Complete elimination of tetanus is still elusive in developing countries: A review of adult tetanus cases from referral hospital in Eastern Nepal

Aim: To analyse demography, clinical presentation, treatment, complications and outcome of patients with tetanus over a 2-year period. Materials and methods: A retrospective analysis of medical records of all patients with tetanus admitted to the intensive care unit of B.P Koirala Institute of Health Sciences, Dharan, Nepal between July 2004 and June 2006. Results: Tetanus accounted for 1.1 % of our ICU admission. Eight tetanus patients (mean age 52 years; M: F ratio 7:1) were admitted. The tetanus prone wounds of seven patients were managed at home. The most common presenting complaints were trismus and stiffness of neck and back (87.5%). Elective intubation was followed by tracheostomy in all the patients. Overall mean duration of ventilatory support was 12.5 days. Treatments given in ICU were diazepam, magnesium sulphate, tetanus immunoglobulin, metronidazole, wound management and supportive measures. Five patients (62.5%) developed autonomic instability and three patients had ventilatory associated pneumonia (37.5%). Average ICU stay was 15.1 days while hospital stay was 20.1 days. Five patients (62.5%) survived the course of disease. Two patients (25%) left the hospital against medical advice while the other (12.5%) died in ICU. Conclusion: Tetanus is a vaccine preventable disease. Tetanus prone wounds should be managed appropriately. Respiratory compromise and autonomic instability are the main causes of morbidity and mortality. Early recognition, intense support and prompt treatment improves morbidity and mortality of patients diagnosed with tetanus.     

Risk factors, morbidity and mortality of neonatal tetanus

A retrospective study was conducted to identify the risk factors, mortality and morbidity of neonatal tetanus in an Infectious Disease Hospital, Mohakhali, Dhaka, Bangladesh, the only referral hospital in the country of its kind. Hospital records of all cases of neonatal tetanus admitted over one year period from 1st May 2008 and 30th April 2009 were analyzed. Demographic data, clinical presentation, progression, hospital stay and outcome were evaluated. Overall mortality was found 52.9%. Hospital stay among the patients was 11.00 ± 8.37 days. Among the patients about two third had unsatisfactory outcome and only 6(35.3%) patients recovered completely. The retrospective study identified that mortality due to neonatal tetanus was very high and the common morbidities were lock jaw, inability to suck, abdominal rigidity, convulsion, fever, irritability etc. It has been explored that low socioeconomic conditions, mothers' illiteracy, lack of antenatal care and involvement of untrained persons during delivery of baby and unclean cord care practices were the important factors contributing to neonatal tetanus. A further study with a larger sample size is recommended for evaluating the findings of the study and formulating the possible preventive strategies against neonatal tetanus.     

Hospital based maternity care in ghana - findings of a confidential enquiry into maternal deaths

Summary BACKGROUND: In Ghana, a universal free delivery policy was implemented to improve access to delivery care in health facilities, thereby improving access to skilled attendance and reducing maternal mortality. OBJECTIVE: A confidential enquiry was conducted to ascertain if changes had occurred in the care provided by reviewing the care given to a sample of maternal deaths before and after introduction of the policy. METHOD: Twenty women who died as a result of pregnancy-related complications (maternal deaths) in selected hospitals in two regions were assessed by a clinical panel, guided by a maternal death assessment form. Unlike the traditional confidential enquiry process, both adverse and favourable factors were identified. FINDINGS: Clinical care provided before and after the introduction of the fee exemption policy did not change, though women with complications were arriving in hospital earlier after the introduction of the policy. On admission, however, they received very poor care and this, the clinical panel deduced could have resulted in many avoidable deaths; as was the case before the implementation of the policy. Consumables, basic equipment and midwifery staff for providing comprehensive emergency obstetric care were however found to be usually available. CONCLUSION: Our findings suggest that the already poor delivery care services women received remained unchanged after introduction of the policy.     

Predictors of maternal mortality among critically ill obstetric patients

Aim

Evaluation of the predictors of maternal mortality among critically ill obstetric patients managed at the intensive care unit (ICU).

Methods

A case control study to evaluate the predictors of maternal mortality among critically ill obstetric patients managed at the intensive care unit (ICU) of the University of Ilorin Teaching Hospital, Ilorin, Nigeria from 1st January 2010 to 30th June 2013. Participants were critically ill obstetric patients who were admitted and managed at the ICU during the study period. Subjects were those who died while controls were age and parity matched survivors. Statistical analysis was with SPSS-20 to determine chi square, Cox-regression and odds ratio; p value < 0.05 was significant.

Results

The mean age of subjects and controls were 28.92 ± 5.09 versus 29.44 ± 5.74 (p = 0.736), the level of education was higher among controls (p = 0.048) while more subjects were of low social class (p = 0.321), did not have antenatal care (p = 0.131) and had partners with lower level of education (p = 0.156) compared to controls. The two leading indications for admission among subjects and controls were massive postpartum haemorrhage and severe preeclampsia or eclampsia. The mean duration of admission was higher among controls (3.32 ± 2.46 versus 3.00 ± 2.58; p = 0.656) while the mean cost of ICU care was higher among the subjects (p = 0.472). The statistical significant predictors of maternal deaths were the patient''s level of education, Glasgow Coma Scale (GCS) score, oxygen saturation, multiple organ failure at ICU admission and the need for mechanical ventilation or inotrophic drugs after admission.

Conclusion

The clinical state at ICU admission of the critically ill obstetric patients is the major outcome determinant. Therefore, early recognition of the need for ICU care, adequate pre-ICU admission supportive care and prompt transfer will improve the outcome.     

Tetanus in adults--a continuing problem: an analysis of 217 patients over 3 years from Delhi, India, with special emphasis on predictors of mortality

Tetanus is still widely prevalent in many parts of the world especially in the developing countries. This study was conducted to assess the demographic and clinical features, treatment and outcome of tetanus in adults with a special emphasis on identification of predictors of mortality. This was a retrospective study of all adult patients admitted with tetanus over a three-year period from 1998 to 2000 at Lok Nayak Hospital, New Delhi, India. The demography, clinical features, treatment and complications of the patients were assessed and were evaluated against two possible outcomes- survival or death, to identify the predictors of mortality. There were 217 adults (148 males, 69 females) admitted with generalized tetanus during the study period. The mean age of the patients was 36.08 +/- 18.84 years. In most instances (63.5%), wounds / injuries served as the source of infection. Overall 31.8% had mild, 21.7% had moderate and 46.5% had severe disease at presentation. Respiratory failure and dysautonomia were the frequently observed complications. Of the 217 patients, 82 died - a mortality rate of 37.78%. Parameters that were significantly associated with increased mortality were: age (especially > 60 years); shorter duration of symptoms - trismus, rigidity and dysphagia; severe disease at presentation and shorter period of onset. Tetanus is a preventable disease associated with a high fatality rate. Universal coverage of immunization programme and appropriate wound prophylaxis is the corner stone of tetanus eradication. The treatment of tetanus is difficult and requires specialized and intensive care. The presence of parameters indicating an adverse outcome at the beginning in the patients will help identify the subset of patients that need more intensive management especially in resource poor nations.     

A review of neonatal tetanus in University of Maiduguri Teaching Hospital,North-eastern Nigeria

Background:

Neonatal tetanus is a vaccine preventable disease and is a leading cause of neonatal mortality in developing countries. The effectiveness of immunization and hygienic umbilical cord care practices in the prevention of the disease has been established.

Objective:

The objective of this study was to audit the scourge of neonatal tetanus in a tertiary health facility in a resource-limited setting.

Materials and Methods:

The study was a retrospective study. Case notes of neonates admitted with clinical diagnosis of tetanus into the Special Care Baby Unit (SCBU) between January 2009 and December 2010 were retrieved and evaluated to identify socio-demographic and clinical characteristics, mode of acquisition and severity of the disease, presence of co-morbidities, duration of hospital stay and outcome.

Results:

Most of the mothers had no tetanus immunization (66.7%) and the main social class of the children was class V (45.1%) and IV (41.2%), respectively. Only 29.4% of the mothers attended ante-natal care (ANC) while majority of the patients were delivered at home (94.1%). Half of the neonates presented with the severe form of the disease (51.0%). Sepsis is a prominent co-morbidity (59.2%). Morality was high with case fatality of 66.7%.

Conclusion:

This high prevalence of neonatal tetanus with high mortality is not only disappointing but unacceptable in the 21^st century. Therefore, all efforts must be re-focused on current preventive strategies while pursuing new areas such as slow-release mono-dose tetanus vaccine and school health programme as well as advocacy on political will for the sustainability of immunization programmes of women of child-bearing age.     

Impact of maternal body mass index on neonatal outcome

Introduction

Maternal body mass index has an impact on maternal and fetal pregnancy outcome. An increased maternal BMI is known to be associated with admission of the newborn to a neonatal care unit. The reasons and impact of this admission on fetal outcome, however, are unknown so far.

Objective

The aim of our study was to investigate the impact of maternal BMI on maternal and fetal pregnancy outcome with special focus on the children admitted to a neonatal care unit.

Methods

A cohort of 2049 non-diabetic mothers giving birth in the Charite university hospital was prospectively studied. The impact of maternal BMI on maternal and fetal outcome parameters was tested using multivariate regression analysis. Outcome of children admitted to a neonatal ward (n = 505) was analysed.

Results

Increased maternal BMI was associated with an increased risk for hypertensive complications, peripheral edema, caesarean section, fetal macrosomia and admission of the newborn to a neonatal care unit, whereas decreased BMI was associated with preterm birth and lower birthweight. In the neonatal ward children from obese mothers are characterized by hypoglycaemia. They need less oxygen, and exhibit a shorter stay on the neonatal ward compared to children from normal weight mothers, whereas children from underweight mothers are characterized by lower umbilical blood pH and increased incidence of death corresponding to increased prevalence of preterm birth.

Conclusion

Pregnancy outcome is worst in babies from mothers with low body mass index as compared to healthy weight mothers with respect to increased incidence of preterm birth, lower birth weight and increased neonate mortality on the neonatal ward. We demonstrate that the increased risk for neonatal admission in children from obese mothers does not necessarily indicate severe fetal impairment.     

超声引导下羊膜腔穿刺对孕妇心理影响的调查

目的了解超声引导下羊膜腔穿刺术对孕妇的心理影响及相关需求,以便采取针对性的措施。方法选择产科门诊拟行羊膜腔穿刺术、孕周为18～25周的汉族孕妇282例为研究对象（羊膜腔穿刺指征为：血清筛查唐氏综合征高风险110例,单项βhCGMOM值≥2.5有16例,单项AFPMOM值≤0.4有2例,高龄孕妇146例,曾分娩染色体异常、畸形患儿5例,颈部透明带厚1例,夫妇一方染色体异常携带2例）。选择相应孕周的非羊膜腔穿刺术汉族孕妇280例做对照。进行焦虑自评量表（SAS,Zung）测定。结果①穿剌组孕妇的焦虑评分（44.81±8.06）高于对照组孕妇（34.84±5.21）,差异有统计学意义（P=0.000）。②穿刺组中高龄孕妇的焦虑评分（36.35±5.01）低于筛查唐氏综合征高风险孕妇的焦虑评分（41.20±7.55）,差异有统计学意义（P=0.025）;文化程度高的孕妇,其焦虑评分（32.36±2.70）低于文化程度低的孕妇（43.58±7.41）,差异有统计学意义（P=0.000）。患者对羊膜腔穿刺术的知识了解不多,希望全面了解有关方面的知识,心理焦虑较严重。结论羊膜腔穿刺术对孕妇可以造成一定程度的焦虑,加重孕妇的心理负担,对拟行羊膜腔穿刺术的孕妇应给于干预措施以缓解、减少患者的焦虑,使羊膜腔穿刺术顺利实施。     

臀位妊娠分娩方式的选择

①目的　分析臀位妊娠影响母儿结局的因素及初产妇是否可以选择阴道分娩。②方法　对我院单胎臀住妊娠369例孕产妇的资料进行整理分析,比较初产妇及经产妇的分娩方式。单因素及多因素分析影响单胎臀位妊娠的母儿结局的因素。③结果　初产妇组143／256(55.9％),经产妇组78／113(69％)选择阴道分娩,两组产妇分娩方式的选择上有显著性差异,但这两组产妇的围生儿结局相似,母亲结局相似(P>0.05)。多因素分析提示,足月妊娠及剖宫产对臀位妊娠的新生儿有利;婴儿结局与产次无关。但多产和剖宫产对母亲来说则是不利因素。④结论　初产妇选择阴道分娩的条件和经产妇相似。臀位妊娠分娩方式的选择应全面考虑围生儿及母亲因素,结合产妇及家属的意愿来决定。     

产程标准变化对分娩影响的临床病例分析

[摘要]　目的　探讨新旧产程标准对分娩的影响。 　方法　回顾性分析大连市中心医院2014年6月至2015年2月间以旧产程标准判定为异常的单胎、头位、足月、自然临产、未行硬膜外麻醉的初产妇100例。将其分为新产程组：应用新产程标准进行管理,50例;旧产程组：应用旧产程标准进行管理,50例。对比两组分娩方式、产程时间、产科干预及母婴并发症发生率等。 　结果　　两组采用会阴侧切术、手取胎盘术、手转胎头术、胎头吸引术情况及产后出血、新生儿窒息、会阴裂伤程度比较,差异均无显著性意义（P>0.05）。应用新产程管理后减少了催产素的使用（P<0.05）。新产程组第二产程的第95百分位数160.7 min,＞2 h,并未增加产妇及新生儿并发症的风险。新产程组较旧产程组剖宫产减少5例（10%）,旧产程组以潜伏期延长为指征行剖宫产的有3例（6%）,以胎头下降停滞为指征的有2例（4%）。未出现明显的活跃期晚期宫颈扩张减速现象。 　结论　新产程标准对于活跃期起点及第二产程时限的修改,未增加产科干预、产妇及新生儿并发症的风险。新产程应用降低了因产程异常为剖宫产指征的剖宫产率。     

Acute pancreatitis in pregnancy: a 6-year single center clinical experience

Background  The acute abdomen remains a challenge for all obstetricians and physicians who take part in the care of women in pregnancy. To add substantially to our understanding of acute pancreatitis (AP) in pregnancy, in particular affirming the increased risks for mother and fetus associated with AP, we explored features of clinical manifestation and the strategy of management of this disease during pregnancy, and its effects on maternal and fetal outcomes.

Methods  A retrospective review of medical records of all pregnant patients diagnosed with AP admitted to the Department of Obstetrics and Gynecology, Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University between 2005 and 2010 was performed. Information was collected from presentation, management, and outcome from medical records.

Results  There were 11 cases in 2010, accounting for 44% of 25 cases. Among these cases, mild AP (MAP) occurred in 15 cases (60%), while the rest cases were severe AP (SAP) (40%). The major etiology of AP in pregnancy was due to gallstone and cholecystitis. Clinical features together with elevation of the plasma concentrations of pancreatic enzymes were the cornerstones of diagnosis. Positive conservative treatment was taken in most of the cases (21 cases, 84%) with a favorable outcome. Seven cases of critically ill patients were monitored in intensive care unit, and 4 patients underwent surgical interventions. As a result, all of 25 patients had better prognosis, no maternal death was observed. There were 8 preterm labors and 2 fetal losses, accounting for the perinatal mortality of 8%. Fetal malformation was not observed.

Conclusions  While a pregnant woman suffers acute abdominal pain, early diagnosis and severity assessment of AP are very important. Conservative comprehensive treatment with intensive care is recommended. Surgical intervention should be performed as late as possible.

     

高龄产妇妊娠风险的回顾性分析

目的 为加强高龄产妇孕期保健、改善妊娠结局提供科学的依据。方法 收集≥35岁的高龄组病例2 994例,和同期住院分娩的适龄组16 172例,对比分析两组产妇的病历资料。结果 高龄组妊娠期糖尿病、前置胎盘、胎盘早剥等妊娠合并症或并发症明显高于适龄组(P＜0.05);高龄组胎儿生长受限、胎儿畸形等围生儿不良结局发生率均高于适龄组(P＜0.01);高龄组干预性早产比适龄组干预性早产发生率高(P<0.01)。结论 高龄妊娠母婴不良妊娠结局多,应加强高龄产妇围产期保健以降低合并症和远期并发症的发生率,保障母婴安全健康,应提倡适龄妊娠。     

Pattern of the cases seen in the accident and emergency department in a Nigerian Tertiary Hospital over a period of twelve months

INTRODUCTION: There is a dearth of information on emergency medical services in Nigeria. This study was conducted to determine the age, sex distribution and the pattern of patient presentation in the Accident and Emergency Department of a Nigeria teaching hospital. METHODS: A retrospective study of all cases seen at the accident and emergency department of the University College Hospital in 2003 was carried out. The information extracted from the records includes age, sex, and diagnosis, department to which the patient was referred, the month of presentation and the outcome within the first twenty four hours of presentation. RESULTS: A total of 4674 patients attended the casualty, with a male: female ratio of 1.2:1. The third decade was the peak age distribution. There was a predominance of surgical cases (61%). In the treatment outcome, 52.1% were referred to other departments while there were ten (0.2%) mortalities. Trauma related cases constituted 45.1%. Road traffic accidents were the commonest cause of trauma. CONCLUSION: The largest proportion of patient were in the active third decade of life. Trauma is the commonest cause of presentation in the Accident and Emergency Department. A significant proportion of patients do not require admission. The doctor in the Accident and Emergency Department must be skilled in basic trauma care.     

前置胎盘合并瘢痕子宫孕妇的严重不良围产结局分析

目的 分析前置胎盘合并瘢痕子宫孕妇的不良围产结局,并研究其相关危险因素。方法 采用回顾性病例对照研究,纳入2005年1月至2015年6月在四川大学华西第二医院再次剖宫分娩的前置胎盘合并瘢痕子宫孕妇,分析严重不良结局的发生情况。严重不良结局定义为（以下任何一项）:输红细胞≥10单位,术后转入ICU,膀胱、肠管或输尿管损伤需要外科修补,二次手术,子宫切除,或孕产妇死亡。并采用单因素及多因素logistic回归分析严重不良结局的危险因素。结果 近10+年共有478例前置胎盘合并瘢痕子宫孕妇在四川大学华西第二医院行再次剖宫产终止妊娠。本组孕妇平均年龄（32.5±4.8）岁,多数孕妇年龄大于30岁;平均孕4次产1次;其中131例（27.4%）孕妇发生严重不良结局。输红细胞≥10单位者有75例 (15.7%,75/478);术后转入ICU 44例(9.2%,44/478);发生膀胱损伤而需修补者共有11例,无输尿管或肠管损伤发生;有4例二次手术,其均是由于保守治疗后内出血而行急诊剖宫产子宫切除。子宫切除（107例,22.4%）是最常见的严重不良结局;最后经过剖宫产术和/或术后病理检查证实的311例胎盘异常附着者,只有172例（55.3%）术前超声或者磁共振检查怀疑有胎盘异常附着。多因素分析显示,凶险性前置胎盘（即胎盘附着于前次剖宫产切口瘢痕上）、产前怀疑胎盘异常附着（粘连、植入或穿透）和产前血红蛋白水平＜100 g/L是严重不良结局的独立危险因素,其比值比和95%可信区间（95%CI）分别为2.4（1.5~3.8）、3.6（2.3~5.6）和2.5（1.6~3.9）。结论 在前置胎盘合并瘢痕子宫的孕妇中,凶险性前置胎盘、产前怀疑胎盘异常附着和产前血红蛋白水平＜100 g/L会显著增加严重不良结局的风险。     

Risk of adverse maternal outcome following macrosomic birth in Nigeria

Objective: To determine the risk of adverse maternal outcome associated with obstetric intervention in labour.Methods:All cases of macrosomic births conducted at the University of Calabar Teaching Hospital,Calabar,between January 1st 1994 and December 31st 2000 were reviewed.Measure of treatment/intervention effect was calculated as relative risk for adverse maternal outcome,using spontaneous vaginal births as control.Results:Frequency of mode of delivery was as follow: vaginal births,139(60.7%);instrumental vaginal deliveries,16(7%);and abdominal deliveries,74(32.3%).Obstetric intervention occurred in 90(39.3%) cases.Sixty-four(28%) cases did not book for antenatal care,with 42 cases(18.3%) requiring obstetric intervention.About one in every two parturients(1: 2.1) in this study,requiring obstetric intervention at delivery had been interfered with at unorthodox health facilities.Relative risks for postpartum haemorrhage,wound sepsis and paralytic ileus were significantly high in parturients with abdominal delivery;while in parturients with instrumental vaginal delivery relative risks were significantly high for puerperal sepsis,paralytic ileus and obstetric palsy.There were no maternal deaths.Conclusion:Obstetric intervention in parturients with macrosomic births was high due to labour complications;and was associated with significant risk for adverse maternal outcome,especially in parturients with unskilled interference.     

心理干预对减轻孕中期引产妇产后抑郁的研究

目的：探讨心理干预对减轻孕中期引产妇产后抑郁的作用。方法：将2007年1月。2009年10月住院的孕中期引产的孕产妇100例随机分为对照组和干预组。对照组50例。只进行产前、产后常规护理,并解答孕产妇提出的问题。干预组50例,在对照组的基础上实施全面的心理干预,包括对孕妇资料的全面评估。实施支持性干预和对经济困难孕妇的支持性治疗和音乐放松疗法。在人院时和实施干预7d时分别采用汉密尔顿抑郁量表评分。结果：干预组的评分显著低于对照组,两组比较差异有统计学意义（10．73±2．32vs16．52±0．88,P〈0．05）。结论：为孕中期引产妇提供及时有效的心理干预能够改善其不良心理状态,促进孕中期引产妇产后恢复,有效减轻产后抑郁的发生。     

信阳市236例死亡孕产妇文化程度与保健服务利用的相关性分析

目的探讨死亡孕产妇文化程度与其保健服务利用的相关性,以便采取有针对性的干预措施,有效降低孕产妇死亡率。方法对信阳市1999~2003年236例死亡孕产妇的监测报告卡内容进行资料整理和统计学分析。结果随着孕产妇文化程度的提高,孕产妇死亡率呈下降趋势(P<0.01),文化程度与孕产妇不可避免死亡因素、产前检查次数和分娩地点呈正相关。结论死亡孕产妇文化程度与其围产期保健服务利用存在较好的相关性,孕产妇文化程度是影响孕产妇死亡率的关键因素。     

社区卫生孕产妇保健的现状与影响因素分析

目的了解深圳市宝安区西乡街道孕产妇保健的现状,分析影响孕产妇保健的相关因素。方法对深圳市西乡医院33个社康中心2009年9月1日-2010年8月31日的《孕产妇系统管理表》进行回顾性调查和分析。结果6608例孕产妇,其中户籍常住人口189人,暂住人口1557人,流动人口4862人;孕产妇的初婚年龄平均为(25.8±3.2)岁;大部分孕产妇知晓避孕方法为宫内节育器,占51.85%;孕产妇在社康接受保健的资料显示,绝大多数人接受过产后访视,接受过儿童保健知识的健康教育;在医院接受孕期保健的人数和项目明显大于社康,影响社区卫生服务中孕期保健的主要障碍是服务资源不足,居民对社区妇幼医生的信任程度不够,社区孕产妇保健的宣传力度不够。结论有必要改革公共卫生经费和资源的投入,加强社区妇幼医师的职能,加强社区卫生服务中对孕产妇保健的指导和宣传工作,提高孕产妇孕期在社康管理的覆盖率。