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Continental J.

Tropical Medicine 4: 1 - 5, 2010 ISSN2141 - 4167


© Wilolud Journals, 2010 http://www.wiloludjournal.com

TRENDS IN CERVICAL CANCER INCIDENCE IN UNIVERSITY OF PORT HARCOURT TEACHING


HOSPITAL (UPTH), RIVERS STATE, NIGERIA.

Onyije F.M., Eroje M.A. and Fawehinmi H.B.


Department of Human Anatomy, Faculty of Basic Medical Sciences, College of Health Sciences, Niger Delta
University, Wilberforce Island, Bayelsa State, Nigeria.

ABSTRACTS
The incidence of cervical cancer varies dramatically, both globally and within individual
countries.This retrospective study was carried out to determine the trend in cervical cancer
incidence in the University of Port Harcourt Teaching Hospital (UPTH) from 2007 to
2009, using the data collected from the Department of Anatomical –Pathology. A total
number of 69 cases were reported. The incidence in age group 50-59 in 2007 (36.8%) and
2009 (33.3%) was the highest, the lowest incidence was in the youngest age group of 20-29
with 5% in 2007 and no case in 2009. In 2008 the age group 50-59 was the lowest having
11%, while age group 30-39 top the list with 20%. From 2007 to 2009 age group 50-59
(23.2%) have the total highest incidence while age group 20-29 (8.7.7%) had the lowest.
Trend in the years (2007-2009) indicated that the highest number of reported cases of
cervical cancer was in 2008 while the lowest number was in 2009 (50% and 21.7%)
respectively. The present result indicates fluctuation in trends in the incidence of cervical
cancer in UPTH. On the other hand the few number of cases reported may not be a
reflection of low cervical cancer cases in the region but rather may indicate poor
knowledge and a negative attitude to the utilization of cervical cytology service, which is
associated with strong cultural and religious reasons and the non availability or at best poor
information about cervical cytology screening could account for under-reporting of cases.
KEY WORDS: Trends, Cervical, Cancer, Incidence.

BACKGROUND
Women in developing countries are yet to extensively utilize the benefits of screening programs. An estimated
371,000 new cases of invasive cervical cancer are diagnosed world wide each year, representing nearly 10% of
all cancers in women (Parkin et al., 1993). The incidence of cervical cancer varies dramatically, both globally
and within individual countries (Laura et al., 2009).

Cervical cancer is an important cause of death throughout the world especially in developing countries. Reports
of trends in cervical incidence from less developed countries are limited by poor data quality and inaccurate
population estimation (Bailie et al. 1995). Cervical cancer is the second most common neoplastic disease
affecting women second only to breast cancer (Franco et al., 2003).

Epidemiologic data have long implicated a sexually transmitted agent based specifically on the risk factors for
cervical cancer, which include early age at first intercourse, multiple sexual partners, and a male partner with
multiple previous sexual partners. Potential risk factors that remain poorly understood includes; oral
contraceptive use, cigarette smoking, parity, familial history, associated genital infections, and lack of
circumcision in the male sexual partner (Franco et al., 2003).

However consumption of fruit and fruit drinks lowers the risk of cervical cancer while vegetables, foods of
animal origin, complex carbohydrates, legumes, or folacin-rish foods do not reduce the risk (Herrero et al.,
1991).

Eighty five percent of a studied population in Nigeria demonstrated very poor knowledge and a negative attitude
to the utilization of cervical cytology service. This is associated with strong cultural and religious reasons and
the non availability or at best poor information about cervical cytology screening. The non existence of a
national cervical cytology screening, the lack of political-will and funding, poor advocacy and poor manpower
were identified as the cause of the continuous high prevalence of this preventable cancer in Nigeria (Ogun et al.,
2006).

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Onyije F.M et al.,: Continental J. Tropical Medicine 4: 1 - 5, 2010.

METHODS
This retrospective study was carried out using the data collected from the Department of Anatomical –Pathology,
UPTH, over a period of three years from 2007 to 2009. Ethical clearance was granted by the authority of UPTH.
The total number of reported cases for each year was noted and categorized into age groups. Data analysis was
by use of Microsoft Excel Package.

RESULTS
There were 69 reported cases of cervical cancer between 2007 and 2009 in the University of Port Harcourt
Teaching Hospital. The age, period and cohort effects on the incidence were examined; using age-period-cohort
(APC) models (McNally et al., 1997). The incidence rate has been on fluctuating side from 2007 to 2009 as well
as the period incidence.

The incidence in age group 50-59 in 2007 (36.8%) and 2009 (33.3%) was the highest, while the incidence in the
youngest group (20-29) in 2007 (5%) and 2009 was the lowest, having no case in 2009 (Table 1 and 3). In 2008
the age group 50-59 was the lowest having 11%, while age group 30-39 top the list with 20% (Table 2).
From 2007 to 2009 age group 50-59 (23.2%) have the total highest occurring cases while age group 20-29
(8.7.7%) had the lowest number (Fig 1, Table 4).

The result indicates fluctuation in trends in the incidence of cervical cancer in UPTH in the past three years.

Table 1 Distribution of Cervical cancer according to age in 2007


Age groups No. of Cases Percentage (%)
20-29 1 5
30-39 4 21.
40-49 2 10.5
50-59 7 36.8
60-69 2 10.5
70+ 2 10.5
Unknown 1 5
Total 19 100

Table 2 Distribution of Cervical cancer according to age 2008


Age groups No. of Cases Percentage (%)
20-29 5 14
30-39 7 20
40-49 6 17
50-59 4 11
60-69 6 17
70+ 5 14
Unknown 2 5.7
Total 35 100

Table 3 Distribution of Cervical cancer according to age 2009


Age groups No. of Cases Percentage (%)
20-29 - -
30-39 1 6.7
40-49 2 13
50-59 5 33.3
60-69 3 20
70+ 4 26.7
Unknown - -
Total 15 100

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Onyije F.M et al.,: Continental J. Tropical Medicine 4: 1 - 5, 2010.

Table 4 Distribution of Cervical cancer according to age from 2007-2009


Age groups No. of Cases Percentage (%)
20-29 6 8.7
30-39 12 17.4
40-49 10 14.5
50-59 16 23.2
60-69 11 16
70+ 11 16
Unknown 3 4.4
Total 69 100

Fig1

No. of Cases No. of Cases from 2007-2009

18
16
14
12
10
8
6
4
2
0
20-29 30-39 40-49 50-59 60-69 70+ Unknown Age groups

Fig 2; Chart Showing Distribution of Cervical cancer according to years

No. 40
of Cases
35
30
25
20
15
10
5
0 0
2007 2008 2009
Years

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Onyije F.M et al.,: Continental J. Tropical Medicine 4: 1 - 5, 2010.

DISCUSSION
At every stage in life a woman in the third world risk some serous health problems, these include HIV/AIDS,
high maternal mortality rate and cervical cancer (Ezem, 2007). Cervical cancer is the most common type of
malignancy in women in most developing countries, and is the second most common form of cancer in the world
(Franco et al., 2003).

The present findings indicate fluctuation in trends in the incidence of cervical cancer in UPTH on a yearly basis.
The total highest affected age group was 50-59 (23%), and the total lowest affected age group was age group 20-
29 (8.7%).This finding is consistent with observation in previous studies in Ibadan Nigeria (Delphine et al.,
2008) and Mauritius (Jeebun et al., 2009) in which the highest prevalence of cervical cancer was observed in the
50-59 years age group. Our finding is however at variance with a previous study in Zambia in which cervical
cancers was more prevalent in the 35-44 years age group (Catherine, 2008) as well as in Spain where the peak
incidencewas in the 25-29 age group (Delphine et al., 2008).

The study also found the highest number of reported cases in 2008 (50.7%) and the lowest in 2009 (21.7%). The
few cases reported may not reflect low cervical cancer incidence in the region, but poor knowledge, cost (Obi et
al., 2007) and a negative attitude to the utilization of cervical cytology service, which is associated with strong
cultural and religious factors (Ezem, 2007) and the lack of available information about cervical cytology
screening could account for underreporting (Aboyeji et al., 2004).

On the other hand the few number of reported cases may also be the result of improved enlightment campaign by
government and non governmental organizations on risk factors that could lead to cervical cancer as well as the
importance of early cervical screening in the last three years. Screening also reduces future treatment costs and
enhances the quality of life of cancer patients.

Cervical cancer still remains a major cause of cancer death in women worldwide. Health authorities in
developing countries should continue to improve on public enlightment. As this will not only deter promiscuity
but reduce cervical cancer.

REFERENCES
Aboyeji P.A., Ijaiya M.A. and Jimoh A.A.(2004). Knowledge, attitude and practice of cervical smear as a
screening procedure for cervical cancer in Ilorin, Nigeria. Tropical Journal of Obstetrics and
Gynaecology;21:114-117

Bailie R. S., Selvey C. E., Bourne D. and Bradshaw D(1995). Trends in Cervical Cancer Mortality in South
Africa. Oxford University press release 1996.

Catherine N. (2008) Cervical cancer a reality for women. Zambia women media association publication

Ciatto S., Cecchini S., Iossa A., Grazzini G., Bonardi R., Zappa M., Carli S. and Barchielli A. (1994). Centro
per lo Studio e la Prevenzione Oncologica, Viale A. 171:I-50131.

Delphine M., Silvia F. and Martyn P. (2008) International Correlation between Human Papillonavirus
Prevalence and Cervical Cancer Incidence. Cancer Epidemiology, Biomarkers & Prevention 17;717.

Ezem B. U, (2007). Awareness and Uptake of Cervical Cancer Screening in Owerri, South-Eastern Nigeria.
Annals of African Medicine, 6. 2:94-98

Franco EL, Schlecht NF, Saslow D. Epidemiology of cervical cancer. Cancer J 2003 Sep-Oct;9(5):348-59.

Herrero R., Potischman N., Louise A. B., Reeves W.C., Brenes M.M., Tenorio F., Britton R.C. and Gaitan E.
(1991). A Case-Control Study of Nutrient Status and invasive cervical cancer. American Journal of
Epidemiology 134, 11: 1335-1346

Jeebun N., Agnihotri S., Manraj S. and Purwar B. (2006) Study Of Cervical Cancers In Mauritius Over A
Twelve Years Period (1989-2000) And Role Of Cervical Screening The Internet Journal of Oncology 3,2.

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Onyije F.M et al.,: Continental J. Tropical Medicine 4: 1 - 5, 2010

Laura G. C., Ruth H. J., Karen M. L., Vivian M., Henrik M. and Elizabeth A. D. (2009). Inequalities in the
incidence of cervical cancer in South East England 2001–2005: an investigation of population risk factors.
BioMed Central Public Health 9:62

McNally R.J., Alexander F.E., Staines A. and Cartwright R.A. (1997). A comparison of three methods of
analysis for age-period-cohort models with application to incidence data on non-Hodgkin's lymphoma.
International Journal on Epidemiological 26: 1, 32-46.

Nandagudi S. M., Chaudhry K. and Saxena S. (2005) Trends in Cervical cancer incidence: Indian Scenerio.
European Journal of Cancer Prevention. 14: 6, 513-518.

Obi S.N., Ozumba B. C., Nwokocha A.R. and Waboso P.A. (2007). Participation in higly subsidised cervical
cancer screening by women in Enugu, south-east Nigeria. Journal of Obstetrics & Gynaecology. 27: 3, 305-307

Ogun G. O. and R. Bejide (2006) Cervical Cancer in Nigeria still a Dismal Story. UICC World Cancer
Congress Presentation, Washington DC, USA.

Pair D. W. and Lin R. S.(1996). Epidemiology of cervical cancer in Taiwan. Annual meeting of the Western
Association of Gynecologic Oncologists. 62, 3:415-426

Parkin D. M., Pisani P. and Ferlay J. (1993). Estimate of the worldwide incidence of 18 major cancers. Internet
Journal of Cancer; 54:594-606.

Parkin D. M., Pisani P. and Ferlay J. (1999). Estimate of the worldwide incidence of 25 major cancers. Internet
Journal of Cancer; 80:827-41.

Received for Publication: 23/03/2010


Accepted for Publication: 08/04/2010

Corresponding Author:
Onyije F.M.
Department of Human Anatomy, Faculty of Basic Medical Sciences, College of Health Sciences, Niger Delta
University, Wilberforce Island, Bayelsa State, Nigeria.
E-mail: onyijefelix@yahoo.com

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Continental J. Tropical Medicine 4: 6 - 8, 2010 ISSN2141 - 4167
© Wilolud Journals, 2010 http://www.wiloludjournal.com

NEONATAL BREAST ABSCESS – A CASE REPORT AND REVIEW OF LITERATURE

Afeyodion Akhator1, Chuck P. Oside1,2


1
Department of Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State
University, Abraka, Nigeria, 1,2Department of Surgery, Central Hospital, Warri

INTRODUCTION
Breast abscess in the neonatal period is uncommon. When it does occur, it most commonly occurs in the first 5
weeks of life when the breast bud is still enlarged (Walsh and McIntosh, 1986). We present a case of neonatal
breast abscess seen in our breast clinic.

CASE REPORT
A three week old female neonate brought to breast clinic with one week history of left breast swelling and
redness. Both breasts were noticed to be swollen at birth and the birth attendant had been massaging both breasts
to remove the ‘milk’ she believed was accumulated in them. There was no systemic symptom. She was a full
term delivery of a para 5+0. The antenatal period was uneventful.

On examination there was enlargement of the left breast with erythema (Fig 1). The mass was fluctuant and
tender. 7mls of thick pus was aspirated and sample sent for microscopy, culture and sensitivity. She was given
co-amoxiclav (augmentinR) syrup for seven days. The aspirate cultured staphylococcus aureus. She was followed
up daily for 5 days but no repeat aspiration was necessary and the inflammation had completely resolved in this
period.

DISCUSSION
Neonatal breast enlargement occurs in majority of neonate at birth. This is easily palpable in the first six months
of life regardless of sex (Mckiernan and Hull, 1981). It is believed to be due to falling maternal estrogen levels at
the end of pregnancy which triggers the release of prolactin from the pituitary of the newborn (Sainsbury, 2008).
It usually resolves spontaneously over the period of a few weeks. However, the belief of expressing ‘witches’
milk from the breast is widely practice and can lead to mastitis and breast abscess (Ramachandraiah, 2000) as
was in the case presented.

Neonatal breast abscess is usually unilateral and there is usually no systemic symptom (Rudoy and Nelson,
1975; Walsh and McIntosh, 1986) just as was the case with this patient.

Early cases of mastitis usually resolve with use of antibiotics but when an abscess is formed surgical drainage is
needed. This can either be by incision and drainage (the incision should be placed as peripherally as possible to
avoid damaging the breast bud) or by aspiration (Efrat, Mogilner, Iujtman et al, 1995). Aspiration was done for
this patient and together with antibiotics resolved the infection.

Culture of the aspirate yielded staphylococcus aureus. This is consistent with other reports in the literature. Other
causes of neonatal breast abscess are enterobacterium and Group B streptococci (Brook, 1991; Efrat, Mogilner,
Iujtman et al, 1995).

CONCLUSSION
Counseling of both birth attendants and pregnant women about neonatal breast development will reduce the
incidence of breast abscess in the neonate. Aspiration of the abscess and antibiotic coverage is recommended for
treatment.

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Afeyodion Akhator, Chuck P. Oside: Continental J. Tropical Medicine 4: 6 - 8, 2010

Figure 1 – Neonatal breast abscess

REFERENCES
Brook I. (1991). The aerobic and anaerobic microbiology of neonatal breast abscess. The Pediatric Infectious
Disease Journal, 10(10): 785-786

Efrat M, Mogilner J.G., Iujtman M. et al. (1995). Neonatal mastitis: diagnosis and treatment. Israel Journal of
Medical Sciences , 31(9): 558-560.

Mckiernan J F, Hull D. (1981). Breast development in the newborn. Archives of Disease in Childhood, 56(7):
525 – 529.

Ramachandraiah A. (2000). Neonatal mastitis. Indian Pediatrics, 37: 1021

Rudoy R.C., Nelson D.N. (1975). Breast abscess during the neonatal period. American Journal of Diseases
Children, 129(9): 1031-1034

Sainsbury R. (2008). Mastitis of infants. In: Bailey and Love’s Short Practice of Surgery. Williams NS,
Bulstrode C.J.K., O’Connell P.R. (eds). 25th edition. Edward Arnold (Publishers) Ltd. 831-832.

Walsh M, McIntosh K. (1986). Neonatal mastitis. Clinical Pediatrics. 25(8): 395-399.

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Afeyodion Akhator, Chuck P. Oside: Continental J. Tropical Medicine 4: 6 - 8, 2010

Received for Publication: 12/02/2010


Accepted for Publication: 08/04/2010

Corresponding Author:
A. Akhator,
Department of Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State University, P.M.B
1, Abraka, Nigeria

EMAIL: doc_akhator@yahoo.com

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Continental J. Tropical Medicine 4: 9 - 10, 2010 ISSN2141 - 4167
© Wilolud Journals, 2010 http://www.wiloludjournal.com

Letter to Editor

THE POOR KNOWLEDGE OF PRESCRIBED MEDICATIONS TO OUR TEEMING POPULATION. NEED


TO IMPROVE PATIENTS EDUCATION!

Anyanwu, E. B.
Department of Family Medicine, Delta State University Teaching Hospital, Oghara. Nigeria

Sir,

It is without doubt that the health care delivery in the country is presently heavily taxed. There are more patients
demanding for care than are health care institutions and care givers.

The Honourable Minister for Health, Professor Babutunde Osotimehin recently bemoaned the poor state of our
health care delivery and stated that “the current health situation is both deplorable and unacceptable”. He further
stated that “Nigeria has about 1.6 public primary care facilities per 10,000 people which is appreciably low”
(Osotimehin, 2009).

Most of the state owned general hospitals are under funded and under-staffed, thereby are not able to render the
desired level of services that are required. The health workers are not satisfied with the state of things, hoping
for improvement and the populace is also not happy with the present situation.

The few health workers are subsequently, over-worked, often stretched to the limit of their patience, working in
environment with a near constant power outages, poor laboratory services and pharmaceutical outlets.

The outcome of all of these negatives is that the patients care is not optimal, with frequent cases of alleged mis-
diagnosis.

Due to the prolonged waiting time before patients are consulted by the physicians, most patients resort to self
medications, purchasing drugs from across the counter without prescription. Most often, these purchases are
ordered by chemist shop owners, and the identity of the drugs are not disclosed to the innocent long-suffering
clients.

Also, because of the huge number of patients that has to been seen by the few attending physicians, the health
worker usually do not have enough time to explain to the patient the rationale behind the choice of medications,
their identity, possible adverse effects and probable expectations on completing the therapeutic doses.

This short-fall has led to our patients taking medicine that they cannot identify. If these patients are to be seen
by any other physician in other health institutions, they are usually not able to list out the current medicines that
they are taking. Often times, they may end up with fresh prescription. This leads to incomplete dosaging, even
cross-reaction of medicines and prolonged ill-health due to hap hazardous dosing of drugs.

Patients need to be properly educated about their diagnosis, the reason for the choice of management, duration of
management, and adverse effect to expect if any. This should include the identity of the medications given,
rather than the general widespread practice of removing label from drug containers.

Sir, physician of all specialties need to be confident. A properly educated and advised patient will not go and
buy drugs from across the counter in chemist shop, but will return to his care giver if the need arises.

Physicians are often concerned that patients will buy drug re-fill by themselves if they know the names of the
presented medications, and by so doing will lead to loss of income to the physicians.

This is possible, but should not be the norm if we have enough time to explain issues to our client.

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Anyanwu, E. B: Continental J. Tropical Medicine 4: 9 - 10, 2010

We recommend therefore that physicians should be encouraged to be up to date by regular continuing medical
evaluations. The government should improve the economic situation of the country, increase the number of
medical staff in hospital out and rehabilitate the hospitals.

REFERENCE
Professor Babatunde Osotimehin (2009).: Honourable Minister for Health. Presentation Titled “Health situation
Analysis in Nigeria: Implementing the Health sector component of vision 2020. Vanguard Newspaper. Good
Health Weekly “Average Health Status of Nigerians unacceptable” Nov. 10, 2009. pg 33.

Received for Publication: 12/02/2010


Accepted for Publication: 08/04/2010

Corresponding Author:
Email: ebirian@yahoo.com

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Continental J. Tropical Medicine 4: 11 - 19, 2010 ISSN2141 - 4167
© Wilolud Journals, 2010 http://www.wiloludjournal.com

SEVERE BIRTH ASPHYXIA: RISK FACTORS AS SEEN IN A TERTIARY INSTITUTION IN THE NIGER
DELTA AREA OF NIGERIA.
1
C.N Onyearugha. and 2HAA Ugboma
1
Departments of Paediatrics Abia State University Teaching Hospital Aba, 2Obstetrics and Gynaecology
University of Port Harcourt Teaching Hospital Port Harcourt Nigeria.

ABSTRACT
BACKGROUND:
Severe birth asphyxia has remained a major contributor to perinatal and neonatal mortality in
developing countries including Nigeria. Efforts at curbing its incidence must begin by obtaining its
prevalence and identifying associated risk factors.

OBJECTIVE:
To determine the incidence of severe birth asphyxia and common risk factors in Port Harcourt South-
South Nigeria.

METHODS:
A prospective case-control study of 98 serially recruited newborns with severe birth asphyxia (Apgar
score 1-3 within the first minute of birth or < 5 at 5 minutes) and other 98 in identical weight bracket
with normal Apgar scores (8-10 in the first minute of life) consecutively recruited as control was
carried out in the labour and isolation wards and the main theatre of the Obstetrics and Gynaecology
Department of the University of Port Harcourt Teaching Hospital Port Harcourt from the 31st March
to 31st August 2004. Other relevant data obtained by participation in the delivery, examination of
babies and referral to antenatal case notes included the birth weight and gestational age of recruited
newborns; parity, booking status, antenatal visits, problems in pregnancy and labour and causes of
delay prior to appropriate intervention in labour in the mothers where applicable. The total number of
live births delivered over the study period was calculated from the obstetric registers in the labour
and isolation wards and the theatre. Data was arranged in frequency tables and analysed using
statistical soft ware EPI-info version 6.04. Student t test was used to compare the means of variables.
P < 0.05 was significant.

RESULTS
The incidence of severe birth asphyxia was 45 cases per thousand live births. There was no
significant difference in gestational age and birth weight of subjects and control. Significantly more
mothers of the subjects than of the controls were primiparous 58(59.1%) vs.44 (44.9%) P=0.045.
Twenty five (25.5%) of mothers of subjects booked in the third trimester and were significantly more
than 7(7.1%) of mothers of the control who booked over the same period P=0.001. Significantly more
mothers of the control 29(29.6%) than of subjects 17(17.4%) made up to 10 or more antenatal visits
prior to delivery P=0.045. Sixty eight (69.4%) of mothers of subjects had pregnancy complications
and were significantly more than 34 (34.7%) of mothers of control with pregnancy complications
P=0.000. Prolonged labour was the commonest pregnancy complication in mothers of subjects and
control but occurred significantly more in mothers of subjects than mothers of control 20(20.4%) vs
6(6.1%) p=0.003. Significantly more mothers of the subjects 42(42.9%) than of control 20(20.4%)
were delivered by emergency Caesarian section. Also 20 (20.4%) of mothers of subjects had delay
prior to appropriate intervention in labour and were significantly more than 6 (6.1%) of mothers of
control in same category. P=0.004.

CONCLUSION
Efforts aimed at encouraging all pregnant women especially the primiparious to register early and be
consistent in attendance for antenatal care should be intensified to reduce the prevalence of severe
birth asphyxia. Also health education to all women on prompt identification of danger signs during
pregnancy and the need to present early to hospital when such occur will go a long way towards
curbing the prevalence of birth asphyxia in the community.

KEYWORDS: Newborn, first-minute, apgar score, Port Harcourt.

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

INTRODUCTION
Birth asphyxia is recognized as an important cause of neonatal morbidity and mortality, fresh still birth and long
term neurodevelopmental sequelae globally( Suzie et al, 2009 ) World Health Organisation (WHO) estimates
that between four and nine million newborns worldwide suffer birth asphyxia annually with most occurring in
developing countries including Nigeria(.WHO,1998; Palsdotir et al, 2007; Ellis 2000 ; Udoma 2001) Twenty
five to sixty percent of this number die or develop severe neurodevelopmental complications (Abhay et al, 2005;
Ellis and Dharma,1999)..

Risk factors for birth asphyxia abound worldwide particularly in developing countries. Socio-economic
problems, negative traditional practices and religious beliefs which hinder utilization of appropriate health care
services generally in developing countries such as low women empowerment, illiteracy, patronage of spiritual
churches and untrained traditional birth attendants for abdominal massage in pregnancy and delivery, poor
access in riverine terrain and lack of medical infrastructure are particularly rife in Niger Delta communities
further predisposing pregnant women to delivery of asphyxiated babies.( Udoma et al, 2002;
Ugboma and Akani , 2004; Etuk et al,2000; Gharoro and Okonkwo,2000)

There is dearth of publications on the incidence and risk factors of severe birth asphyxia in Niger Delta area of
Nigeria. This study was therefore undertaken to determine the incidence and common risk factors of severe birth
asphyxia in the University of Port Harcourt Teaching Hospital and to evaluate measures that can be adopted to
prevent and manage them.

SUBJECTS AND METHODS:


This was a prospective case control study conducted at the Obstetrics and Gynaecology and Paediatrics
Departments of University of Port Harcourt Teaching Hospital Port Harcourt (UPTH) between 1st March and 31st
August 2004.

UPTH, located in Port Harcourt, capital of Rivers State was founded in the year, 1979 and became baby friendly
in the year 1993. Though a tertiary health care institution, it also serves as a secondary health care centre since
there is only one other secondary health care centre in the densely populated city of Port Harcourt. It is usually
well attended because it serves both as a secondary health care centre and referral centre for peripheral hospitals
in Rivers State and beyond. It has an annual delivery rate of approximately 3000.

Approval was obtained from the Ethics committee of the hospital before the study was commenced.
One hundred and one severely asphyxiated newborns delivered in the labour and isolation wards and the main
theatre of the hospital were serially recruited as study subjects. Apgar scoring was used to determine the degree
of birth asphyxia. The author attended the deliveries and did the Apgar scoring of most of the high risk
pregnancies delivered over the 6 month study period.

Apgar scoring of the newborn was done within the first minute of life and at 5 minutes. Scores of 1-3 in the first
minute of life and 5 or less at 5 minutes signified severe birth asphyxia (.Palsdotir et al, 2007). Apgar score of 8-
10 within first minute of life was taken as normal (.Palsdotir et al, 2007). When it was not feasible for the author
to attend a particular delivery a resident on special care baby unit posting who had participated competently in
the rehearsal of the Apgar scoring technique attended the delivery and did the Apgar scoring. Newborns whose
mothers refused informed consent or with major congenital malformations such as cyanotic congenital heart
disease, severe meningomyelocele, anencephaly were excluded from the study. Out of the first 101 serially
recruited babies delivered in UPTH with severe birth asphyxia and satisfying the inclusion criteria, the mothers
of three died post-partum before relevant information could be obtained from them so 98 severely asphyxiated
newborns were ultimately enrolled as study subjects for further analysis. The first 98 consecutive newborns in
identical weight brackets with Apgar scores 8-10 were recruited as control. Each recruited newborn was weighed
on an infant weighing scale. Each severely asphyxiated baby was resuscitated using the standard protocol. The
gestational age of each recruited newborn was determined using the Dubowitz method (Dubowitz et al, 1970).
All babies of low birth weight were classified as small for gestational age, appropriate or large for gestational
age using Olowes chart (Olowu , 1981).

Structured questionnaire was used to interview mothers consenting to the study to obtain information on
personal data, preconception medical, pregnancy and birth history, family and social history and causes of delay

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

prior to reception of appropriate intervention in labour as applicable. During the study period, the two residents
on each 3 month Special Care Baby Unit (SCBU) posting were recruited and participated in the study. Therefore
a total of 4 residents on SCBU posting took part.
Information on gestational age of mothers at booking, number of antenatal visits, problems in pregnancy and
labour, drugs administered in pregnancy and labour, and labour duration for mothers whose labour started in the
hospital was obtained from pregnancy and obstetric record of the mothers.

For each selected newborn, the duration of labour for mothers whose labour started before arrival at the hospital
was estimated as the time interval between the onset of labour pain that did not allow the mother any other
activity (in the primiparous) to the moment of complete expulsion of the baby while in the multiparous it was
estimated as time interval before onset of regular painful abdominal contractions and the moment of complete
expulsion of the baby. For the mothers whose labour started in the hospital the duration of labour was calculated
from the obstetric partogram. Prolonged labour was taken as labour lasting more than 24hours while prolonged
rupture of membrane was taken as rupture of membrane lasting more than 24hours. The total number of live
births delivered during the study period was obtained from the obstetric registers of the labour and isolation
wards and the theatre.

Data was arranged in frequency tables and results were analysed using statistical soft ware EPI-info version 6.04
and SPSS version 11.0 Student t test was used to compare means of variables. P values <0.05 were considered as
significant.

RESULTS
The total number of live births delivered during the study period was 2206. Only 101 of them were severely
asphyxiated and of these the mothers of 3 died post partum before relevant information could be obtained from
them so only 98 newborns with severe asphyxia were enrolled as subjects of further analysis. These consisted of
54 males and 44 females with male female ratio of 1:2:1. The prevalence rate of severe birth asphyxia obtained
was 45 cases/1000 live births. Ninety-eight new born (57 males, 41 females) in identical weight bracket were
enrolled as controls with male: female ratio of 1:3:1.

The mean gestational age of the subjects was 37.2+1.18 weeks (range 31-42 weeks) while the mean gestational
age of the control group was 37.04+1.0 weeks(range 31-43 weeks) with no significant difference between them
P=0.559. Table I

The mean birth weight of the subjects was 2684.86±290 grams (range 1200-4990 grams) whereas the mean birth
weight of the controls was 2789.90+166 grams (range 1250-4370 grams) with no significant difference in birth
weight of both categories P=0.226. Table II

Eighteen (18.5%) of the subjects were small for gestational age (SGA) but this number is not significantly more
than 15(15.5%) of the control that were SGA P=0.350. Two (2.1%) of subjects were large for gestational age
(LGA) while I (1%) of the control was LGA with no significant difference in this birth weight category between
the subjects and control.

Antenatal data of mothers of subjects and control:


Place of booking:
Seventy one (72.4%) of mothers of subjects and mothers of all controls (100%) booked at the Teaching Hospital
with no significant difference in places of booking between them P=0.071. Seventy-nine (80.7%) of mothers of
control booked in the second trimester and this was significantly more than 52(53.3%) of mothers of subjects
who booked at the same period P=0.000. Seven (7.1%) of mothers of subjects were unbooked. Twenty-five
(25.5%) of mothers of subjects booked in the third trimester and were significantly more than 7(7.1%) of
mothers of control who booked over the same period. P=0.001

Number of antenatal visits prior to delivery:


Twenty nine (29.6%) of mothers of subjects and 17(17.4%) of mothers of control made up to 10 antenatal visits
prior to delivery. Also, 31 (31.5%) of mothers of subjects and 11(11.5%) of mothers of control made 6 or less
antenatal visits prior to delivery. Mothers of control made significantly more antenatal visits than those of
subjects P=0.045

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

Parity of mothers of subjects and control:


The mean parity of mothers of subjects is 1.2 (range 0-6). The mean parity of mothers of control is 1.6(range 0-
6).

Majority (59.1%) of mothers of subjects were primiparous compared with 44 (44.9%) of mothers of control.
There is a significant difference in parities of mothers of subjects and control P=0.045.

Pregnancy and labour complications in the mothers of subjects and control:


Pregnancy complications occurred in 68 (69.4%) of mothers of subjects and this number was significantly more
than 34 (34.6%) of mothers of control who developed pregnancy complications P=0.000. Preeclampsia was the
most common pregnancy complication in both mothers of subjects 33(33.6%) and control 11(11.3%) but
occurred significantly more in mothers of subjects P=0.000.

Prolonged labour and prolonged rupture of membrane were the commonest labour complications in both mothers
of subjects and control but occurred more significantly in mothers of subjects than those of control: 20(20.5%)
vs 6 (6.1%) P= 0.003; 18(18.5%) vs 5(5.1%) P= 0.004 respectively.

Forty-six point eight percent of the subjects were given drugs in labour and these were significantly more than
12.2% of control who received drugs in labour. Other details are shown in Table III.

Mode of delivery:
Seventy eight (79.6%) of mothers of control and 54(55.1%) of mothers of subjects had spontaneous vertex
delivery with the difference between them being statistically significant P=0.000. Also, 42(42.9%) of the
mothers of subjects were delivered by Caesarian section and were significantly more than 20(20.4%) of mothers
of control delivered in similar manner P=0.001.

Significantly more mothers of subjects (20.4%) suffered delay prior to receiving appropriate intervention in
labour when compared with the mothers of control (6.1%) who had a delay prior to intervention P= 0.004. Table
IV indicates other details.

Table 1 Gestational age of enrolled subjects and control

Gestational Number of % Mean GA Number % Mean GA P


Age (weeks) subjects +SD of controls ±SD Value
<37 25 25.51 33.0+2.23 23 23.5 33.7±2.03 P=0.559
37-41 70 71.43 38.6±1.33 74 75.4 38.0±0.97
>41 3 3.06 42.0+0.0 1 1.0 43+0.00
SD = Standard deviation, GA = Gestational age

Table 2 Birth weight of enrolled subjects and control

Birth weight Number of % Mean BW Number % Mean BW P


Value
(Grams) subjects +SD of controls ±SD
<1500 12 12.24 1290 +100 6 6.12 1317+69
1500-2499 13 13.27 1969+329 19 19.39 1980+280
2500-4000 70 71.43 3172+443 71 72.45 3079+284 P=0.223
>4000 3 3.06 4550+439 2 2.04 4350+23

SD = Standard deviation, BW = Birth weight

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

Table 3
Drugs given in labour to mothers of subjects and control.
Drugs Number of % Number % P-value
given in mothers of mothers of
labour subjects control
No drugs 56 57.2 86 87.8 0.000
Hydralazine 15 15.4 2 2.0 0.001
Pentazocine 12 12.3 0 0.0 0.477
Oxytocin 7 7.1 5 5.1 0.21
Diazepam 2 2 0 0.0 0.477
Aldomet 2 2 0 0.0 0.477
Ampiclox 2 2 5 5.1 0.477
Flagyl 2 2 0 0.0 0.477

Table IV : Causes of delay prior to intervention in labour in mothers of subjects and control.

Cause of Number of % Number % P-value


Delay. mothers of mothers of
Subjects. control
No delay prior
to intervention 78 79.7 92 93.9
Mother’s late
recognition of labour 6 6.1 4 4.1
Labour initially
managed in maternity 5 5.1 2 2.0
Delay in transportation 4 4.1 0 0.0
Delay in consent for
operation 2 2.0 0 0.0
Labour initially
managed by T.B.A 2 2.0 0 0.0
Financial constraint 1 1.0 0 0.0

P = 0.004
T.B.A Traditional birth attendant.

DISCUSSION:
The prevalence of severe birth asphyxia in any community is to a large extent dependent on prevailing risk
factors, these in turn being influenced by the extent and impact of health education, literacy level, women
empowerment, cultural and traditional beliefs affecting efficient utilization of health care services as well as the
quality of antenatal, obstetric and neonatal care. (Dubowitz et al, 1970). Poverty, ignorance, poor
communication network, harmful traditional and cultural practices with significant negative effect on utilization
of appropriate health care services by women in pregnancy and labour are particularly rife in the developing
countries, the Niger Delta region of Nigeria inclusive (Dubowitz et al, 1970).The prevalence rate of severe birth
asphyxia of 45 cases per thousand live births obtained in this study is unacceptably high like previous results
obtained from different parts of Nigeria – 63 cases per thousand live births reported from Benin ( Omene and
Diejomaoh,1978) 25 cases/1000 live births reported from Jos (Airede, 2000) and 36/1000 live births reported
from Ife.( Okwu and Olomu,1996). The higher value than those of Jos and Ife obtained in this study could be
due to high patronage of private maternities and unorthodox places by pregnant women for antenatal care and
delivery even for some after booking in hospitals and clinics due to high cost of health care service delivery in
Port Harcourt. (Ugboma and Akani ,2004; Gharoro and Okonkwo ,2000; Okwu and Olomu , 1996). Many of
these cases result in complicated pregnancy and labour often with late referral to the Teaching Hospital with a
significant proportion resulting in severe birth asphyxia or even still birth (Ade-Oja and Loto, 2008)

Majority of the asphyxiated newborns were of birth weight equal to or more than 2,500grams compared with the
number that were of low birth weight.

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

This is in agreement with previous reports by Oruamabo from this centre and others(Etuk et al, 2000; Uzoigwe
and John, 2004; Udoma et al, 2003) that mature and larger newborns are likely to be associated with feto pelvic
disproportion, resulting in prolonged or obstructed labour and birth asphyxia as compared with low birth weight
babies.

There was no significant difference in the birth weight distribution between the subjects and control in this
analysis probably because the subjects and control in identical weight brackets were recruited to assess the risk
factors for birth asphyxia.

This study reveals that significantly more mothers of control than of subjects booked in second trimester while
significantly more mothers of subjects than of control booked in the third trimester. Also, mothers of control had
significantly more antenatal visits prior to delivery than mothers of subjects. This highlights one of the major
problems in pregnancy with women in developing countries – poor utilization of appropriate health services in
pregnancy and labour as noted previously by several authors (.Palsdotir et al, 2007; Udoma et al, 2003; Imogie et
al, 2002; Adeoye et al, 2005). Significant numbers of mothers of asphyxiated babies were either un-booked,
booked late, booked in unorthodox places or have low frequency of antenatal visits prior to delivery (Ade-Oja
and Loto 2008)

There was no significant difference in the place of booking of mothers of subjects and control but five of eight
and two of three mothers of subjects who booked in private maternities and with traditional birth attendants
(TBAS) respectively, had delayed referral to the Teaching Hospital in labour. The operators and staff of these
private maternities and TBAS are often not trained adequately to recognize promptly pregnancy and labour
complications demanding immediate referral hence the usual delay often resulting in birth asphyxia (Imogie et
al, 2002).

The result of this study also highlighted primiparity as a significant risk factor for severe birth asphyxia. This is
in corroboration of previous reports by several authors (Ellis et al, 2000; Palsdotir et al, 2007; Wu et al,2004).
The primiparous are often ignorant of the demands of pregnancy and their responsibility to themselves and their
unborn foetus often neglecting early booking and regular attendance to antenatal care (Adeoye et al, 2005)
This may result in complications that lead to severe birth asphyxia.

Pre-eclampsia was also observed as a significant pregnancy complication in mothers of subjects in the study. Pre
eclampsia has also been severally reported previously as a risk factor for severe birth asphyxia (Ellis et al, 2000;
Palsdotir et al, 2007; Wu et al,2004)

Preeclampsia if prolonged is associated with reduced blood supply, nutrients and oxygen to the fetus resulting in
intrauterine growth restriction (Macgillivray et al, 2000). This complication in itself can be associated with birth
asphyxia (Ellis et al, 2000). In labour, management of severe preeclampsia often includes use of
antihypertensive and sedatives such as diazepam and lorazepam which have depressive effect on the respiratory
centre, further exacerbating the asphyxiogenic effect on the fetus. Early detection and prompt management of
pre-eclampsia during antenatal period reduce this complication.

Prolonged labour and prolonged rupture of membrane were observed as significant labour related risk factors in
mothers of asphyxiated babies. Such reports have been published previously by other authors (Ellis et al, 2000;
Palsdotir et al, 2007). Prolonged labour is often associated with foetal distress and sometimes foetal and
maternal exhaustion which often result in birth asphyxia. Also, prolonged labour often results in delivery by
Caesarian section. If this is done using general anaesthesia, some of the agents and adjuncts such as diazepam
may further depress the newborn at birth. Prolonged rupture of membrane may be associated with intrauterine
infection resulting in birth asphyxia (Ellis et al, 2000). Regrettably, some mothers even book in appropriate
places only for the purpose of delivery without presenting for further antenatal supervision often resulting in
development of pregnancy complications possibly leading to birth asphyxia (Adeoye et al, 2005). Pregnancy and
labour complications contributing to occurrence of SBA in this study were likely to have resulted from
inadequate supervision of pregnancy and labour in the mothers of the subjects. This therefore underscores the
need for early booking in pregnancy, regular attendance for antenatal supervision and delivery in appropriate
health care facilities.

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

Significantly more mothers of subjects than of control were delivered by emergency Caesarian section. Birth
asphyxia in those subjects might have resulted from the indication for the Caesarian section or drugs
administered prior to or during operation.

It was also observed that delay prior to reception of appropriate intervention in labour was a significant risk
factor for severe birth asphyxia in our study. The main reasons of delay were mothers’ late recognition of labour
30%; prior management of labour in private maternities 25% and delay in transportation 20%. Delay in
transportation from reverine communities is often due to the difficult terrains and water ways encountered
between these localities and the city of Port Harcourt where the Teaching Hospital is located.

Limitation of the study: Inability to obtain reliable information on the treatment modalities of mothers of
recruited newborns who were not booked in the University of Port Harcourt Teaching Hospital.

Application of study: Early identification of high risk pregnancies such as the primiparous, those with poor
antenatal supervision, pre-eclampsia, prolonged labour, prolonged rupture of membrane and prompt referral to
appropriate health facility with adequate equipment and staff including obstetricians, paediatricians and
anaesthesiologists for further management of pregnancy or labour as applicable will go a long way in curbing the
incidence of birth asphyxia in the community.

CONCLUSION
The prevalence of severe birth asphyxia in Port Harcourt is unacceptably high. To curb this trend, urgent
measures including health education of the general populace on the need for early booking and regular
attendance of appropriate health facilities by pregnant women for antenatal supervision and delivery should be
commenced now. Pregnancy related issues should be included in school curricula for adolescents. There is an
immediate need for organization of regular workshops and seminars for TBAS, employees of public and private
health institutions emphasing the need for early identification and prompt referral of complicated pregnancies
and labour to appropriate health care institutions.

Finally, the government at local, state and federal levels must demonstrate sustained commitment to the
provision of efficient ambulance services and good network of roads.

ACKNOWLEDGEMENT
My warm gratitude goes to Mr. Victor Nwogwugwu and his staff of Medical Records Department for their
usually ready assistance in retrieving patients’ folders.

REFERENCES
Abhay T B, Rani A B, Sanjay B B, Hanimi M R (2005). Management of Birth Asphyxia in Home Deliveries in
Rural Gadchiroli. Journal of Perinatology, 25: 82-91

Ade-Oja IP, Loto O N.( 2008),Outcome of maternal eclampsia in Ife, Nigeria Journal of clinical practice 11 (3):
279-284.

Adeoye IS, Ogbonnaya LU, Umeora OUJ, Asiegbu U. (2005) Concurrent use of multiple antenatal care
providers by women utilizing free antenatal care at Ebonyi State University Teaching Hospital, Abakaliki. Afr. J
Reprod. Health 9 (2): 101-106.

Airede AI. (2000) Birth asphyxia and hypoxic ischaemic encephalopathy. Incidence and severity. Nigerian
medical practice30: 58-62.

Dubowitz LMS, Dubowitz V, Golderberg S. (1970). Clinical assessment of gestational age in the newborn. J
Pediatr 77: 1-10.

Ellis M , Dharma M. (1999) Progress in perinatal Asphyxia. Semin Neonatol, 4:183-191.

Ellis M, Manandhar N, Manandhar DS. (2000) Risk factors for Neonatal Encephalopathy in Kathmandu, Nepal.
Br Med J 320: 1229-36.

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Etuk SJ, Etuk MI, Udoma EJ. (2000) Perinatal outcome in pregnancies booked for antenatal care but delivered
outside health facilities in Calabar, Nigeria. Acta Tropica, 75: 29-33.

Gharoro EP, Okonkwo CA. (2000) Changes in service organization: antenatal care policy to improve attendance
and reduce maternal mortality. Int J Gynaecol Obstet, 67( 3):179-181.

Imogie AO, Agwubuike EO, Aluko K. (2002) Assessing the role of traditional birth attendants (TBAs)in health
care delivery in Edo state, Nigeria. Afr J Repord health 6 (2) : 94-100.

Macgillivray I, McCaw Binns A M, Ashley D E, Fredrick A, Golding J. (2004) Strategies to prevent eclampsia
in a developing country: Use of a maternal pictorial card. Int J Gynaecol Obstet, 87 (3): 295-300.

Okwu WA, Olomu SC. (1996).Birth Asphyxia: Risk factors for mortality. Nigerian medical practitioner, 31:69-
72.

Olowu S A. (1981).Standards of intrauterine growth for an African population at sea level. J Pediatr 99: 285-
495.

Omene JA, Diejomaoh PME. (1978) Analysis of 226 asphyxiated infants at the University of Benin Teaching
Hospital (1974-1976). Nigerian Journal of Paediatrics, 5: 25-29.

Palsdotir K, Dagbjartisson A, Thorlkelsson T, Hardardottir H. (2007) Birth asphyxia and hypoxic ischaemic
encephalopathy, incidence and obstetric risk factors Laeknabladid, 93:599-601.

Palsdotir K, Thorkelsson T, Hardardotti H, Dagbjartsson A. (2007). Birth Asphyxia, Neonatal risk factors for
hypoxic ischemic encephalopathy. Laeknabladid, 10: 669-73.

State of the World’s Newborns. (2001). Save the Children Washington, DC

Suzie D, KS Joseph, A Allen, D Young (2009). Decreasing Diagnosis of birth Asphyxia in Canada: Fact or
Artifact. Pediatrics, 123: 668.

Udoma EJ, Ekanem AD, John ME. (2002).The role of institutional factors in maternal mortality from obstructed
labour. Global Journal Med Sc, 1: 13-17.

Udoma EJ, John ME, Udosen GE, Udo AE.( 2003). Obstetric practices in spiritual church in South Eastern
Nigeria. Mary Slessor Jour Med Sc, 32: 51-56.

Udoma EJ, Udo JJ, Etuk SJ. (2001). Morbidity and Mortality among infants with normal birthweight in a
Newborn Unit Nig J Paediatr, 28(2): 13-17.

Ugboma HAA, C I Akani. (2004) Abdominal massage: Another cause of maternal mortality. Nigeria Journal of
Medicine, 13(3): 259-62.

Uzoigwe SA, John CT. (2004).Maternal mortality in the University of Port Harcourt Teaching Hospital, Port
Harcourt in the last year before the new millennium. Nig. J Med, 13 (13): 32-35.

World Health Organization.The World Health Report, (1998): Life in 21st century-A vision for All WHO:
Geneva. 1998

Wu Y W, Backstrand K H, Zhao S, Fullerton H, Johnston S C. (2004) Declining diagnosis of birth asphyxia in


California: 1991-2000. Pediatrics, (114):584-590.

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C.N Onyearugha. and HAA Ugboma: Continental J. Tropical Medicine 4: 11 - 19, 2010

Received for Publication: 28/06/2010


Accepted for Publication: 09/08/2010

Corresponding Author:
H.A. Ugboma.
University of Port Harcourt Teaching Hospital. Rivers State Nigeria.
E-mail: haugboma@yahoo.co.uk

19
Continental J. Tropical Medicine 4: 20 - 22, 2010 ISSN2141 - 4167
© Wilolud Journals, 2010 http://www.wiloludjournal.com

HYDRANENCEPHALY: CASE REPORT AND LITERATURE REVIEW

G I Mcgil UGWU
Department of Paediatrics, Delta State University, C/O: P O Box 3217 Warri
E-Mail: gnclinic@yahoo.com

ABSTRACT
A case of a one month old girl who was delivered by a teenager and had a normal head size
at birth but with a progressive head enlargement is presented. She had normal primitive
reflexes at birth. A Computerized tomography showed she had hydranencephaly. A review
of the literature on hydranencephaly is also presented.

KEYWORDS: Head Circumference, Hydranencephaly,Neonate, Teenage-mother

CASE PRESENTATION
Baby girl M. D. was delivered by an 18-year-old mother and had a normal head size at birth. However, one week
later the head started enlarging and she was then taken to a hospital where ampicillin-cloxacillin combination
was prescribed. The head continued to enlarge and she was then taken to anther hospital where she was then
abandoned by the mother and subsequently referred to our clinic.

The prenatal and other histories including maternal habits events in the pregnancy could not be obtained.
She was found on examination to have macrocephaly with a head circumference of 51cm at age one month
(expected is 35 + or -2cm), the anterior and posterior fontanelles were enlarged and buldging with sutural
diasthesis. The primitive reflexes were present but sluggish and there was no sun setting appearance of the eyes.
There was no evidence of spinal bifida or lower limb deformity. A diagnosis of Hydrocephalus was made and
she then referred to a Neurosurgeon. A C-T scan done showed among other things the presence of only the
structures of the posterior fossa, namely, the brain stem, cerebellum and the thalamus which protrude 32cm into
the fluid filled cranial cavity. The third ventricle was not obvious and the brain mantle was also not obvious.
These are shown in Fig 1. A diagnosis of Hydranencephaly was confirmed and child was sent back to us. She
was managed conservatively until her death at age six months.

LITERATURE REVIEW
Hydranencephaly is the complete or near complete absence of the cerebral cortex and basal ganglia, which are
then replaced by a membranous sac of fluid, glial tissue and the ependyma in an intact skull. (Pangui et al 1991;
Byers et al 2005) In this situation, some of the primitive reflexes are (Byers et al 2005; Kaga 2002). It is
thought to follow occlusion of the internal carotid arteries which leads to generalized cerebral infarction. Byers
et al 2005). Several causes have been advanced as initiators of this occlusion. It could follow an intrauterine viral
infection (Parish 1989; Kubo et al 1994), especially Herpes simplex (Parish 1989), or it may be metabolic
(Castro-Ciago et al 1999), oestrogenic (Blare et al 1988), genetic or parasitic (Pangui et al 1991) or toxic (Nieto
et al1994). It has even been reported to follow twin-twin transfusion with the recipient developing the condition
(Barrent et al 2000). A case has been reported to in the vertebral/basilary artery territory (Rossmann , Parks
1978).

Hydranencephaly is generally classified as a circulatory encephalopathy and two opposing hypotheses have been
postulated. One is the destructive theory in which the cortex is formed but destroyed in utero and the other is the
dysontogenesis in which there is early disruption of organogenesis (Pangui et al 1991).

Hydranencephaly can be bilateral or unilateral, in which case only one cerebral hemisphere is involved, leading
to hemihydranencephaly (Ulmer et al 2005; Greco et al 2001). The incidence of bilateral Hydranencephaly is
0.5 per 1000 births (Pangui et al 1991), while only about seven cases of hemihydranencephaly have been
reported in the medical literature (Ulmer et al). The incidence is lower as the maternal age advances. (Lubinsky
1997; Lubinsky et al 1997). Our patient’s mother was18years.

The diagnosis can be made in utero using ultrasonography or magnetic resonance imaging (Byers et al 2005).
Postnatally, one can suspect the illness if the child’s head size at birth is normal, but increases progressively after
birth, with normal primitive reflexes and by Transillumination of the skull (Barozzino , Sgro 2002). CT scan
and MRI are important diagnostic tools postnatally (Garcia-Inigo et al 2004; Poe , Coleman 1989). The two

20
G I Mcgil UGWU: Continental J. Tropical Medicine 4: 20 - 22, 2010

major differential diagnoses are extreme Hydrocephalus and bilateral extra cerebral collection of fluid in the
skull. These can be differentiated form Hydranencephaly by using an EEG (Guruuaji et al 2005; Linuma et al
1989). Extreme Hydrocephalus will show evidence of cortical activity while hydranencephaly will not, and will
give a flat isoelectric recording (Guruuaji et al 2005). There will be no evoked visual potential in
hydranencephaly (Linuma et al 1989).

Most neurosurgeons believe that surgery is unnecessary as majority will die in infancy (Adeloye 2000).
However, some believe that repeated and even complex surgery such as choroid plexectomy can be done
(Wellons et al 2002). Although most will die in infancy, survival upto 10years have been reported (Corington et
al 2003). Infact the longest survival reported is twenty years (Corington et al 2003). Children with
hemihydranencephaly can lead a normal life (Ulmer et al 2005)

CONCLUSION
One of the ethical questions is the appropriate treatment for this seemingly fatal illness. Should surgery be
offered to them using the merger resources available or wait for the death of these patients whenever it will
come. Our patient was referred back to us after the diagnosis was made by C-T scan. Mention must be made that
there was a time complex cardiac surgeries were denied children with Trisomy 21. These ethical issues will
continue to be considered especially when organ transplantation is involved (McAbee et al 2000).

ACKNOWLEDGEMENT
I am indeed most gratefully to Lady E.N. Ugwu for her immense contributions.

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hemispheric hydranencehpaly. Pediatrics 2005; 11(6): 242-245

Wellons JC 3RD, Tubbs RS, Leveque JC, Blount JP, Oakes WJ. Choroid Plexectomy reduces neurosurgical
intervention in patients with Hydranencephaly. Pediatr Neurosurg. 2002; 36(3): 148-152

Received for Publication: 28/06/2010


Accepted for Publication: 09/08/2010

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Continental J. Tropical Medicine 4: 23 - 26, 2010 ISSN: 2141 - 4167
© Wilolud Journals, 2010 http://www.wiloludjournal.com

POSTOPERATIVE SYNERGISTIC GANGRENE ON THE ANTERIOR ABDOMINAL WALL – REPORT


OF A CASE

Afeyodion Akhator, Emmanuel A. Sule, Emmanuel E. Akpo


Department of Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State
University, Abraka, Nigeria

ABSTRACT
The management of a 23 year old boy who postoperatively developed severe anterior abdominal wall
infection diagnosed as postoperative synergistic gangrene (Meleney disease) following laparotomy for
penetrating abdominal injury is presented. The patient was managed with early aggressive debridement
in the theatre, repeated bedside debridement over several weeks and intravenous antibiotics. His wound
healed by secondary intention and he was discharged after 46 days on admission.

KEYWORDS: postoperative synergistic gangrene, bedside debridement

INTRODUCTION
Postoperative synergistic gangrene is a rare rapidly spreading and relentless destructive subcutaneous lesion first
described by Meleney as post operative synergistic gangrene in 1931 (Meleney, 1931). A variety of terms has
been used to describe this condition including necrotizing fasciitis, progressive synergistic bacterial gangrene,
and hospital gangrene (Wilson, 1952; Gannon, 1994). Differentiation from cellulitis and abscesses is important
but difficult in the early phase because of paucity of early signs, and is usually diagnosed because the disease
continued to progress in spite of therapy (Wong et al, 2003).

The infection usually dissects along fascial planes with extensive necrosis of the fascia and undermining of the
surrounding structures. Skin gangrene is due to thrombosis of the nutrient vessels. The disease lies as a clinical
entity between cellulitis and myonecrosis with aggressive necrosis of skin and fascia while sparing muscle
(Goldberg et al 1984). Mortality has been reported to be 21.3% from Singapore and 50% in Ilorin, Nigeria
(Wong et al 2003; Adigun & Abdulrahaman, 2004).

The incidence of necrotizing fasciitis has been on the increase because of increase of immunosuppressed patient
with diabetes mellitus, cancer, alcoholism and HIV (Sharkawy et al 2004). A case of postoperative gangrene in a
previously healthy young man is presented and the challenges we had in managing him is discussed.

CASE REPORT
A 23 year old boy was referred to our center on account of spreading infection in his operative wound. He was
involved in an inter-tribal clash and sustained an extensive laceration in the left hypochondrial region from a
cutlass. He had immediate laparotomy in the referral center where repair of small bowel laceration was done. On
the fourth day post surgery the wound was noticed to be draining brownish fluid and the skin sutures were
removed. Two days later, extensive bullae were noticed in the anterior abdominal wall and he was then referred.
On examination, the patient was febrile temperature of 38.4 degree Centigrade, tachypnoiec with a respiratory
rate of 32 cycles/min with tachycardia of 104/min. Examination of the abdomen showed a transverse left
hypochondrial wound and a midline wound without skin sutures with extensive bullae of the skin of the anterior
abdominal wall. Both the wounds and bullae were draining brownish foul smelling fluid (Figures 1 & 2).

Investigations done showed a white cell count of 15,700 cells with 92% neutrophils. Packed cell volume was
23%. Electrolytes, urea and creatinine were within normal limits. Urinalysis showed no abnormality. Culture of
the wound showed mixed growth of streptococcus and coliform organism. Abdominal ultrasound did not show
any intraperitoneal fluid collection or abscesses and plain abdominal X-rays were normal. He was assessed has
having postoperative synergistic gangrene.

He was commenced on intravenous fluids – Ringers lactate alternating with 5% dextrose water 3 liters a day,
intravenous ceftriaxone 1 gram 12 hourly and metronidazole 500mg 8 hourly. He was transfused with 3 units of
blood. He underwent a wound debridement in theatre. It was noticed that there was extensive fascia involvement
beneath the skin. All bullae and dead fascia were excised; wound was irrigated with copious saline and dressed.
Daily saline dressing was continued and bedside debridement was done four times over the following three
weeks. Figure 3 shows appearance of wound after 3 weeks of treatment.

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Afeyodion Akhator et al.,: Continental J. Tropical Medicine 4: 23 - 26, 2010

The patient’s condition improved and wound healed by secondary intention (Figures 4 & 5). He was discharged
home on the 46th day of admission.

DISCUSSION
Postoperative synergistic gangrene is a deadly form of soft tissue infection that has been tagged “Meleney’s
Minefield” (Wong et al, 2006). It has a mortality rate of 34% (range of 6%-76%). Survival depends on early
recognition and prompt aggressive debridement along with targeted antibiotic therapy.

Most patients with postoperative synergistic gangrene had pre existing immunosuppressive condition such as
diabetes mellitus, chronic renal failure and HIV or are elderly or obese. Our patient was a healthy young man
who had not used any hard drugs and the only identifiable risk factor was surgery as reported in 4.5% of cases
(Wong et al 2003).

Diagnosis of postoperative synergistic gangrene is difficult due to paucity of early cutaneous signs. In the review
by Wong et al 2003, only 14.6% of their 89 patients were diagnosed at the time of admission (Wong et al, 2003).
They gave an excellent guide for making early diagnosis of this condition. Diagnosis in this patient was made
because of the presence of characteristic bullae in the anterior abdominal wall. Subsequent full-thickness skin
and superficial fascia necrosis sparing underlying muscle differentiated it from a clostridial myonecrosis.
Invading organisms were identified from culture of wound swab. Although culture of wound biopsies could not
be done for logistic reasons, culture of wound biopsies taken from the spreading periphery of the necrotizing
infection gives higher yield. Associated systemic conditions including diabetes mellitus, HIV were ruled out in
this case as non-recognition and management of systemic comorbdities may prove inimical to success. The
diagnosis was confirmed intra-operative by the presence of foul smelling and dirty serous fluid, pus and grayish
necrotic fascia. Other significant findings were the loss of resistance of the deep fascia to blunt dissection and
lack of bleeding of the fascia during dissection as described in the literature (Akhtar et al, 2010). Plain
abdominal xray and abdominal ultrasound showed negative findings. However computerized tomography scan
and MRI have been reported to aid early diagnosis (Wyoskki et al 1998, Schmid et al 1997) but their use should
never delay operative intervention (Wong et al 2003). A high index of clinical suspicion is thus required for
early diagnosis and intervention.

The management of postoperative synergistic gangrene is aggressive resuscitation, surgical debridement with
excision of all dead tissues and targeted elaboration of broad spectrum antibiotics (Adigun and Abdulrahaman
2004). A second look within 24 and 48hrs should be done to assess the need for serial debridement; (Wong et al
2003) as occurred in our case. Due to limited financial resources, our case had subsequent serial debridement by
bedside under some analgesia. The resultant skin defects contracted adequately and were allowed to heal by
secondary intention. Skin grafts/flaps are recommended to cover the extensive defects resulting from
debridement, but the financial constraint in this patient precluded skin graft (Adigun and Abdulrahaman 2004).
The use of negative pressure wound therapy and hyperbaric oxygen therapy in the management of these patients
have been reported to improve survival and shorten treatment times (Phelps et al, 2006). These modalities are
not available in resource limited countries. Therefore management should be based on early recognition, early
surgical debridement and broad spectrum antibiotic therapy.

CONCLUSION
We recommend a high index of suspicion for postoperative synergistic wound infection and early radical
debridement of suspicious postoperative wound. Repeated debridement can be done safely by the bedside of the
patient, thereby reducing overall cost in the treatment of these patients.

REFERENCES
Adigun AI, Abdulrahaman LO (2004). Necrotizing fasciitis in a plastic surgical unit: a report of 10 patients from
Ilorin. Nigerian Journal of Surgical Research; 6(1-2): 21-24.

Akhtar M, Akhtar F, Bandyopadhyay D, Montgomery H, & Mahomed A (2010). Abdominal Wall Necrotizing
Fasciitis: A Survivor from “Meleney’s Minefield”. The Internet Journal of Surgery; 22(1)

Gannon T (1994). Dermatologic emergencies. Postgrad Med;96(1):67-82.

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Goldberg GN,Hansen RC, Lynch PJ (1984). Necrotising fasciitis in infancy; Report of three cases and review of
the literature. . Paediatric Dermatology;2:55-63.

Meleney F.L (1933). A differential diagnosis between certain types of infective gangrene of skin. Surgery,
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Phelps JR, Fagan R, Pirela-Cruz MA (2006). A case study of negative pressure wound therapy to manage acute
necrotizing fasciitis. Osteotomy Wound Management; 52(3): 54-59.

Schmid MR, Kossmann T, Duewell S (1998). Differentiation of necrotizing fasciitis and cellulitis using MR
imaging. AJR AMm J Roentgenol;170:615-20.

Sharkawy A, Low DE, Saginur R, et al. Severe group A streptococcal soft tissue infections in Ontario: 1992-
1996. Clinical Infectious Disease 2002;34:454-60.

Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, & Low CO (2003). Necrotizing Fasciitis: Clinical
Presentation, Microbiology, and Determinants of Mortality. The Journal of Bone & Joint Surgery; 85-A(8):
1454-1460.

Wong CH, Song C, Ong YS, Tan BK, Tan KC, Foo CL (2006). Abdominal wall necrotizing fasciitis: it is still
“Meleney’s minefield”. Plast Reconstr Surg; 117(7): 147-150.

Wyoski MG, Santora TA, Shah RM, Friedman AC (1997). Necrotising fasciitis; CT characteristics.
Radiology;203:859-63.

Figure 1 – Appearance at presentation 1 Figure 2 – Appearance at presentation 2

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Afeyodion Akhator et al.,: Continental J. Tropical Medicine 4: 23 - 26, 2010

Figure 3 – Appearance at 3rd week of treatment Figure 4 – Appearance at discharge 1

Figure 5 – Appearance at discharge 2

Received for Publication: 28/10/2010


Accepted for Publication: 09/11/2010

Corresponding Author
A. Akhator
Department of Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State University, PMB
1, Abraka, Nigeria.
EMAIL: doc_akhator@yahoo.com

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