Vol. 4 - Cont. Tropical Med

8/8/2019 Vol. 4 - Cont. Tropical Med.

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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 to2009, 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% ofall 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 forcervical 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 ofanimal 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 wasby 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


20-29 5 14

30-39 7 20

40-49 6 17

50-59 4 11

60-69 6 1770+ 5 14

Unknown 2 5.7

Total 35 100

Table 3 Distribution of Cervical cancer according to age 2009


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


20-29 6 8.730-39 12 17.4

40-49 10 14.550-59 16 23.2

60-69 11 16

70+ 11 16

Unknown 3 4.4

Total 69 100

Fig1

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

0

2007 2008 2009

0

5

10

15

20

25

30

35

40

No. of Cases from 2007-2009

0

2

46

8

10

12

14

16

18

20-29 30-39 40-49 50-59 60-69 70+ Unknown Age groups

No. of Cases

No. of Cases

Years


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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 ofmalignancy 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 the50-59 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 etal., 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 ATwelve 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 20012005: 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 ofanalysis 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 cervicalcancer 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 WesternAssociation 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: [email protected]


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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 StateUniversity, 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 neonatalbreast 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 fullterm 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 witchesmilk 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 forthis 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 Loves Short Practice of Surgery. Williams NS,

Bulstrode C.J.K., OConnell 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



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: [email protected]


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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 selfmedications, 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 seenby 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.

REFERENCEProfessor 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.



Corresponding Author:

Email: [email protected]


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SEVERE BIRTH ASPHYXIA: RISK FACTORS AS SEEN IN A TERTIARY INSTITUTION IN THE NIGER

DELTA AREAOF NIGERIA.

1

C.N Onyearugha. and2

HAA Ugboma1Departments of Paediatrics AbiaState University Teaching Hospital Aba, 2Obstetrics and Gynaecology

University of Port Harcourt Teaching Hospital Port Harcourt Nigeria.

ABSTRACTBACKGROUND:

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 31 st 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 indeveloping countries including Nigeria(.WHO,1998; Palsdotir et al, 2007; Ellis 2000 ; Udoma 2001) Twentyfive 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 spiritualchurches 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; Etuket 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 ofNigeria. 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 hospitalsin 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 firstminute of life and 5 or less at 5 minutes signified severe birth asphyxia (.Palsdotiret 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 whosemothers 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 seriallyrecruited 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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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 andlabour, drugs administered in pregnancy and labour, and labour duration for mothers whose labour started in thehospital 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 completeexpulsion 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


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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%) butoccurred 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

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

4000 3 3.06 4550+439 2 2.04 4350+23

SD = Standard deviation, BW = Birth weight


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Table 3

Drugs given in labour to mothers of subjects and control.

Drugs Number of % Number % P-value

given in mothers of mothers oflabour 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 0.477Ampiclox 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

Mothers laterecognition 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 0.0Labour initially

managed by T.B.A 2 2.0 0 0.0

Financial constraint 1 1.0 0 0.0

P = 0.004T.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 thequality 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 andDiejomaoh,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 asignificant 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 thenumber that were of low birth weight.


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This is in agreement with previous reports by Oruamabo from this centre and others(Etuket 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 hadsignificantly 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 respiratorycentre, 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 inmothers 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 andmaternal 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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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 riskfactor 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 ofrecruited 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 theincidence 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 careproviders 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 attendanceand 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 Worlds Newborns. (2001). Save the Children Washington, DC

Suzie D, KS Joseph, A Allen, D Young (2009). Decreasing Diagnosis of birth Asphyxia in Canada: Fact orArtifact. 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 aNewborn 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, PortHarcourt 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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Corresponding Author:H.A. Ugboma.University of Port Harcourt Teaching Hospital. Rivers State Nigeria.

E-mail: [email protected]


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HYDRANENCEPHALY: CASE REPORT AND LITERATURE REVIEW

G I Mcgil UGWU

Department of Paediatrics, Delta State University, C/O: P O Box 3217 WarriE-Mail: [email protected]

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 combinationwas 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 thedysontogenesis 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 patients 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 childs 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 scanand MRI are important diagnostic tools postnatally (Garcia-Inigo et al 2004; Poe , Coleman 1989). The two


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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 inhydranencephaly (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 willcontinue 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.

REFERENCES

Adeloye A. Hydranencephaly in Malawian Children. East Ari Med J. 2000;77(6): 316-318

Barozzino T, Sigro M. Transillumination of the neonatal skull: seeing the lignt. CMAJ. 2002. 167(11): 1271-

1272

Barrent CJ. Hydranencephaly owing to twin-twin transfusion. Pediatr Neurol. 2004; 40:56-58

Blare JF, Lapillonne A, Pouillaude JM, Badinand N. Hydranencephaly and ingestion of estrogen during

pregnancy. Fetal cerebral complication? Arch French Pediatr 1988; 45(7): 483-485

Byers BD, Barth WH, Stewart TL, Pierce BT. Ultrasound and MRI appearance and evolution of

Hydranencephaly in utero: a case report. J Reprod Med. 2005; 50(1): 53-56

Castr-Ciago M, Eiris-Pinal J, Iglesias, Diz M. Congenital Hydranencephaly-hydrocephalus syndrome and

mitochondrial dysfunction. J Child Neurol. 1999; 14(12): 824

Corington C, Talor H, Gill C, Padaliya B, Newman W, Smart JR 3RD, Charles PD. Prolonged survival in

Hydranencephaly. Ten Med. 2003; 96(9): 423-424

Garcia-Inigo P, Paniagua-Escudeo JC, de Castro Garcia FJ. Hydranencephaly Findings from computerized axialtomography and magnetic resonance scans. Rev Neurol 2004; 39(4): 398-399

Greco F, Finnocchano M, Pavone P, Trifiletti RR, Parano E. Hemihydrancephaly: a case report and literature

review. J Child Neurol. 2001; 16(3): 218-221

Guruunji A, Varady E, Sztriha L, Al-Gazali, Gorka W, Nork M. Electroencephalography, Doppler vascular

scanning and single positron emission computed tomography in a child with Hydranencephaly and intractable

seizures. J Child Neurol. 2005; 20(5): 446-449

Kaga K, Yusui T, Yuge T. Auditory behaviors and auditory brainstem responses of infants with hypogenesis of

the cerebral hemispheres. Acta Otolaryngol. 2002; 122(1): 16-20


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Kubo S, Kishino T, Satake N, Okano M, Mikawa M, Isnikawa N. A neonatal case of Hydranencephaly caused

by atheromatous plaque obstruction of the aortic arch: possible association with congenital cytomegaloviral

infection? Perinatol 1994; 14(6): 483-486

Linuma K, Harda I, Kojima A, Hayamizu S, Karahashi M. Hydranencephaly and maximal hydrocephalus:Usefulness of electrophysiological studies for their differenciation. J Child Neurol 1989; 4(2): 114-117

Lubinsky MS. Association of prenatal of vascular disruption with decreasing maternal age. Am J Med Genet

1997; 69(3): 237-239

Lubinsky MS, Adkins W, Kaveggia EG. Decreased maternal age with Hydranencephaly. Am J Genet 1997;69(3): 232-234

McAbee GN, Chan A, Erde EL. Prolonged survival with hydranecephaly: report of two patients and literature

review. Pediatr Neuro. 2000; 23(1): 80-84

Nieto BM, Rufo CM, Slieston A, Ribel ML, Partial Hydranencephaly in a child coincidental with intrauterineexposure to Sodium valproate. Neuropediatrics. 1994; 45(7): 483-485

Pangui E, Macumi E, Brnderrouch C, Houilliez B, Saout L, Grall Y. Hydranencephaly> Report of a new case.

Rev French Gynecl Obstet. 1991; 86(5): 401-405

Poe LB. Cloman L. MR of Hydranencephaly. Am J Neuroradiol. 1989; 10(5): 561

Rossmann U, Parks J Jr. Hydranencephaly in the vertebral-basilar territory. Acta Neuropathol 1978; 44(2): 41-43

Ulmer S, Moeller F, Brockmann M, Kuttz-Buschbeck JP, Stephani U, Jarsen O. Living a normal life with the

nondorminant hemisphere: magnetic resonance imaging findings and clinical outcome for a patient with left

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




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Continental J. Tropical Medicine 4: 23 - 26, 2010 ISSN: 2141 - 4167


POSTOPERATIVE SYNERGISTIC GANGRENE ON THE ANTERIOR ABDOMINAL WALL REPORT

OF A CASE

Afeyodion Akhator, Emmanuel A. Sule, Emmanuel E. AkpoDepartment 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 debridementin 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

INTRODUCTIONPostoperative 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 wereremoved. 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 anteriorabdominal 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 threeweeks. 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 patients condition improved and wound healed by secondary intention (Figures 4 & 5). He was discharged

home on the 46th

day of admission.

DISCUSSIONPostoperative synergistic gangrene is a deadly form of soft tissue infection that has been tagged MeleneysMinefield (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 skinand 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 arenot available in resource limited countries. Therefore management should be based on early recognition, early

surgical debridement and broad spectrum antibiotic therapy.

CONCLUSIONWe 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 thepatient, thereby reducing overall cost in the treatment of these patients.

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


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

Figure 5 Appearance at discharge 2



Corresponding AuthorA. Akhator

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

1, Abraka, Nigeria.

EMAIL: [email protected]

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Vol. 4 - Cont. Tropical Med