal fistula should be determined by accessibility of the fistula and whenever possible, the vaginal route should be preferred.     

Potential of resveratrol in anticancer and anti-inflammatory therapy

Phytochemicals present in food have shown significant prospects in the treatment and management of a vast array of human diseases. Resveratrol is a stilbene-type aromatic phytoalexin predominantly found in grapes, peanuts, berries, turmeric, and other food products. Resveratrol has been reported to exhibit several physiological activities including anticancer and anti-inflammatory activities in vitro and in experimental animal models, as well as in humans. Anticancer activity of this compound is mainly due to induction of apoptosis via several pathways, as well as alteration of gene expressions, all leading to a decrease in tumor initiation, promotion, and progression. Resveratrol exhibits anti-inflammatory activity through modulation of enzymes and pathways that produce mediators of inflammation and also induction of programmed cell death in activated immune cells. Resveratrol has been shown to produce no adverse effects, even when consumed at high concentrations. Hence, resveratrol possesses good potential to be used as an adjunctive or alternative therapy for cancer and inflammatory diseases.     

Examining appropriate diagnosis and treatment of malaria: availability and use of rapid diagnostic tests and artemisinin-based combination therapy in public and private health facilities in south east Nigeria

Background  

Rapid diagnostic tests (RDTs) and Artemisinin-based combination therapy (ACT) have been widely advocated by government and the international community as cost-effective tools for diagnosis and treatment of malaria. ACTs are now the first line treatment drug for malaria in Nigeria and RDTs have been introduced by the government to bridge the existing gaps in proper diagnosis. However, it is not known how readily available these RDTs and ACTs are in public and private health facilities and whether health workers are actually using them. Hence, this study investigated the levels of availability and use of RDTs and ACTs in these facilities.     

Obstetricians' opinions and attitudes toward maternal refusal of recommended cesarean delivery in Nigeria

Objective

To assess the opinions and attitudes of Nigerian obstetricians toward women's refusal of cesarean delivery.

Method

We used a questionnaire with 5 clinical scenarios drawn from published cases in which Nigerian women refused to undergo a recommended cesarean delivery.

Results

Most obstetricians (84.8%) advocated continuous counseling of these women but, from their response to the scenarios, few (13.7%-16.1%) would actually do so. Insufficient facilities and poor logistics for emergency obstetric care were their stated major reason for not respecting maternal choices in situations where vaginal delivery could have been given a chance.

Conclusion

The possibility of providing emergency obstetric care would remove many indications for cesarean delivery from the list of absolute indications in Nigeria; and management guidelines would protect obstetricians in the event of litigation, and improve their acceptance and respect of maternal choice.     

Lessons learned from the outcome of bloodless emergency laparotomies on Jehovah’s Witness women presenting in the extremis with ruptured uterus

Objective  We compared the outcomes of bloodless emergency laparotomies for uterine rupture in twenty Jehovah’s Witness (JW) women who were in a state of haemorrhagic shock with 45 other women who received blood transfusion. Methods  The case records of twenty Jehovah’s Witness patients, who underwent bloodless emergency laparotomies for ruptured uterus complicated by haemorrhagic shock between 1 January 2000 and 31 December 2006 were reviewed. We also reviewed the case records of 45 other patients who underwent similar surgical procedures for similar indications and in whom blood was transfused. The outcome variables compared were maternal deaths, infectious morbidity, acute respiratory distress syndrome, disseminated intravascular coagulation, length of post laparotomy ventilatory support, and length of postpartum hospitalization. Results  Demographic and obstetric characteristics were similar in both groups. Seventeen out of the twenty Jehovah’s Witness patients who refused blood transfusion survived the laparotomies and were discharged home in good condition. Three died of peritonitis. Six out of the 45 patients who received blood transfusion also died of peritonitis and one died of disseminated intravascular coagulopathy. The average duration of post partum hospitalization was 8 days in the group of patients transfused and 7 days in the group not transfused. Disseminated intravascular coagulation occurred post partum in two of the patients transfused. No case of acute respiratory distress syndrome or amniotic fluid embolism was identified in either group. Conclusion  Patients who are in haemorrhagic shock from ruptured uterus and refuse blood transfusion can still be salvaged in a low resource setting. The study adds evidence that major operative procedures can be carried out on Jehovah’s Witness patients without blood transfusions or blood products.