Pediatric Endocrinology Practice in Nigeria: Challenges and Way Forward

The prevalence of endocrine disorders in children in Nigeria is not well known. Therefore the burden of these diseases is often overlooked as most cases are undiagnosed or diagnosed too late; and yet they constitute a significant cause of morbidity and mortality in children. There has been a paucity of Paediatric Endocrinologists, absence of laboratory equipments and even drugs for the treatment of these diseases are often not in stock. The desired attention these endocrine diseases should receive from both health care institutions and the government is lacking. Therefore, the aim of this review article was to highlight the challenges facing the practice of Paediatric endocrinology in Nigeria and to proffer a way forward to building a robust endocrine care services in health institutions in Nigeria. Keywords: Challenges, endocrinology, paediatrics, way forwar

Factors Influencing Antenatal Haematinics Prescription Behaviour of Physicians in Calabar, Nigeria

BACKGROUND: Routine iron and folic acid supplementation in pregnancy have been proved to be effective in reducing the prevalence and morbidities of anaemia. However, there is limited data regarding the prescription habits of physician obstetric care givers.AIM: This study set to investigate the attitudes and factors which influence the practice among physicians in University of Calabar Teaching Hospital (UCTH).MATERIAL AND METHODS: A questionnaire based cross-sectional survey was conducted among randomly recruited physician offering antenatal services between August and September 2015. Systemic sampling was used to select 70 doctors in the departmental duty roster. Data were presented in percentages and proportion. Chi-square test was used to test the association between variables. Statistical significance was set at p < 0.05.RESULTS: The response rate was 100%. The mean age of the respondents was 30.26 ± 6.67 years. All the respondents routinely prescribed haematinics to pregnant women but 34.3% of them did not prescribe to apparently healthy clients in their first trimester. Only 30% and 11.4% of them prescribed it in the postnatal and preconception periods respectively. Brands that contained iron, folate and vitamins as a single capsule were mostly favoured, and information about brands of drugs was mostly provided by the pharmaceutical sales representatives. Younger doctors were more likely to offer haematinics with nutritional counselling compared to older respondents. However, there was no significant relationship between haematinics prescription and sex (p = 0.3560), Age (p = 0.839), current professional status (p = 0.783), and client complaint of side effect of medication (p = 0.23). Oral medication was mostly utilised.CONCLUSION: Effort to effectively control anaemia in pregnancy should involve re-orientation of physician obstetric care providers especially about prenatal and postnatal medication and counselling

Antenatal Deworming and Materno-Perinatal Outcomes in Calabar, Nigeria

BACKGROUND: Studies have shown that administration of anthelmintic drugs in pregnancy can reduce the incidence of maternal anaemia; however, data on other maternal and perinatal outcomes are limited.AIM: This study was therefore conducted to evaluate the direct impact of mass deworming on delivery and perinatal outcome.MATERIAL AND METHODS: A total of 560 healthy pregnant women in their second trimester were randomised to receive a single dose of oral mebendazole (500 mg) and placebo. Each participant received the standard dose of iron supplement and malaria prophylaxis. They were followed up to delivery and immediate postpartum period to document the possible impact on maternal and perinatal outcomes.RESULTS: The prevalence of anaemia at term, 37 weeks gestation and above, among the treatment arm was 12.6% compared with 29.9% in the placebo arm (p < 0.001). Caesarean section rates was higher in the treated group and the placebo (p = 0.047).There were no statistically significant differences in incidences of postpartum haemorrhage (p = 0.119), Puerperal, pyrexia (p = 0.943), low birth weight (p = 0.556) asphyxia (p = 0.706) and perinatal death (p = 0.621).CONCLUSION: Presumptive deworming during the antenatal period can significantly reduce the incidence of peripartum anaemia. However, more studies may be needed to prove any positive perinatal outcome

Are Female Undergraduates at the University of Calabar Equipped with the Knowledge, Positive Attitudes, and Effective Practices of Contraceptives?

BACKGROUND: The global challenge of rapid population growth necessitates family planning programs to address reproductive health needs and control population increase. However, unintended pregnancies, particularly among adolescents, remain a significant problem, leading to increased risks of sexually transmitted infections and unsafe abortions. In Nigeria, contraceptive use is low among youths, resulting in high incidences of induced abortions and sexually transmitted infections. Barriers such as religious beliefs, cultural factors, limited availability, personal beliefs, and fear of side effects contribute to the under-utilization of contraceptives. METHODS: A descriptive cross-sectional study was conducted among female undergraduates of the University of Calabar, Cross River State. Data was collected using a 42-item questionnaire after obtaining informed consent. Multi-stage sampling was employed, and data was analyzed with IBM SPSS version 26 using descriptive and inferential statistics. RESULTS: The mean age of respondents was 21.5 ± 2.72 years. Most participants were in their first (26.7%) or second (22.6%) level of study. 28.8% were in sexual relationships, while 71.2% were not. Approximately a quarter of respondents had experienced symptoms of sexually transmitted infections. 71.5% had no knowledge of emergency contraception. Condoms (71.2%) and pills (54.5%) were the most commonly mentioned methods of contraception, while tubal ligation was the least popular (4.7%). The main benefit cited for contraception was the prevention of unwanted pregnancy (92.2%). 47.3% had no idea about the side effects of contraception, with irregular menstruation being the most commonly mentioned side effect (19.3%). Friends/peers, the internet, and school were the primary sources of information on contraception. 56.4% believed that contraception is not solely for females and should not be reserved for the literate. Over a third of respondents thought contraception encourages promiscuity and has too many side effects, with more than half demanding contraceptive services on campus. Less than half of the respondents (43.9%) reported using contraception at some point, with even smaller percentages using contraception in the last six months (25.2%) or during their last sexual intercourse (23.8%). Of the 101 who used contraceptives in their last sexual intercourse, the majority (83%) used condoms, while pills (7%) and emergency contraception (10%) were less common. Preferred sources for contraception were pharmacies (57.5%) and chemist shops/patent medicine vendors (24.7%). Religion (41.5%), fear of side effects (34.9%), and partner consent (28.3%) were the main influences on contraceptive use. Several factors were significantly associated with contraception utilization, including age, partner's educational level, knowledge of contraception, and level of study (p<0.05). CONCLUSION: The low utilization of contraception among female undergraduates at the University of Calabar despite high awareness and poor knowledge highlights the need for interventions. Factors influencing utilization include age, knowledge, and level of study. Barriers such as religion, fear of side effects, and partner consent must be addressed. Recommendations include sensitization campaigns, establishing a youth-friendly center on campus, incorporating contraception into curricula, collaborating with NGOs, and increasing funding for research

Secondary analysis of the WOMAN trial to explore the risk of sepsis after invasive treatments for postpartum hemorrhage.

OBJECTIVE: To examine the association between the use of invasive treatments for postpartum hemorrhage and the risk of sepsis and severe sepsis. METHODS: Secondary data analysis of the WOMAN randomized controlled trial, including 20 060 women with postpartum hemorrhage in 21 countries. Logistic regression with random effects was used. RESULTS: The cumulative incidence was 1.8% for sepsis and 0.5% for severe sepsis. All-cause mortality was 40.4% in women with severe sepsis versus 2.2% for women without. After adjusting for bleeding severity and other confounders, intrauterine tamponade, hysterectomy, and laparotomy increased the risk of sepsis (aOR 1.77 [95% CI 1.21-2.59], P=0.004; aOR 1.97 [95% CI 1.49-2.65], P<0.001; and aOR 6.63 [95% CI 4.29-10.24], P<0.001, respectively) and severe sepsis (aOR 2.60 [95% CI 1.47-4.59], P=0.002; aOR 1.97 [95% CI 0.83-2.46], P=0.033; and aOR 5.35 [95% CI 2.61-10.98], P<0.001, respectively). CONCLUSION: In this secondary data analysis, certain invasive treatments for postpartum hemorrhage appear to increase the risk of sepsis. Further research is needed to confirm this finding and investigate the role of prophylactic antibiotics during these procedures. The harms and benefits of such interventions must be carefully weighed, both in treatment guidelines and during individual patient management. TRIAL REGISTRATION: ISRCTN76912190

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: the INTERCOVID Multinational Cohort study

At the beginning of the COVID-19 pandemic, the extent of the risks of a COVID infection during pregnancy were unknown. During the start of the pandemic, there were only a few studies published comparing outcomes between pregnant women with and without COVID-19 infections. The INTERGROWTH-21st Consortium conducted a prospective, longitudinal, observational study (INTERCOVID), which assessed the association between COVID-19 and maternal/neonatal outcomes in pregnant women with a COVID-19 diagnosis compared with enrolled pregnant women without a COVID-19 diagnosis. This study enrolled patients from 43 hospitals in 18 different countries between March 2020 and October 2020. As a comparison group, the researchers enrolled 2 unmatched, consecutive, uninfected women immediately after each infected woman was identified, at any stage of pregnancy or delivery, and at the same level of care. Both women and neonates were followed until hospital discharge. COVID-19 was diagnosed by laboratory confirmation and/or radiological pulmonary findings or 2 or more predefined COVID-19 symptoms. The primary outcomes of the study were indices of maternal and severe neonatal/perinatal morbidity and mortality. In all, 706 pregnant women with a COVID-19 diagnosis and 1424 pregnant women without a COVID-19 diagnosis were enrolled. The women had broadly similar demographic characteristics (mean [SD] age, 30.2 [6.1] years). Three hundred twenty-three women were overweight early in pregnancy (48.6%) with COVID-19 diagnosis and 554 women (40.2%) without. Women with COVID-19 diagnosis were more likely to have preeclampsia/eclampsia (relative risk [RR], 1.76; 95% CI, 1.27–2.43), severe infections (RR, 3.38; 95% CI, 1.63–7.01), intensive care unit admission (RR, 5.04; 95% CI, 3.13–8.10), maternal mortality (RR, 22.3; 95% CI, 2.88–172), preterm birth (RR, 1.59; 95% CI, 1.30–1.94), medically indicated preterm birth (RR, 1.97; 95% CI, 1.56–2.51), severe neonatal morbidity index (RR, 2.66; 95% CI, 1.69–4.18), and severe perinatal morbidity and mortality index (RR, 2.14; 95% CI, 1.66–2.75). Women with a fever and shortness of breath were more likely to have severe maternal complications (RR, 2.56; 95% CI, 1.92–3.40) and neonatal complications (RR, 4.97; 95% CI, 2.11–11.69). Women who were asymptomatic with a COVID-19 diagnosis remained at higher risk only for maternal morbidity (RR, 1.24; 95% CI, 1.00–1.54) and preeclampsia (RR, 1.63; 95% CI, 1.01–2.63). Among women who tested positive for COVID-19 (98.1% by real-time polymerase chain reaction), 54 (13%) of their neonates tested positive. Cesarean delivery (RR, 2.15; 95% CI, 1.18–3.91) but not breastfeeding (RR, 1.10; 95% CI, 0.66–1.85) was associated with increased risk for neonatal COVID-19 test positivity. In this study, COVID-19 in pregnancy was associated with consistent and substantial increases in severe maternal morbidity and mortality and neonatal complications compared with pregnant women without a COVID-19 diagnosis. These findings highlight the importance of following the recommended COVID-19 preventative measures

Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study

Background: It is unclear whether the suggested link between COVID-19 during pregnancy and preeclampsia is an independent association or if these are caused by common risk factors. Objective: This study aimed to quantify any independent association between COVID-19 during pregnancy and preeclampsia and to determine the effect of these variables on maternal and neonatal morbidity and mortality. Study Design: This was a large, longitudinal, prospective, unmatched diagnosed and not-diagnosed observational study assessing the effect of COVID-19 during pregnancy on mothers and neonates. Two consecutive not-diagnosed women were concomitantly enrolled immediately after each diagnosed woman was identified, at any stage during pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed until hospital discharge using the standardized INTERGROWTH-21st protocols and electronic data management system. A total of 43 institutions in 18 countries contributed to the study sample. The independent association between the 2 entities was quantified with the risk factors known to be associated with preeclampsia analyzed in each group. The outcomes were compared among women with COVID-19 alone, preeclampsia alone, both conditions, and those without either of the 2 conditions. Results: We enrolled 2184 pregnant women; of these, 725 (33.2%) were enrolled in the COVID-19 diagnosed and 1459 (66.8%) in the COVID-19 not-diagnosed groups. Of these women, 123 had preeclampsia of which 59 of 725 (8.1%) were in the COVID-19 diagnosed group and 64 of 1459 (4.4%) were in the not-diagnosed group (risk ratio, 1.86; 95% confidence interval, 1.32–2.61). After adjustment for sociodemographic factors and conditions associated with both COVID-19 and preeclampsia, the risk ratio for preeclampsia remained significant among all women (risk ratio, 1.77; 95% confidence interval, 1.25–2.52) and nulliparous women specifically (risk ratio, 1.89; 95% confidence interval, 1.17–3.05). There was a trend but no statistical significance among parous women (risk ratio, 1.64; 95% confidence interval, 0.99–2.73). The risk ratio for preterm birth for all women diagnosed with COVID-19 and preeclampsia was 4.05 (95% confidence interval, 2.99–5.49) and 6.26 (95% confidence interval, 4.35–9.00) for nulliparous women. Compared with women with neither condition diagnosed, the composite adverse perinatal outcome showed a stepwise increase in the risk ratio for COVID-19 without preeclampsia, preeclampsia without COVID-19, and COVID-19 with preeclampsia (risk ratio, 2.16; 95% confidence interval, 1.63–2.86; risk ratio, 2.53; 95% confidence interval, 1.44–4.45; and risk ratio, 2.84; 95% confidence interval, 1.67–4.82, respectively). Similar findings were found for the composite adverse maternal outcome with risk ratios of 1.76 (95% confidence interval, 1.32–2.35), 2.07 (95% confidence interval, 1.20–3.57), and 2.77 (95% confidence interval, 1.66–4.63). The association between COVID-19 and gestational hypertension and the direction of the effects on preterm birth and adverse perinatal and maternal outcomes, were similar to preeclampsia, but confined to nulliparous women with lower risk ratios. Conclusion: COVID-19 during pregnancy is strongly associated with preeclampsia, especially among nulliparous women. This association is independent of any risk factors and preexisting conditions. COVID-19 severity does not seem to be a factor in this association. Both conditions are associated independently of and in an additive fashion with preterm birth, severe perinatal morbidity and mortality, and adverse maternal outcomes. Women with preeclampsia should be considered a particularly vulnerable group with regard to the risks posed by COVID-19