Postgraduate Medical Journal

Towards zero mortality in sickle cell pregnancy: A prospective study comparing haemoglobin SS and AA women in Lagos, Nigeria Ochuwa Adiketu Babah, Monsurat Bolanle Aderolu, Ayodeji A Oluwole, Bosede B Afolabi Nigerian Postgraduate Medical Journal 2019 26(1):1-7 Introduction: Sickle cell disease in pregnancy carries increased risk of maternal and perinatal morbidity and mortality. Past studies on pregnancy complications in sickle cell disease women were limited by relatively small sample sizes, and use of retrospective and hospital discharge data. Study Design: This prospective case-control study compared booked pregnant Haemoglobin (Hb) SS women with AA controls from two tertiary centres in Lagos, in order to precisely identify their complication and mortality rates and identify associated factors. Eligible pregnant HbSS and HbAA women were recruited from antenatal clinics at booking and follow-up visits. Information was collected on a proforma and data was analyzed using IBM SPSS version 20. Results: We found higher complication rate in HbSS group, commonest complications being vaso-occlusive crisis (RR 1.47, 95% CI 1.22 – 1.78), pregnancy induced hypertension (RR 1.31, 95% CI 1.08 – 1.57), urinary tract infection (RR 1.32, 95% CI 1.12 – 1.57), and intrauterine growth restriction (RR 1.2, 95% CI 1.05 – 1.34). HbSS group had higher systolic and mean arterial blood pressure values in early puerperium compared to HbAA group (p = 0.014 and 0.024 respectively). No maternal death recorded in both group. Incidence of low birth weight <2.5Kg was 38% in HbSS and 4% in HbAA subjects, p = 0.001. However, overall maternal and perinatal outcomes were comparable in both groups (p = 1.000). Conclusion: Although sickle cell disease poses higher obstetric risk in pregnancy, maternal and perinatal outcome can be as good as in the non-sickle cell pregnant women if adequate and prompt individualized care is given to this group of women.

Heart rate variability study in adult Nigerian subjects with sickle cell disease during vaso-occlusive crisis Adewole Adesoji Adebiyi, Olaniyi Mabayomije Oyebowale, Ayodele John Olaniyi, Ayodele Olawale Falase Nigerian Postgraduate Medical Journal 2019 26(1):8-12 Context: Autonomic nervous system (ANS) dysfunction assessed by abnormalities in heart rate variability (HRV) is thought to play a role in the pathophysiology of sickle cell disease (SCD). There is suggestion that changes in ANS may occur in SCD subjects during episodes of vaso-occlusive crises (VOC). Aims: The aim of this study was to evaluate the ANS by determining the HRV in patients with SCD during VOC. Settings and Design: This was a cross-sectional observational study. Materials and Methods: HRV studies were carried out in 76 participants with SCD during episodes of VOC. Eighty-two SCD participants in steady state served as controls. Statistical Analysis Used: Comparison of two independent groups with Student's t-test and Mann–Whitney's test, and multiple linear regressions were also carried out. Results: Participants with SCD and VOC had significant reductions in the time-domain HRV parameters of standard deviation of RR intervals (45.8 [59.36] ms vs. 66.3 [129.2] ms, P = 0.0073) and root mean square of successive differences of RR intervals (48.3 [87.66] ms vs. 74.2 [174.5] ms, P = 0.0015). The frequency-domain HRV indices of low frequency (145.8 [81.62] ms2 vs. 157.5 [68.9] ms2, P = 0.1442) and high frequency (145.0 [118.40] ms2 vs. 146.3 [90.3] ms2, P = 0.3683) were similar between the two groups. Age and the heart rate were the major independent relations of the HRV parameters. Conclusions: Time-domain HRV parameters were impaired during crises in participants with SCD. This finding suggests further impairment of ANS activity in SCD patients during crises. Further studies are needed to clarify the prognostic implication of these findings.

Haematological values in steady-state sickle cell anaemia patients and matched heamoglobin AA Controls in a Rural Area of Eastern Gabon Landry Erik Mombo, Gaël Mabioko-Mbembo, Cyrille Bisseye, Kevin Mbacky, Fatoumata Thiam, Apollinaire Edou Nigerian Postgraduate Medical Journal 2019 26(1):13-17 Background: In Gabon, universal neonatal screening of sickle cell disease is not carried out in rural areas, often leading to late detection of the disease. However, complete blood counts are available in rural areas. Materials and Methods: We evaluated the haematological parameters of 45 homozygous steady-state sickle cell anaemia (SCA) patients and compared them with 45 sex- and age-matched Haemoglobin AA controls in Koula-Moutou, a rural area in Eastern Gabon. Results: Homozygous SCA patients had low erythrocyte values (red blood cells: 2.50 × 1012/L, haemoglobin: 7.20 g/dL and haematocrit: 20.70%) and high leucocyte values (white blood cells: 14.40 × 109/L, lymphocytes: 5.24 × 109/L and monocytes: 1.60 × 109/L). Most of the SCA patients had severe anaemia (67%), normochromia (76%), lymphocytosis (73%) and monocytosis (84%). A haemoglobin level of < 8.5 g/dL together with a leucocyte level above 9.5 × 109 cells/L was used as screening test to detect homozygous SCA patients, with sensitivity of 84.4% and specificity of 97.8%. Conclusion: The values for erythrocyte and leucocyte cell lines of SCA patients in steady state are clearly different from those of the matched HbA/A controls. This makes it possible to set up a tool to detect SCA based on the haemogram in a rural area that does not possess haemoglobin electrophoresis. This tool could be used by healthcare workers in the absence of universal newborn screening for SCA.

Medication adherence and 24-h blood pressure in apparently uncontrolled hypertensive Nigerian patients Abiodun Moshood Adeoye, Akindele Olupelumi Adebiyi, Oladimeji Muritala Adebayo, Mayowa Ojo Owolabi Nigerian Postgraduate Medical Journal 2019 26(1):18-24 Background: Uncontrolled hypertension is a major risk for major cardiovascular events. While medication adherence determines blood pressure (BP) control, studies on treatment adherence among apparently uncontrolled hypertensives are sorely lacking in sub-Saharan Africa. We report the pattern and correlate of medication adherence among the uncontrolled hypertensive population. Materials and Methods: We investigated 148 age- and sex-matched hypertensive adults on anti-hypertensive medication for a minimum of 1 year. Apparent uncontrolled BP was defined as clinic BP ≥140/90 mmHg, whereas 24-h ambulatory BP monitoring was used to determine the true uncontrolled hypertension and other BP phenotypes. Using the 8-item Morisky medication adherence scale participants were classified into high, moderate and low adherence while Modified Morisky Scale was used to assess knowledge and motivation. Results: The mean age and BP were 61 ± 13.3 years and 158/91 mmHg, respectively. High adherence was found in 4.1% of the participants while 68.9% and 27% had moderate and low adherence, respectively. A third had true uncontrolled hypertension. A high proportion of the study participants also had a high motivation (68.9%) and knowledge (89.2%). Medication adherence was associated with motivation (P = 0.0001), knowledge (P = 0.002) and obesity (P = 0.036). Knowledge was an independent determinant of medication adherence with no significant effect on BP control. Conclusion: High medication adherence was low and a third had true uncontrolled hypertension. Knowledge was an independent predictor of medication adherence with no significant effect on blood control. High medication adherence rather than moderate adherence, and knowledge are indeed needed for adequate BP control.

Comparison of visual estimation of intra-operative blood loss with haemoglobin estimation in patients undergoing caesarean section Sampson Uzo Anya, Fidelis Anayo Onyekwulu, Elias Chukwujioke Onuora Nigerian Postgraduate Medical Journal 2019 26(1):25-30 Background: Obstetrical haemorrhage is a potentially preventable cause of maternal morbidity and mortality; and measurements of surgical blood loss (BL) are often inaccurate. Accurate BL estimation is paramount as it may substantially alter the timing of interventions to control haemorrhage. The study compares the assessment of intra-operative BL by visual estimation with BL calculated from haemoglobin estimation using the HemoCue®201+. Materials and Methods: A total of 60 pregnant patients at term undergoing elective caesarean section under spinal anaesthesia were enrolled into the study. In the theatre, the patients' haemoglobin level was determined before and after the surgery using the HemoCue®201+; and a modified Gross formula was used to calculate the BL. BL was also visually estimated and documented by counting the blood-soaked abdominal mops and gauze pieces and multiplying them by the estimated volume of blood each would hold; fixed size mops and gauzes were used. Statistical analysis was performed to compare both methods using SPSS Version 17. To compare BL assessment, Pearson's correlation and the Bland and Altman's method of assessing agreement between two methods of clinical measurement were used. Results: The mean visually estimated BL (EBL) and HemoCue calculated BL (CBL) were 470 ± 221 ml and 563 ± 204 ml, respectively (P = 0.125). The bias (mean difference between both methods) was negligible (45.25 ml), and the limit of agreement between both methods was −222.20–275.43 ml. The discrepancy between the two methods increased when BL was ≥500 ml. Conclusion: This study showed that visually EBL was closely related to HemoCue CBL when the quantity of BL was <500 ml.

Post-operative management in uncomplicated caesarean delivery: A randomised trial of short-stay versus traditional protocol at the Lagos University Teaching Hospital, Nigeria Nuvie Oyeyemi, Lawal Oyeneyin, Ayodeji Oluwole, Abisoye Oyeyemi, Bosede Afolabi Nigerian Postgraduate Medical Journal 2019 26(1):31-37 Context: Caesarean section (CS) is the most common major obstetric operation. There has, therefore, been an increasing interest in issues pertaining to the management and length of hospital stay following the procedure. Aim: This study aimed to evaluate morbidity outcomes as well as incurred costs between traditional and short-stay protocols, following uncomplicated CS deliveries. Settings and Design: This was a randomised controlled trial conducted among booked antenatal patients who had elective CS at the Lagos University Teaching Hospital. Materials and Methods: Using a parallel study design, patients were randomised into short-stay and traditional protocols. Patients in the short-stay group were ambulated and graded oral intake initiated from 6 h post-operation. Their urethral catheters were discontinued at 12 h, and subsequent discharge was at 3rd day post-op. Those in the traditional group were ambulated from 12 h, graded oral intake initiated and urethral catheters removed at 24 h, then the patients were discharged on the 5th day post-operation. Pain scores of all the patients at 72 h, fever in the first 10 days (excluding the first 24 h), clinical signs of wound sepsis, urinary tract infection and puerperal sepsis in the first 14 days post-op were recorded. Statistical Analysis: Descriptive statistics were used to summarise the quantitative variables. The association between categorical variables was tested using Chi-square test, and differences in group means were assessed using t-test. The confidence level was 95%, and the level of significance was set at P < 0.05. Results: There were no significant differences in febrile and infective morbidities between the two groups. However, women in the short-stay group had significantly lower pain scores (t = 4.75, P < 0.001) and hospital expenses (t = 5.53, P < 0.0001) than women in the traditional group. Conclusions: The short-stay protocol following uncomplicated CS delivery was safe and more cost-effective than the traditional protocol.

Mentoring in a resource-constrained context: A single-institutional cross-sectional study of the prevalence, benefits, barriers and predictors among post-graduate medical college fellows and members in South-Eastern Nigeria Gabriel Uche Pascal Iloh, Miracle Erinma Chukwuonye, Obianma Nneka Onya, Ezinne Uchamma Godswill-Uko Nigerian Postgraduate Medical Journal 2019 26(1):38-44 Background: Globally, the post-graduate medical education has undergone tremendous changes with emphasis on training, services and research to equip trainees with competence for independent professional development. However, not all the fellows and members of the West African Post-graduate Medical College and the National Post-graduate Medical College of Nigeria recognise the values of mentoring in achieving the career success. Aim: The study was aimed at describing the prevalence, benefits, barriers and predictors of mentoring in a cross-section of the Post-graduate Medical College fellows and members in a tertiary health institution in South-Eastern Nigeria. Participants and Methods: A cross-sectional study was carried out among 168 study participants who were sampled from the Post-graduate Medical College fellows and members in the Federal Medical Centre, Umuahia, Nigeria. Data collection was done using a pre-tested, self-administered questionnaire that elicited information on awareness, prevalence, barriers and benefits of mentoring. Results: The age of participants ranged from 26 to 59 (41 ± 9.4) years. All the respondents were aware of the mentorship. The prevalence of mentoring was 33.3%. The most common benefit was personal and professional growth and development (100.0%). The most common barrier was the pressure of professional duties and personal exigencies (100.0%). The most significant predictor of mentoring had departmental mentoring programme participants who had departmental mentoring programmes were two times more likely to have mentoring relationships when compared to their counterparts who had none (adjusted odds ratio = 2.32; 95% confidence interval: 1.20–3.10; P = 0.002). Conclusion: The level of awareness of mentoring was very high but did not translate to appropriate involvement in mentoring. The most common benefit was personal and professional growth and development. The most common barrier was the pressure of professional duties and personal exigencies. The most significant predictor of mentoring relationship had departmental mentoring programme.

Demographic characteristics and causes of death for persons brought in dead to emergency department of a Tertiary Health Facility in South-West Nigeria Oluseyi Adegoke, Janet Ngozi Ajuluchukwu Nigerian Postgraduate Medical Journal 2019 26(1):45-52 Introduction: Identifying the demographic characteristics and causes of death in persons 'brought-in-dead' (BID) will inform possible strategies for the prevention of their occurrence. Objective: To characterise the demography as well as document the autopsy-determined underlying and immediate causes of death in BID cases presenting to the emergency department (ED) of a tertiary health facility. Methods: This is a 5-year retrospective descriptive study of 253 autopsied-BID cases. Data were obtained from ED 'death-register' and the hospital 'autopsy-register'. The underlying and immediate causes of death were classified and analysed across the age groups of 21–40, 41–60 and >60 years. Results: The age of the cases ranged from 22 to 101 years with a median of 56.0 (38-72) years. Almost half [110(43.5%)] of the cases were in the age-group >60 years. The male-to-female ratio was 1.04:1, and their ages were comparable. Non-communicable diseases accounted for 216 (85.4%) of the underlying causes of death. Three major specialities contributing to death were medicine 117 (46.2%), oncology 45 (17.0%) and surgery/trauma 42 (16.6%). Specialties of medicine and surgery/trauma were predominantly in age groups >60 years (60.0%) (P ≤ 0.0001) and 20–40 years (31.5%) (P = 0.0001), respectively. The chief underlying causes of death in the specialities of medicine, oncology and surgery/trauma were cardiovascular diseases (61 [52.1%]), breast cancer (11 [24.4%]) and road traffic accidents (31 [73.8%]), respectively. Overall immediate causes of death included heart failure (21.3%), unspecified circulatory collapse (17.0%), central nervous system pathologies (16.6%) and haemorrhagic shock (10.7%). Heart failure (33.6% [37/110]) and haemorrhagic shock (28.8% [21/73]) were the most common immediate causes of death in the >60 years' and 20–40 years' age groups, respectively. Conclusion: Non-communicable diseases are the leading causes of death in persons 'BID'. Deaths from medical conditions, especially heart failure, occurred mainly in the elderly. Deaths from trauma and haemorrhage occurred predominantly in the young.

The pattern and outcomes of childhood renal diseases at University of Abuja Teaching Hospital, Abuja, Nigeria: A 4 year retrospective review Emmanuel Ademola Anigilaje, Temilade Christianah Adesina Nigerian Postgraduate Medical Journal 2019 26(1):53-60 Introduction: Renal disorders contribute to childhood morbidity and mortality in developing countries. Therefore, the knowledge of the burden of childhood renal diseases is required for preventive and management purposes. This article determines the pattern and the outcomes of childhood renal diseases seen at the University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja, Nigeria. Materials and Methods: This was a retrospective review of children aged 1 month to 17 years, who were seen at the paediatric nephrology clinic, emergency paediatric unit and paediatric ward of the UATH over 4 years from January 2013 to December 2016. Results: A total of 4327 children were seen during the study period, with 163 of them having renal disorders, including 95 (58.3%) males and 68 (41.7%) females (mean age of 5.9 ± 4.7 years) giving a prevalence of 3.8% (38 cases per 1000 children). There was a progressive increase in the diagnoses of renal diseases during the study period, from 3.1% in 2013 to 5.4% in 2016. The most common disorders were urinary tract infection (UTI) 50 (30.7%) and acute kidney injury (AKI) 50 (30.7%). Others included nephrotic syndrome (11.7%), congenital anomalies of the kidney and the urinary tract (9.2%), acute glomerulonephritis (7.9%), chronic kidney disease (CKD, 6.7%), nephroblastoma (3.7%) and urolithiasis (2.5%). Twenty-three children died (mortality rate of 14.1%), resulting mostly from AKI (7.8%) and CKD (9.1%). Conclusion: UTI and AKI are the leading renal disorders in this study. Concerted efforts are needed to promote preventive nephrology in the face of high cost of treating acute kidney disease and CKD in Nigeria.

Undiagnosed placenta praevia percreta: A rare case report and review of management Adeyemi Adebola Okunowo, Ephraim Okwudiri Ohazurike, Fatimah Murtazha Habeebu-Adeyemi Nigerian Postgraduate Medical Journal 2019 26(1):61-64 Placenta accreta spectrum disorders, especially placenta percreta (PP) and placenta praevia (PLP), are major risk factors for massive obstetric haemorrhage which is a common cause of maternal morbidity and mortality in our environment. This risk becomes exponential and life-threatening when the two conditions co-exist in the same patient. Even in advanced countries with readily available expertise and state of the art resuscitative and supportive facilities, these conditions are associated with grave maternal and perinatal morbidity and mortality. We present a challenging case of PP co-existing with major PLP, which was diagnosed intraoperatively and the patient had total abdominal hysterectomy and bilateral internal iliac artery ligation to control haemorrhage.