Continental J. Medical Research Volume 4 (2010)



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Medical Research 4: 1 - 2, 2010                                                            ISSN: 2141 - 4211

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

Letter to Editor



THE POOR GAINS OF THE NATIONAL HEALTH INSURANCE SCHEME DUE TO PATIENTS ATTITUDES AND OTHER INTERESTS

Anyanwu, E. B.

Department of Family Medicine, Delta State University Teaching Hospital Oghara, Nigeria



Dear Editor



Health Insurance is a mechanism for spreading the risks of incurring health care costs over a group of individuals and households. The health insurance schemes are policy concepts whereby officials formally hold funds consisting of contributions by insured participants and the resultant pool is designed to finance all or part of members’ health costs (Obembe, 2007).



The health insurance scheme is a pre-payment scheme which ensures that participants are treated at the point of service delivery, thereby removing the user fees or ‘out of pocket scheme’. Out of pocket payment is one of the least desirable mechanism of financing health care, as it often denies health care to those who cannot pay at the time of their illness (Obembe, 2007).



Thus, the removal of “out of pocket payment” at the point of service delivery is the goal of health insurance scheme.



The scheme assures or presumes that all participants are gainfully employed and that their financial contributions are deducted from source of salary income, while their employers also pay their contributions to the Health Management Organization (HMO) that they subscribe to.

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<p style="text-align: justify;">This assures that the participants should enjoy good health care at all times, with functional health facilities retained as health care providers. But in reality what we see is often a far cry from what is expected. Several deviations are noted from the participants of the scheme.

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<p style="text-align: justify;">First, many of the participants intermittently walk into their health care provider facilities asking to be given money while they do not have any ailments. If the care provider collaborates with the participants, he is therefore expected to give out an obviously falsified claim documents to the HMO. Reportedly, most care providers adamantly refuse to be involved in this practice.

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<p style="text-align: justify;">Second, many of the participants report “ill” to their health care providers only to ask for days on “sick off”. This is mostly to enable them go on their private activities while being properly and legally covered by the sick off certificate given to them by their care providers.

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<p style="text-align: justify;">Third, several of the scheme participants often bring in their friends and other family members who are not entitled to be treated, to be treated on their enrolment card, thereby increasing the financial burden of the HMO. This will lead to false statistical report of illness by the HMO.

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<p style="text-align: justify;">Fourth, even the truly ill participants, on being seen at the care providing facilities, often dictate and insist on a particular line of management. They often will not want to be admitted even when the condition demands so. And even if they agree to be admitted, usually will want to be discharged on short notices.

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<p style="text-align: justify;">Again, some of the participants often walk in with a list of drugs that they want written out for them.

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<p style="text-align: justify;">Most of them will not honour medical appointment for check-up, only returning when their medical condition relapses or some new ill-health develops.

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<p style="text-align: justify;">A lot of re-educating of the participants is still necessary so as to change their attitude to the scheme. It should not be seen as their share of the national cake. We have to show some more honesty and dedication to make this new innovation work.

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<p style="text-align: center;">Anyanwu, E. B: Continental J. Medical Research 4: 1 - 2, 2010

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<p style="text-align: justify;">REFERENCE

<p style="text-align: justify;">Dr. Kayode Obembe. Based on Lecture delivered on 8th Alumni Day Lecture, Ibadan, College of Medicine Alumni Association. Community Health Insurance: The Panacea for Achieving the Millennium Development Goals in Nigerian. 19th November, 2007.

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Received for Publication: 15/01/10

Accepted for Publication: 10/02/10

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<p style="text-align: justify;">Email: ebirian@yahoo.com

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<p style="text-align: justify;">Continental J. Medical Research 4: 3 - 7, 2010                                                            ISSN: 2141 - 4211

<p style="text-align: justify;">© Wilolud Journals, 2010                                                                                 http://www.wiloludjournal.com

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<p style="text-align: center;">NEONATAL TETANUS IN WARRI NIGER DELTA: A TEN YEAR RETROSPECTIVE STUDY

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<p style="text-align: center;">1G I Mcgil Ugwu and 2N E Okolugbo

<p style="text-align: center;">1Department of Paediatrics, 2Department of Otorrihnolaryngology, Delta State University Abraka

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<p style="margin: 0cm 43.2pt 0.0001pt; text-align: justify;">ABSTRACT

<p style="margin: 0cm 43.2pt 0.0001pt; text-align: justify;">Neonatal tetanus remains a very major cause of morbidly and mortality in the newborns in Nigeria. Despite the UNICEF and WHO goal of eliminating neonatal tetanus by the year 2005, Nigeria is one of the ninety four countries where this has remained impossible. Infact this retrospective study in Warri Niger Delta shows an increase in the incidence since 2005. The possible reasons have been advanced in the body of the study. The morbidity and mortalities have also been documented. The review covers a period from 1999 to 2008

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<p style="text-align: justify;">INTRODUCTION

<p style="text-align: justify;">Neonatal tetanus is one of the major causes of neonatal and under-five mortality in the developing countries. (Vandelaer et al., 2003) It accounts for about 20% and 25% of all neonatal mortality worldwide and Nigeria respectively.(Lawn J et 2005, Okolo et al 1985, Njokanma et al., 1995). This is so because of inadequate routine immunization coverage and the practice of using unclean procedures to cut the umbilical cord after birth. (UNFPA/UNICEF/WHO, 2005). The 1989 World Health Assembly set a goal to eliminate neonatal tetanus globally by 2000 (definition of elimination: <1 case per 1000 live birth in each health district in the country) (UNFPA/UNICEF/WHO 2005, WHO, 2004). By December 1999, 104 out of the 161 developing countries have achieved elimination but due to problems in the remaining countries including Nigeria, UNICEF, the WHO and the United Nation Population Fund (UNFPA) agreed a new five-year strategic plan, setting the year 2005 as target date for worldwide elimination.(UNFPA/UNICEF/WHO 2005). Though there may be decline in the incidence of neonatal tetanus in some countries especially with better surveillance, (UNFPA/UNICEF/WHO 2005) our experience in Warri Niger Delta of Nigeria has shown otherwise. We present a ten year review of neonatal tetanus in Warri Niger Delta of Nigeria from 1999 to 2008.

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<p style="text-align: justify;">MATERIALS AND METHODS

<p style="text-align: justify;">The study was done in Central Hospital Warri a government hospital and GN children’s and Gen Med Clinic a private hospital in Warri. All the case notes of patients with neonatal tetanus from January 1999 to December 20008 were reviewed and analyzed. Information obtained from the case notes include age, sex of the newborn, presenting symptoms, perinatal records ( mode and place of delivery and procedures during delivery etc) onset of symptoms and onset interval, duration of illness before presentation, portal of entry of the tetanus, immunization status of the mother ( has she completed T1-5 or Tetanus toxoid in the pregnancy of the patient etc), social background ( occupation of parents, place of domicile) birth order of the child, any treatment given before presentation. The management of the child in the hospital and end point of the illness: whether the child survived without/with complications or died was also noted. Follow up treatment for each patient was also documented. The number of patients per year was also noted

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<p style="text-align: justify;">RESULTS

<p style="text-align: justify;">  A total of sixty nine neonates were seen over this period in both hospitals. Forty of them were males and twenty nine females, giving a male: female ratio of approximately 1.8:1 Table 1 shows the number of neonates per year.

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<p style="margin-left: 36pt; text-indent: 36pt;">G I Mcgil Ugwu and N E Okolugbo: Continental J. Medical Research 4: 3 - 7, 2010

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<p style="margin-left: 72pt; text-align: justify; text-indent: 36pt;">TABLE 1 SHOWING DISTRIBUTION PER YEAR

<p style="text-align: justify;"> <p style="text-align: justify;">There was a steady decline in the incidence from 2000 to 2004, but this started rising from 2005.

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<p style="text-align: justify;"> Table 2 shows the portal of entry of the clostridia organisms.

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<p style="margin-left: 72pt; text-indent: 36pt;">TABLE 2: SHOWING THE PORTALOF ENTRY

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<p style="text-align: justify;">Over 70% of cases were through the umbilical cord. The second most common portal entry is from scarification marks on the child’s body for whatever reason. In about 10% of the cases the portal of entry was not know. Forty of the neonates were males and twenty nine females, giving a male: female ratio of 1.8:1.This is shown in table 3

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<p style="margin-left: 72pt; text-align: justify; text-indent: 36pt;">TABLE 3: SHOWING THE MALE TO FEMALE RATIO

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<p style="text-align: justify;">Of the sixty nine patients, fifty one of them had their prenatal care and delivered at home giving a per centage of 73.9%. This is shown in Table 4

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<p style="text-align: justify; text-indent: 36pt;">TABLE 4: SHOWING PLACE OF PRENATAL CARE/ DELIVERY

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<p style="margin-left: 36pt; text-indent: 36pt;">G I Mcgil Ugwu and N E Okolugbo: Continental J. Medical Research 4: 3 - 7, 2010

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<p style="text-align: justify;">   The treatments given generally include antitetanus serum (ATS) 10, 000IU. 5000IU was given intramuscularly and 5000IU by intravenous infusion. Diazepam was given either intravenously or rectally every six hours, while phenobarb or chlorpromazine was also given six hourly. These sedatives were staggered in such a way that the child received a sedative every three hours. Paraldehyde was given for breakthrough seizures. Ceftazidine and gentamicin were given especially when sepsis is a strong differential diagnosis. Adequate hydration was ensured and hypoglycemia was also prevented. Spasms were monitored with spasm charts. Those that survived were all immunized before discharge.

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<p style="text-align: justify;">Of the sixty nine patients, twenty eight died, giving a mortality rate of 40.6%. Twenty of the deceased neonates were males and eight females, giving a mortality rate of 71.4% males and 28.6% females. The case fatality rate for males is 50% and 27.6% for females. These are shown in table 5.

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<p style="text-align: justify;">     TABLE 5 SHOWING THE MORTALITY RATE AND CASE FATALITY RATE ACCORDING TO SEX

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<p style="text-align: justify;">Table 6 shows the various complications and their per centage of the total. Eight out of the surviving forty one had complications, giving a per centage of 20%. Of this, five (62.5%) had cerebral palsy, while 2 (25%) had deafness and one (12.5%) had mental retardation.

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<p style="margin-left: 36pt; text-align: justify; text-indent: 36pt;">TABLE 6 SHOWING THE COPLICATIOS OF THE SURVIVING NEONATES

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<p style="text-align: justify;">These are being followed up by the various specialists including the otorhinolaryngologist. The causes of death as shown in Table 7 are apnea 60%, uncontrollable spasms 15%, hyperpyrexia 10% and hypoglycemia 5%. In about 10%, the cause of death was not identifiable.

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<p style="margin-left: 36pt; text-align: justify; text-indent: 36pt;">TABLE 7: SHOWNING THE CAUSES OF DEATH

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<p style="margin-left: 36pt; text-indent: 36pt;">G I Mcgil Ugwu and N E Okolugbo: Continental J. Medical Research 4: 3 - 7, 2010

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<p style="text-align: justify;">DISCUSSION

<p style="text-align: justify;">Our findings have shown that neonatal tetanus is on the increase. This is in keeping with the observation that tetanus is generally in the increase in Warri and not just neonatal tetanus. (Mcgil Ugwu et al 2009). Infact Orumabo et al asked the question ‘Does Neonatal Tetanus still pose a threat to neonatal survival?’ (Orumabo, 2007). The mortality rate of 40% is in keeping with the findings in other parts of Nigeria.(Akani et al 2004, Eregie et al 1994, Oyedeji et al 1982) and Turkey (Quddus et al 2002), but lower than that in the Unites States of America (Bardenheier et al 1998). Nigeria is one of the twenty seven countries which account for over ninety per cent of the global burden of neonatal tetanus (Akani 2004). While a remarkable decrease in the incidence of neonatal tetanus has been noted in some areas, (Bunyamni et al 2008) we observed an increase as from 2005 after an initial decline. The increase in the incidence is probably due to the political acts of announcing free maternal health services without adequate back up with resources. The supply of Tetanus toxoid in Warri health facilities has not been steady. Moreover, the power supply to the area has been so epileptic, coupled with shortage of petroleum products to even fuel generators, making storage of these vaccines and sustenance of the cold chain difficult. This makes the available vaccines less potent. Other reasons for persistence of neonatal tetanus have been advanced, include declining maternal coverage with tetanus toxoid and delivery by unskilled personnel.(Akani et al 2004) Most of our patients were delivered at home or churches where proper antenatal and postnatal care is lacking. This is similar to the experience in Ile-Ife where out of the 74.6% of women who claimed to have received tetanus toxoid in pregnancy, it was confirmed in only 4.1% and only in 2.8% could the babies be said to have been protected from neonatal tetanus, again, most of the deliveries of the patients with neonatal tetanus were at home and in churches.(Owa et al 1992) The mortality rate was highest when the onset interval is less than forty eight hours. This was compounded with the fact that some of the patients had scarification marks as treatment for the convulsions, thereby worsening the case. Our experience shows that more males were affected with even a higher cease fatality ratio which is keeping with the view worldwide. (Orumabo 1996, Aseku.Olminoye 2003, Eriten M 2004 Grange et al 1991) Upto 60% of our deceased patients were from the riverine areas of Warri without adequate transport facilities. Of the surviving ones, 20% of them had complications James 1987) which are similar to the observations in Nigeria and worldwide This has been attributed to apnoea due to prolonged spasm which leads to brain damage.( James  1987)

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<p style="text-align: justify;">CONCLUSION

<p style="text-align: justify;">Neonatal tetanus remains a scourge in developing countries. It will continue to increase if the power problem in Nigeria is not solved. Moreover there is no point in announcing free health services without a compensatory increase in the health budget of the states in Nigeria. The T1-5 tetanus toxoid immunization should be started during the school age and made part of a comprehensive school health services program. This will greatly improve tetanus toxoid immunization coverage in women. Traditional birth attendants and the church ‘midwives’ should be taught to immunize pregnant women since most of the cases come from them.

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<p style="text-align: justify;">ACKNOWLEDGEMENT.

<p style="text-align: justify;">We wish to thank Lady Ugwu sincerely for her immense contributions.

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<p style="text-align: justify;">REFERENCES

<p style="text-align: justify;">Akani AI, Nte RS, Orumabo RS. (2004): Neonatal Tetanus in Nigeria; One Scourge Too many! Nigerian Journal of Paediatrics. 31(1): 1-9

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<p style="text-align: justify;">Asekun-Olarinmoye EO, Lawoyin TO, Onadeko MO. (2003): Risk factors for neonatal tetanus in Ibadan Nigeria. Euro Journal Paediatr. 162: 526-527

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<p style="text-align: justify;">Bardenheier B, Prevos DR, Kgetsuriani N, Wharton M. (1998): ''Tetanus Surveillance- United States 1995-1997. Morbidity and Mortality Weekly Report''. CDC Surveillance Summary. Report number 47: 1-13

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<p style="text-align: justify;">Bunyaamin Dikici, Hakam Uzum, Ebru Tilnaz-Keskin, Taskin Tas, Ali Gunes, Halil Kolamaz, Capan Konea, Mehment A Tas (2008): Neonatal Tetanus in Turkey; What has happened in the last decade. BMC Infectious Disease. 8: 112

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<p style="text-align: justify;">Eregie CO, Ofovwe G. Cluster (1993): Survey on neonatal Tetanus Mortality in Nigeria; Observations and some clinical aspects. Journal of Tropical Paediatrics. 39(6): 372-373

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<p style="text-align: justify;">Erten M, Cakmak A, Saka G, Ceylan A (2004): Neonatal tetanus in the South Eastern region of Turkey. Changes in prognostic aspect by better health care. Journal of Trop Pediatr .50: 297-300

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<p style="text-align: justify;">Grange AO (1991): Neonatal Tetanus in Lagos Metropolis. Nigerian Journal of Paediatr; 18: 12-21

<p style="margin-left: 36pt; text-indent: 36pt;">G I Mcgil Ugwu and N E Okolugbo: Continental J. Medical Research 4: 3 - 7, 2010

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<p style="text-align: justify;">James B Besunder, William T Speck (1987): Tetanus neonatorum In: Nelson’s Textbook of Pediatrics 13th edition; Richard E Behrnam, Victor C Vaughen 111 and Waldo E Nelson Eds, Saunders Publishers; p620.

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<p style="text-align: justify;">Lawn JE, Couseus S Zupan J (2005): 4 million neonatal deaths; When? Where? Why? Lancet. 36: 5891-5900

<p style="text-align: justify;">

<p style="text-align: justify;">Maternal and Neonatal Tetanus Elimination in 2005. Strategies for Achieving and Maintaining Elimination. UNFPA/UNICEF/WHO (unpublished document WHO/V&B/02.09) available at http://www.who.int/vaccines-document/Docs.PDF02/www.692

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<p style="text-align: justify;">Mcgil Ugwu GI, OKolugbo NE (Nov 2009): Childhood Tetanus in Warri Niger Delta; A Ten Year Retrospective Study. The Nig Journal of General Practice; 8(4): 45-49

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<p style="text-align: justify;">Njokanma OF, Olanrewaju DM (1995): A study of neonatal deaths in Ogun State University Teaching Hospital Sagamu/ Journal of Trop Med Hyg. 98: 155-160

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<p style="text-align: justify;">Okolo AA, Omene JA (1985): Trends in neonatal mortality in Benin City Nigeria. International Journal Gynaecol Obstet. 23:191-195

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<p style="text-align: justify;">Orumabo RS (2007): Neonatal Tetanus in Nigeria. Does it still pose a major threat to neonatal survival? Archives of Disease in Childhood Ian. 92(1): 9-10

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<p style="text-align: justify;">Orumabo RS, Igbagiri FP (1996): Neonatal Tetanus in Port Harcourt. African Journal of Medical Science. 25265-25268

<p style="text-align: justify;">

<p style="text-align: justify;">Owa TA, Makinde OO (1992): Maternal Tetanus Toxoid Coverage. Inter Journal Gynaecol Obstet. 39(2): 123-130

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<p style="text-align: justify;">Oyedeji GA, OLaminjulo SK and Joiner KT (1982): Neonatal Tetanus in Ilesa; A review of present status. Nig Med Journal. 12:131-135

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<p style="text-align: justify;">Quddus A, Luhy S, Rahbar M, Pervaiz Y (2002): Neonatal tetanus in Lorala District Pakistan. Inter Journal Epidermiol. 31: 648-653

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<p style="text-align: justify;">Vandelaer J, Birmingham M, Gasse F, Kurian M, Shaw C, Garnier S (2003): Tetanus in developing countries, an update in the maternal and neonatal tetanus elimination initiative. Vaccine, 21: 3442-3445

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<p style="text-align: justify;">WHO, (2004): Neonatal Tetanus Reported Cases, Vaccines, Immunization and Biologicals. Geneva. http://www-ntwho.int/vaccines/global summary//time series/tsincidenceneo.htm

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<p style="text-align: justify;">Received for Publication: 15/01/10

<p style="text-align: justify;">Accepted for Publication: 10/02/10

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<p style="text-align: justify;">Corresponding author:

<p style="text-align: justify;">G I McGIL UGWU

<p style="text-align: justify;">P O BOX 3217 WARRI

<p style="text-align: justify;">E- mail: gnclinic@yahoo.com

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<p style="text-align: justify;">Continental J. Medical Research 4: 8 -12, 2010                                                          ISSN: 2141 - 4211

<p style="text-align: justify;">© Wilolud Journals, 2010                                                                                 http://www.wiloludjournal.com

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<p style="text-align: center;">BILATERAL WEBBED FINGERS IN A SET OF FRATERNAL TWINS - CASE REPORT

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<p style="text-align: center;">Anyanwu, E. B and Akhator

<p style="text-align: center;">Department of Family Medicine, Delta State University Teaching Hospital Oghara, Nigeria

<p style="margin: 0cm 43.2pt 0.0001pt;">Abstract

<p style="margin: 0cm 43.2pt 0.0001pt; text-align: justify;">Syndactyly or webbing or fusion of the fingers or toes is a congenital anomaly characterized by the fusion of the digits. This may be cutaneous, due to bridging of soft tissues or osseous, due to bone fusion of varying severity. Our clients, a set of male twins presented with bilateral webbing of the ring and fifth fingers in both twins. No other abnormalities were detected on physical examination, and no similar family history is known. No probable teratogenic substances were taken during pregnancy except for the maternal ingestion of native herbal concoction which was laced with native gin. Surgical separation was done with good result.

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<p style="margin: 0cm 43.2pt 0.0001pt; text-align: justify;">Keywords: Syndactyly, twin male boys, surgical separation.

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<p style="text-align: justify;">Introduction

Syndactyly is a congenital anomaly characterized by webbing or fusion of the fingers or toes. Syndactyly of the fourth and fifth fingers has been previously reported in literature by Bell J (1931), Collette A.T. (1954) and Johnston and Kirby (1955). In their series they were able to prove a dominant genetic inheritance. To the best of our knowledge, this is the first case of a set of fraternal twins presenting with syndactyly involving the fourth and fifth finger.

Presentation

<p style="text-align: justify;">The twin babies presented in a busy family practice and general clinic in Warri, the main oil city of Delta State, Nigeria. The presenting complains was that the two last fingers of both hands of the two babies were united or webbed. There was no other problem identified.

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<p style="text-align: justify;">Their mother reported that the pregnancy was uneventful and that the routine ante-natal clinic was done at another private clinic in the state. She had the routine immunization and haematinics given while pregnant and did not abuse any drugs.

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<p style="text-align: justify;">Labour and eventual delivery of the twins was uneventful. Mother reported that there were two placentas at birth.

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<p style="text-align: justify;">After birth, routine examination revealed that the ring and the small fingers of both hands of both twins were joined throughout their entire length. No other abnormalities were identified. The babies cried well at birth and were discharged home some days later.

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<p style="text-align: justify;">Later, when age about three weeks, and baby 1 weighing 2.80 kilogram, and baby II weighing 3.0kilogram, their parents brought them to the reviewing clinic for review and for any further actions.

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<p style="text-align: justify;">Physical examination revealed bilateral syndactyly occurring in the two babies (figure 1). No other congenital abnormalities were detected. Systemic examinations of the system of both babies were essentially normal. The problem and possible line of management were explained to their parents. They were made to understand that surgery was the main-line of management and they consented.

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<p style="text-align: justify;">The plan subsequently was surgical separation of the webbed finger and the procedure and expected results were explained to the parents. They agreed and the babies were booked for surgery while routine investigations were done.

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<p style="text-align: justify;">Findings at surgery revealed that the bones of the joined fingers were not joined but were covered with skin. The tip of the terminal phalanx however was united, with the nail beds united but with a groove delineating the two finger-nails.

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<p style="text-align: justify;">Surgical separation was successful, and the united terminal phalangeal bones were divided, thereby separating the fingers (figure 2). The procedure was well tolerated and adequate post-operative care was given.

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<p style="text-align: center;">Anyanwu, E. B: Continental J. Medical Research 4: 8 -12, 2010

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<p style="text-align: justify;">Both babies were followed up on a daily basis while adequate care of the wound was been followed up. They were both discharged home well.

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<p style="text-align: justify;">Discussion

<p style="text-align: justify;">Syndactyly is a congenital anomaly characterized by the fusion of the fingers or toes. It varies in degree of severity from incomplete webbing of the skin of two digits to complete union of digits and fusion of the bones and nails. The human development begins with the formation of the gametes and includes five sequential processes. These are fertilization, cleavage, implantation, gastrulation and organogenesis. Organogenesis is the process by which individual organ arises. The major landmark of organogenesis includes information of the neural plate and it’s folding into a neural fold, and also the arrangement of the derivatives of the three germ layers into specialized structures such as limbs, eyes and ear (Bernfeild, M. H. 1999).

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<p style="text-align: center;">Fig 1: PICTURES SHOWING THE WEBBED FINGERS OF THE TWINS

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<p style="text-align: center;">Anyanwu, E. B: Continental J. Medical Research 4: 8 -12, 2010

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<p style="text-align: center;">Fig 2: PICTURE OF BABIES AFTER OPERATIONS

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<p style="text-align: justify;">During organogenesis, the cell in the embryo undergoes differentiation and morphogenesis to form specific tissues and organs. This process is a very delicate time-controlled process and several factors are known to disrupt it, thereby giving rise to congenital malformation.

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<p style="text-align: justify;">A major malformation is usually defined as a structural abnormality that has surgical, medical or cosmetic importance. Having a single major malformation is much more common than having multiple malformations (Holmes, L. B., 1999).

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<p style="text-align: justify;">Minor malformations, which are more common than major malformations, are defined as having no surgical or cosmetic significance and occur in fewer than 4% (four percent) of all newborns of the same race and gender (Holmes, L. B., 1999).

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<p style="text-align: justify;">The most common malformations are attributed to multifactorial inheritance, which include interplay between mutant genes and environmental factors. Huge efforts are made to identify the underlying genetic and environmental factor.

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<p style="text-align: justify;">New insights have been gained into the pathogenesis of various structural defects. The potential prenatal effects of various drugs, chemicals, and environmental agents are being better appreciated, and the number of defects in which prenatal defection is possible has increased (Jones, K. L,, 1996).

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<p style="text-align: justify;">The teratogenic exposure during pregnancy that cause malformation include maternal conditions or diseases, maternal infection, drugs taken during pregnancy and exposure to heavy metals. The first trimester of the pregnancy is the period where exposure most likely to produce malformation (Holmes, L. B., 1999).

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<p style="text-align: justify;">Exposures in the second and third trimester are also of concern. In general, the higher the exposure, the greater the risk of damages. Some major and minor abnormalities are seen in infants exposed to drugs such as thalidomide, tetracycline, diethylstilbesterol, and phenytoin and in maternal conditions such as alcoholism.

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<p style="text-align: justify;">The mother of the babies is 37 years old, while their father who does not know his age agrees that he is older than his wife. Both of them are local farmers. They have three children before this present set of twins. The siblings of the twins are normal with no history of webbing noted.

<p style="text-align: center;">Anyanwu, E. B: Continental J. Medical Research 4: 8 -12, 2010

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<p style="text-align: justify;">They deny the use of chemicals on their farms, or at home to repel insects. The mother of the babies attended regular ante-natal clinic while pregnant but agreed to drinking native herbal concoction laced with native gin which was used to treat maternal fever while she was about seven month pregnant. She denied the use of any other medicine other than the one she was given at the clinic that she attended.

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<p style="text-align: justify;">Also, the mother of the babies reported that the twins had two placentas at birth and were therefore not identical twins. This implies that the cause of the malformation was not genetic but due to chemical exposure, likely the ingested herbal concoction.

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<p style="text-align: justify;">Syndactyly or webbed fingers is one of the most common congenital hand abnormalities, occurring in one out of every 2,000 – 3,000 live births (HHCWF; PPS)

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<p style="text-align: justify;">Webbed fingers are usually obvious at birth, diagnosis usually done early at the time of examination by the attending midwives.

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<p style="text-align: justify;">Syndactyly is seen most commonly between the ring fingers and middle fingers, but can also be seen occurring at the other fingers (HHCWF). In about 50% of cases, both hands are involved, just as in our clients (PPS). Syndactyly may occur alone, or it may be the external manifestation of a syndrome such as Apert’s syndrome (PPS).

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<p style="text-align: justify;">Syndactyly tends to have a family history, as approximately about 40% of cases may have a family history. If syndactyly occurs alone, it is then inherited as an autosomal dominant condition. The condition is seen more in Caucasians than in other races of the world. It affects boys twice as often as girls (PPS).

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<p style="text-align: justify;">There are many different forms of syndactyly:

<p style="margin-left: 36pt; text-align: justify; text-indent: -36pt;">1. When the affected fingers are completely joined together, it is known as “complete syndactyly”.

<p style="margin-left: 36pt; text-align: justify; text-indent: -36pt;">2. When the joining involves only parts of the sides of the fingers, it is called “incomplete” syndactyly.

<p style="margin-left: 36pt; text-align: justify; text-indent: -36pt;">3. If the joining between the fingers involves just the skin and flesh, it is described as “simple”.

<p style="margin-left: 36pt; text-align: justify; text-indent: -36pt;">4. If the bones are joined together, it is called “complex syndactyly” (PPS, ETHS).

<p style="text-align: justify;">Additionally, when adjacent fingers are completely joined and have bones fused together, it is described as “complete complex” syndactyly (ETHS).

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<p style="text-align: justify;">The main issue in syndactyly is the function of the hand and digits. Syndactyly causes limitations of functions, because the involved digits cannot move completely independently. The main decision is to decide on whether or not to do anything for the problem. Every patient is treated individually, but generally, syndactyly is treated surgically with an operation that separates the digits. The surgery is advised if the webbing causes problem with appearance or functions. Surgery for syndactyly is best done in first few years of life so that the looks and feel and function of the corrected hand is most natural for the child (PPS, ETHS).

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<p style="text-align: justify;">The surgery usually involves general aneasthesia, with all its concomitant risks such as breathing problems, reactions to medications, bleeding from the operation sites and even infections of the cut surfaces (HIL).

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<p style="text-align: justify;">Our clients were a set of male baby boys each presenting with fused ring and small (5th) fingers of both hands. No other physical abnormalities were detected. There was no family history given.

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<p style="text-align: justify;">The webbed fingers had the terminal phalanged bones fused together with the nail beds joined together. The nail bed of the ring finger of both boys was better developed than that of the small (5th) finger. Separation was successfully done and both boys were discharged home well.

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<p style="text-align: justify;">We are limited here by the fact that we could not do genetic mapping to determine whether there was any genetic abnormality involved. We also do not know whether the native herbal concoction that the pregnant mother took had any effect on the babies. But then, this activity was at the seventh month of pregnancy when organogenesis was already complete.

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<p style="text-align: justify;">We suggest therefore that the government should provide facilities for genetic matching to enable proper screening of possible genetically inherited disorders.

<p style="text-align: center;">Anyanwu, E. B: Continental J. Medical Research 4: 8 -12, 2010

REFERENCES

<p style="text-align: justify;">Bell J. Three further cases of hereditary digital anomaly. Ann Eugen 1931; 4: 233-237.

<p style="text-align: justify;">

<p style="text-align: justify;">Bernfield, M. H. Development Biology, General Principles of Growth and Development: In: Oski’s Pediatrics Principles and Practice. 3rd edition. Eds: McMillan, J. A., DeAngelis, C. D., Feigin, R. A., and Worshaw, J. B. Lippincott Williams and Wilkins Publisher, 1999, pp 130 – 136.

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<p style="text-align: justify;">Collette A.T. A case of syndactylylism of the ring and little fingers. Am J. Hum Gen 1954; 6: 241-243

<p style="text-align: justify;">

<p style="text-align: justify;">Hayes Hand Centre Webbed Fingers (Syndactyly) http://www.hayeshamecenter.com/webbed-fingers.html.

Health Information Library. Repair of webbed fingers or toes. http://pennstatehershey.org/health.info/hie/i/002969/htm

<p style="text-align: justify;">

<p style="text-align: justify;">Holmes, L.B. Congenital Malformations. In: Oski’s Pediatrics Principles and Practice. 3rd edition. Eds: McMillan, J. A., DeAngelis, C. D., Feigin, R. A., and Worshaw, J. B. Lippincott Williams and Wilkins Publisher, 1999 pp 136 – 139.

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<p style="text-align: justify;">Johnston O, Kirby VV. Syndactyly of the ring and little finger. Am J Hum Genet 1955; 7(1): 80-82

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<p style="text-align: justify;">Jones, K. L. Dysmorphology. In: Nelson Textbook of Pediatrics. 15th edition. (Eds) Behrman, R. E., Kliegman, R. M., and Arvin A. M. W. B. Saunders Company. USA, 1996; PP.473 – 476.

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<p style="text-align: justify;">Pediatric Plastic Surgeon, University of Missouri Children’s Hospital Syndactyly. Smilesforkids.Missouri.edu/common/ syndactyly.php

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<p style="text-align: justify;">The Electronic Textbook of Hand Surgery. Syndactyly (webbed fingers). http://www.eatonhand.com/hw/hw019.htm.

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<p style="margin: 0cm 0cm 0.0001pt; text-align: justify; line-height: normal;">Received for Publication: 07/03/2010

<p style="margin: 0cm 0cm 0.0001pt; text-align: justify; line-height: normal;">Accepted for Publication: 24/05/2010

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Corresponding Author:

Anyanwu, E. B

Department of Family Medicine, Delta State University Teaching Hospital Oghara, Nigeria

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<p style="text-align: justify;">Continental J. Medical Research 4: 13 -17, 2010                                                        ISSN: 2141 - 4211

<p style="text-align: justify;">© Wilolud Journals, 2010                                                                                 http://www.wiloludjournal.com

<p style="text-align: center;">PAP SMEAR: AN IMPORTANT SCREENING TECHNIQUE FOR PREVENTING AND DETECTING CERVICAL CANCER

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<p style="margin-left: 18pt; text-align: center;">Ugboma HAA and Aburoma HLS

<p style="margin-left: 36pt; text-align: center;">Department of Obstetrics and Gynecology, University of Port Harcourt, Nigeria.

<p style="margin: 0cm 17pt 0.0001pt;">ABSTRACT

<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Background:

<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Cervical cancer is the second most preventable cancer in women worldwide, and the fifth leading cause of cancer deaths. Cervical cancer is less common than it once was in developed nations due to early detection through Pap smear technique. However, in developing countries especially the Sub Saharan region, the number of deaths resulting from cervical cancer is unquantifiable as a result of inaccurate data.

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<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Method:

<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">A review of literature, utilizing the PUBMED and those obtained through nominal search and general text books was done to determine the epidemiology, overview, screening methods and obstacles, risk factor, guideline for prevention and health promotion of cervical cancer through Pap smear on women of child bearing age.

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<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Result: Most of the early cervical cancer detections were from developed countries showing that early cervical cancer rarely produces symptoms, and if present, may go unnoticed as a thin watery vaginal discharge. When discharge, irregular bleeding or pain and bleeding after sexual intercourse occur, the disease may have advanced.

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<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Conclusion: Population-based cervical cancer screening in women has shown to reduce mortality. Advanced disease could be prevented if all women have access to Pap smear and gynecological care and avail themselves to utilize the opportunity.

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<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">KEY WORDS: Pap Smear: Women Health: Cervical Cancer Prevention.

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<p style="text-align: justify;">INTRODUCTION:

<p style="text-align: justify;">Pap smear is an important method for screening cervical cancer. Global efforts to prevent the disease have focused on screening women using Pap smears, and treating precancerous lesions. Before the introduction of the Pap smear by Dr. George Papanicolaou in the 1930s, cervical cancer was the most common cause of cancer death in women (McNeely 2003; McNeely 2001). Pap smear screening, also called cytological screening, has achieved impressive results in most developed nations with 100% efficacy, with a geographical variation of the incidence in Europe and North America as compared to South America, Asia and Africa (Rogo et al, 1990). Pap smears screening in developed nations have resulted in increased detection of preinvasive lesions and decreased cancer death rates however, in developing countries especially the Sub Saharan region, the number of deaths resulting from cervical cancer is unquantifiable secondary to inaccurate data. In a major developing country like Nigeria and many other developing nations, current reports have noted an increase in the incidence and mortality rate (Rogo et al, 1990; Bickley and Szilagyi, 2003)undefined. Knowledge deficits, ignorance, poverty, societal norms and religious beliefs daunt efforts to initiate Pap smear in health care settings in the Sub Saharan region and most developing countries. Pap smear screening can identify preinvasive lesions that can prevent cervical cancer (Nanda et al, 2000). Whereas cervical cancer cells are difficult to detect or prevent; annual pelvic examination with a Pap smear is a relatively inexpensive method of early detection. Health care providers can encourage women to follow this health practice by providing non-stressful examinations that are educational and supportive and offering opportunity for patients to ask questions and clarify misinformation. If more women could be made to understand that the gynecological examination and Pap smear do not have to be uncomfortable and embarrassing, early detection rates would likely be improved, and lives would be saved. Factors that enhance early detection of cervical cancer are discussed. The health care providers’ role in access and utilization of Pap smear is crucial and may prevent the delay of detection of cervical cancer until advanced stage.

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<p style="text-align: justify;">Epidemiology:

<p style="text-align: justify;">Whereas cervical cancer is less common than it once was because of early detection of cell changes by Pap smear in the United States and other developed nations, cervical cancer in the developing world is on the increase(Nanda et 

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<p style="text-align: center;">Ugboma HAA and Aburoma HLS: Continental J. Medical Research 4: 13 -17, 2010'' ''

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<p style="text-align: justify;">al, 2000). Approximately, 80 percent of all new cases are found in developing countries, where early detection methods are often not available, and almost none of these women have had a Pap smear (Brown and Garber, 1999) undefinedThe toll of increasing malignancies needs to be considered where all of the cervical cancer deaths occur. Cervical cancer incidence theoretically can be reduced by as much as 90 percent where screening quality and coverage are high (Koutsky et al, 2002)undefined.

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<p style="text-align: justify;">The Pap smear: An overview:

<p style="text-align: justify;">The Pap smear is a cytological test used to detect abnormal cervical cancer cells. Because of the effectiveness of the Pap smear as a screening method, cervical cancer is now less common than breast cancer or ovarian cancer (Jemal et al, 2006).undefinedThe procedure involves gently rotating a small spatula at the cervical os followed by a cervical brush-like device, rotated in the os, to obtain cervical secretions. Pap smear is best done if the woman is not menstruating, or has no other frank bleeding, unless where there is high suspicion of vaginal neoplasia (cancer bleeding), because blood obscures a proper reading of cells. To avoid washing away cellular materials, the patient is instructed not to douche before having a Pap smear taken. The tissue obtained is smeared and spread on a glass slide, and fixed immediately, or immersed into a solution (see FIG. 1 A-C). The slides are sent to a cytology laboratory and evaluated by a trained cytologist or a cytotechnician who determines the cell classification. A specimen of any purulent material appearing at the cervical os is obtained for culture. In a patient who has a high risk of infection, routine cultures for gonococcal and chlamydial organisms are recommended, because of the high incidence of both diseases and the complications of pelvic infection, fallopian tube damage, and subsequent infertility(Jemal et al, 2006). Most protocols suggest that women with low-grade abnormalities return for regular follow-up smears until the abnormality either resolves or persists, warranting further investigation. High-grade pre-invasive disease generally is further evaluated by colposcopy (examination of the cervix with a magnifying scope) and biopsy; precancerous lesions are then treated through surgical removal or ablation.

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<p style="text-align: justify;">This review study was done to bring to the notice of our increasing population an important screening tool in the prevention of cervical cancer.

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<p style="text-align: justify;">                                                     A

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<p style="margin-left: 108pt; text-align: justify; text-indent: 36pt;">C

<p style="margin-left: 108pt; text-align: justify; text-indent: 36pt;">B

<p style="text-align: justify;">FIGURE 1: Methods of using a cotton swab to obtain cervical secretions for cytology. (A) Speculum in place and the swab in position at the cervical os. (B) The tip of the swab is placed in the cervical os and the swab rotated 360 degrees, firmly but nontraumatically. (C) Cellular material cling to the swab is then smeared smoothly on a glass slide. Smear is then sprayed with fixative and then sent to laboratory for cytological study.

<p style="text-align: justify;">Source American Cancer Society.

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<p style="text-align: center;">Ugboma HAA and Aburoma HLS: Continental J. Medical Research 4: 13 -17, 2010'' ''

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<p style="text-align: justify;">Cervical cancer Screening:

<p style="text-align: justify;">Screening is the identification of persons within an asymptomatic population who have or are likely to develop specified disease at a time when intervention may result in the improvement of the progress of the disease. Population-based cervical cancer screening in women between the ages of 30 to 40 and beyond by Pap smear has shown to reduce mortality by 35-40% (Schiffman 2004). However economic constraints and knowledge deficits in developing countries impede the availability of Pap smears screening while it’s efficacy in the developed world remains well proven (Rogo et al 1990)undefined. Periodic screening, and follow-up evaluation of women in their 30s or older is an acceptable, cost-effective approach to preventing cervical cancer, assuming that the screening approach is accurate and coverage high (Goldie et al, 2004)undefined.

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<p style="text-align: justify;">Obstacles that hinder effective Pap smear screening <p style="text-align: justify;">            specula, a light source and specimen-tracking forms or log books to function effectively.
 * Intensive infrastructural requirements and the relatively high rate of false negative test results (low test sensitivity) are some of the obstacles that make providing effective Pap smear screening problematic in most developing countries. Effective Pap smear screening requires significant infrastructural support. Pap smear screening efforts can succeed only when implemented in an environment that has a reliable infrastructure (Lentz et al,2004). Minimum requirements for establishing an effective Pap smear screening effort include:
 * Well-trained Pap smear providers (including non-physicians): Ongoing training of providers ensures that they can successfully perform pelvic exams and obtain and prepare adequate cervical samples. Training non-physicians to provide Pap smear screening is cost-effective and makes the services more widely accessible to the women who need them (Murphy et al 2004).
 * Initial and ongoing access to supplies and equipment: Cytology programs require consistent access to supplies such as slides, and fixatives. Programs also must have equipments such as exam tables,

<p style="margin-left: 18pt; text-align: justify; text-indent: -18pt;">·         Linkage transportation, to reliable cytology laboratory: Any program providing Pap smear screening must be linked to a cytology laboratory. Effective training and quality control mechanisms must be in place to ensure that providers are skilled to interpret slide specimens. Strong linkages between the screening program and the laboratory ensure that specimens are transported in a timely manner and test results are clearly communicated to the screening programs.

<p style="margin-left: 18pt; text-align: justify; text-indent: -18pt;">·        Timely communication of test results to screened women: All women screened by cytology need to be notified of their test results. Since immediate results are not available, cytology programs must have      functional information systems in place to ensure that results are communicated promptly. These systems ensure that all results are recorded, missing results are traced and abnormal results are followed up.

<p style="margin-left: 18pt; text-align: justify; text-indent: -18pt;">·        Effective referral system for diagnosis and treatment: Programs performing cytologic screening will need to develop an effective referral system for women who need treatment for precancerous lesions or whose diagnosis is unclear. Treatment or palliative care referrals for women found to have cancer also are necessary.

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<p style="text-align: justify;">When any of these key requirements is missing, cytology programs are not likely to be successful (Wilson et al, 2004)undefined. In developing countries with limited resources, the above mentioned obstacles are the greatest pitfalls to initiating Pap smear screening, which prevents cervical cancer and most gynecological malignancies. Other impediments are the failure to provide key decision makers with up to date evidence on the burden of cervical cancer and the need to initiate prevention and save lives of women who die from cervical cancer. Unfortunately, bereaved families and loved ones of cervical cancer patients naively remain adamant as they have the notion that such deaths occurred as a result of witchcraft spells; a lack of understanding of economic factors that influence the risk of cervical cancer. Policy makers in the developing world should be made to understand that efforts should be devoted to the prevention of these untimely demises because the economic and health benefits of tackling these gynecological problems, outweighs the cost of ignoring the problem (Shinn, 2004; Franco et al, 2001).

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<p style="text-align: justify;">Risk Factor for Cervical Cancer

<p style="margin-left: 57pt; text-indent: -18pt;">·        Sexual activity:

<p style="margin-left: 57pt; text-indent: -18pt;">·          Multiple sex partners.

<p style="margin-left: 57pt; text-indent: -18pt;">·        Early age (younger than 20) at first coitus (exposes the vulnerable young cervix to potential viruses from partner that traumatize the  cervix with the likelihood of carcinogenous growth

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Sex with uncircumcised males

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Sexual contact with males whose partners have had cervical cancer

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Early childbearing age

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Exposure to diethylstilbestrol (DES) in utero

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Family history of cervical cancer

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Low socioeconomic status (may be related to early marriage and early childbearing)

<p style="margin-left: 57pt; text-align: center;">Ugboma HAA and Aburoma HLS: Continental J. Medical Research 4: 13 -17, 2010'' ''

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<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Nutritional deficiencies (folate, beta-carotene and vitamin C level are lower in women with cervical cancer than in women without it)

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Chronic cervical infection

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Overweight

<p style="text-align: justify;">Courtesy: American Cancer Society 2009

Cervical Cancer Screening Guidelines For prevention And Health Promotion

<p style="margin-left: 39pt; text-align: justify; text-indent: -18pt;">·        Routine Pap smear annually for all women who have been sexually active or have reached age of 18 (After a woman has had three consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of her physician

<p style="margin-left: 39pt; text-align: justify; text-indent: -18pt;">·        Pelvic examination every 1 to 3 years with Pap test beginning at age 18 to age 40, annually for women over 40

<p style="margin-left: 39pt; text-align: justify; text-indent: -18pt;">·        Endometrial tissue sample at menopause and if at high risk and thereafter at the discretion of her physician

Courtesy: American Cancer Society Recommendation for Early Detection of Cervical Cancer

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<p style="text-align: justify;">CONCLUSION:

<p style="text-align: justify;">Identification of persons within an asymptomatic population who have or are likely to develop specified disease at a time when intervention may result in the improvement of the progress of the disease is a crucial tool to saving lives. Population-based cervical cancer screening in women between the ages of 30 to 40 and beyond by Pap smear screening has shown to reduce mortality by 35-40% (Schiffman 2004). However economic constraints and knowledge deficits in developing countries impede the availability of Pap smears screening while it’s efficacy in the developed world is well proven. Early cervical cancer rarely produces symptoms, and if symptoms are present, they may go unnoticed as a thin watery vaginal discharge often noticed during sexual intercourse or douching. When symptoms such as discharge, irregular bleeding or pain and bleeding after sexual intercourse occur, the disease may have advanced. Advanced cervical cancer disease could be prevented if all women have access to Pap smear and gynecological care and avail themselves to utilize the opportunity. Pap smear screening can identify preinvasive lesions and prevent cervical cancer. Annual pelvic examination with a Pap smear is a relatively inexpensive method of early detection. Nurses/health care providers can encourage women to follow this health practice by providing non-stressful examinations that are educational and supportive and offering opportunity for patients to ask questions and clarify misinformation. Annual pelvic examination with a Pap smear is a relatively inexpensive method of early detection. This underscores the importance of nurses and healthcare givers in helping detect cervical cancer on the naive vulnerable women.

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<p style="text-align: justify;">Key Recommendations:

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Screen all women in their 30s and 40s whether sexually active or not at least once before expanding services to other age groups or increasing screening frequency

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Screen  for high risk factors for cervical cancer: sexual activity at an early age, multiple sexual partners, or history of sexually transmitted diseases (STD)

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Many young adults and even most matured women are reluctant to have these examinations and screenings. Therefore it is important for health care providers to explain the purpose of the test and to encourage all women to begin this preventive measure by age 20 at least.

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Preventive counseling should include delaying first intercourse, avoiding herpes virus infection (HPV), education about reproductive health and safer sex, smoking cessation, and consideration of HPV immunization.

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Notification of the patients is often the responsibility of health care providers. Pap smear follow-up is essential because appropriate follow-up can prevent cervical cancer.

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·         Many women do not adhere to recommendations, particularly those women who are young, those of low socioeconomic status, those who have difficulty coping with diagnosis and those without social support

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Cultural practices that allow multiple sexual partners whether single or married should be prohibited.

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Polygamous husbands indirectly expose the wives to various forms of sexually transmitted diseases from their multifarious women.

<p style="margin-left: 57pt; text-align: justify; text-indent: -18pt;">·        Fear, knowledge deficit and child care responsibilities have all been identified by women as reasons for poor follow-up. Interventions are tailored to meet the needs of the particular patients. Intensive telephone counseling, tracking system, brochure, video and financial incentives have all been used to encourage follow-up.

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<p style="margin-left: 57pt; text-align: center;">Ugboma HAA and Aburoma HLS: Continental J. Medical Research 4: 13 -17, 2010'' ''

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<p style="text-align: justify;">REFERENCES:

<p style="text-align: justify;">Bickley LS, Szilagyi PG. (2003) Bates’ guide to physical examination and history taking (8th edition) Philadelphia: Lippincott Williams & Wilkins.

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<p style="text-align: justify;">Brown AD, Garber AM (1999). Cost-effectiveness of 3 methods to enhance the sensitivity of Papanicolaou testing. JAMA 281: 347-353.

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<p style="text-align: justify;">Franco E, Duarte-Franco E, Ferenczy A. (2001).Cervical cancer: Epidemiology,    prevention and the role of human papillomavirus infection. Can Med Assoc J.164: 1017-1025.

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<p style="text-align: justify;">Goldie S, Kim J, Wright T. (2004).Cost-effectiveness of HPV DNA testing for cervical cancer in woman aged 30 or more. J Obstet Gynecol,103: 619-638.

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<p style="text-align: justify;">Jemal A, Siegel R, Ward El. (2006).Cancer statistics, CA: J Can Clinic, 56: 106-130.

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<p style="text-align: justify;">Koutsky LA, Ault KA, Wheeler C. (2002) A controlled trial of human  papillomavirus type 16 vaccine. N Engl J Med 347: 1645-1651.

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<p style="text-align: justify;">Lentz S, Muderpach L, Felix J. (2004) Identification of micrometastases in histologically lymph node of early stage cervical cancer patients. Obstet Gynecol 103: 1204-1210.

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<p style="text-align: justify;">McNeely PD( 2001). Improving adherence to abnormal Pap smear follow-up. J Obstet Gynecol and Neonat Nurs. 30: 80-88.

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<p style="text-align: justify;">McNeely S. (2003) New cervical cancer screening techniques. Am J Obstet Gynecol; 189: 40-41.

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<p style="text-align: justify;">Murphy VH, Krumholz HM, Gross CP ( 2004). Paricipation in cancer clinical trials: Race-, Sex-, and age-base disparities. JAMA 291: 2720-2726.

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<p style="text-align: justify;">Nanda K, McCory D, Myer E. (2000) Accuracy of the Papanicolaou test in screening for and follow-up of cervical cytologic abnormalities: a systemic review. Annal Intern Med 16: 132: 810- 819.

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<p style="text-align: justify;">Rogo KO, Omany J, Onyango JN, Ojwang SB, Stendahl U. (1990) Carcinoma of the cervix in African setting. Intern J Obstet, 33: 249-255

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<p style="text-align: justify;">Schiffman M. (2004) Evidenced-based screening and management: Guidelines address the realistic concerns of practicing clinicians and pathologists. J Lower Gen Tract Dis. 8: 150-154.

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<p style="text-align: justify;">Shinn S. (2004) Taking a stand against cervical cancer. Nursing, 34: 36-41.

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<p style="text-align: justify;">U.S. Preventive Service Task Force. Screening for cervical cancer: Recommendations and Rationale. ''Amer J Nurs 2003; 103: 101-109. ''

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<p style="text-align: justify;">Wilson C, Tobin S, Young R. (2004).The exploding worldwide cancer burden: The impact of cancer on women. Inter J Gynecol Cancer 1-11.

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<p style="margin: 0cm 0cm 0.0001pt; text-align: justify; line-height: normal;">Received for Publication: 17/11/2010

<p style="margin: 0cm 0cm 0.0001pt; text-align: justify; line-height: normal;">Accepted for Publication: 28/12/2010

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Corresponding Author:

Ugboma HAA

Department of Obstetrics and Gynecology, University of Port Harcourt, Nigeria.

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<p style="text-align: justify;">Continental J. Medical Research 4: 18 -23, 2010                                                        ISSN: 2141 - 4211

<p style="text-align: justify;">© Wilolud Journals, 2010                                                                                 http://www.wiloludjournal.com

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<p style="text-align: center;">PREVALENCE AND AETIOLOGIC AGENTS OF URINARY TRACT INFECTION IN PREGNANCY IN ABAKALIKI METROPOLIS

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<p style="text-align: center;">1Nworie A. and 2Eze U. A

<p style="margin-left: 36pt; text-align: center;">1Department of Medical Laboratory Science, 2Faculty of Health Sciences, Ebonyi State University, Abakaliki, Nigeria.

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<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">ABSTRACT

<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Urinary tract infections are common in pregnancy and are associated with complications such as abortion, prematurity, low birth weight, stillbirth, maternal anemia, preterm labour, hypertension, thrombosis, phlebitis, pre-eclampsia, chronic pyelonephritis, and rarely, kidney failure. A total of two hundred (200) urine samples were randomly collected from pregnant women attending the antenatal clinics of Ebonyi State University Teaching Hospital and Mile 4 Hospital, both in Abakaliki Metropolis to determine the prevalence of urinary tract infections in pregnancy, aetiologic agents and assess some predisposing factors.

<p style="margin: 0cm 17pt 0.0001pt; text-align: justify;">Using > 105 colony forming unit per milliliter as significant level of bacteriuria, the prevalence was found to be 48. 0%. There was no significant difference between age and rate of infection (P> 0.05). There was a high incidence in 21 – 25 age group (41.7%). There was also high incidence of infection in the third trimester (82.3%) while the second trimester was (17.7%). Multiparty is associated with increased urinary tract infection in pregnancy. Staphylococcus aureus was the most frequently isolated pathogen (44.8%), followed by Klebsiella pneumonia (15.2%), Escherichia coli (10.5%), Enterococus faecalis (9.5%), Coagulase – Negative Staphylococci (8.6%). Pseudomonas aeruginosa (6.7%), Streptococcus pyogenes and Candida spp. (1.9%) each, and Proteus mirabilis (0.9%). These findings underscore the importance of screening all pregnant women for significant bacteriuria so that positive cases should be treated subsequently with antibiotics in order to reduce the adverse effects on both maternal and fetal health.

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<p style="text-align: justify;">      KEYWORDS: Klebsiella pneumonia, preterm labour, pregnant women, Abakaliki Metropolis , antibiotics

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<p style="text-align: justify;">INTRODUCTION

<p style="text-align: justify;">Urinary tract infections (UTI), which are caused by the presence and growth of microorganisms in the urinary tract, are perhaps the single commonest bacterial infections of mankind1 (Theodore, 2007) and in pregnancy, it may involve the lower urinary tract or the bladder (Brook, 2001). Significant’ bacteriuria is based on the presence of 100 000 organism per/ml in a carefully collected sample of clean – voided or midstream urine (Kass, 1962), distinguishing between infection and contamination. However, this relationship does not hold true in all circumstances. According to Leigh (1989), high fluid intake increases the rate of bladder emptying and lowers the bacterial count; inadequate chemotherapy may reduce the bacterial count; and use of alkalinizing or acidifying agents may also slow growth and give rise to a low bacterial count. It has been reported that in woman with acute infection of the lower urinary tract, 30 – 50% have counts less than 100,000 organisms/ml (Leigh, 1989).

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<p style="text-align: justify;">Symptomatic and asymptomatic urinary tract infection is a common phenomenon in pregnancy. The main factor predisposing women to bacteriuria are pregnancy, sexual intercourse and short urethra. About 1/3 of urinary tract infections in sexually active women is mainly associated with sexual intercourse. Bladder infections in women often occur from the massaging effect of sexual intercourse on the urethra which introduces bacteria from the urethra to the urinary bladder. Further more, the position of the urethra in women makes it subject to faecal contamination and colonization with potentially pathogenic intestinal bacteria (Theodore, 2007)1. The hormonal effects in ureteric vasculature in pregnancy aided, perhaps, by mechanical pressure from the gravid uterus leads to urinary stasis and therefore, encourage bacterial growth in urine (Duguid et al, 1987)5. Reduced immune reactions that occur during pregnancy also contribute to increased incidence of urinary tract infection in pregnancy (Onuh eh all, 2006)6.

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<p style="text-align: justify;">Urinary tract infection during pregnancy contributes significantly to maternal and perinatal morbidity (Akerele et al, 200). Abortion, small birth size, maternal anemia, hypertension, preterm labour, phlebitis, thrombosis and chronic pyelonephritis are related to urinary tract infection during pregnancy (Pfau and Sacks, 1992; Akerele et al., 2002; Onuh et al., 2006).

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<p style="text-align: justify;">E. coli remains the predominant organism implicated in urinary tract infection in pregnancy, though recent reports show change in pattern of the infection (Onuh et al, 2006). Recent studies in Nigeria show an increasing involvement of ''Klebsiella Spp. Staphylococcus aureus, Proteus spp., and Pseudomonas spp'' in urinary tract infection in pregnancy (Abdul and Onile, 2001).

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<p style="text-align: center;">Nworie A. and  Eze U. A: Continental J. Medical Research 4: 18 -23, 2010

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<p style="text-align: justify;">In view of this, this study aims at evaluating the prevalence of urinary tract infection and the etiologic agents amongst pregnant women in Abakaliki metropolis in Ebonyi State, South-east Nigeria.

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<p style="text-align: justify;">MATERIALS AND METHODS

<p style="text-align: justify;">Study Area and Population.

<p style="text-align: justify;">This cross-sectional study was conducted at both the Ebonyi State University Teaching Hospital (EBSUTH) and mile 4 Hospitals located in Abakaliki metropolis between 1st august and 5th November, 2009. Abakaliki is the capital of Ebonyi state and as an urban settlement; it has hospitals, dispeneries and markets. Abakaliki is inhabited by civil servants, traders, farmers, and students. The highest temperature in Abakaliki occurs between march and April (immediately before the rainy season) and the lowest experienced in the peak of harmattan period (January); wet and dry seasons are distinct in the area, the wet season spans from April to October with an annual rainfall of between 1.700 mm and 20. 20 mm and while dry season spans from November to march (Ugo, 2003), the lush vegetation, inadequate drainage system and poor environmental sanitation prevail in the area.

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<p style="text-align: justify;">Consecutive booked antenatal women who presented at the antenatal clinics of the above mentioned hospitals during the study period were randomly selected for this study. Pregnant women in the first trimester were excluded from the study as the hormonal changes affecting the urinary system might have not been fully elaborated at this gestational age. Also, pregnant women on antibiotics therapy within 72 hours to the study days were excluded due to the fact that the antibiotics must have inhibited or destroyed the pathogens.

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<p style="text-align: justify;">Ethical Consideration

<p style="text-align: justify;">Approval was sought and collected from the Research/Ethics Committee of the above hospitals and informed consent obtained from the pregnant women before the commencement of the research. Demographic information such as age, occupation, number of children (parity), and duration of gestation were collected from the pregnant women using standard questionnaires and kept confidential during the research.

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<p style="text-align: justify;">Sampling Technique

<p style="text-align: justify;">Two hundred (200) pregnant woman attending the above mentioned hospitals during the research period that either had any of the symptoms suggestive of urinary tract infections or without any symptoms were recruited into the study upon informed consent. The subjects were trained on vilval cleansing and urine collection to avoid contamination. Sterile universal containers were given to the eligible pregnant woman and mid – stream “Clean Catch” urine specimens collected and carried immediately to the Microbiology Unit. Department of Laboratory Services. Ebonyi State University Teaching Hospital (EBSUTH), for culture and Microscopy.

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<p style="text-align: justify;">Culture Technique

<p style="text-align: justify;">All the urine samples were aseptically inoculated unto Blood agar, and MacConkey agar using calibrated loop technique (Vandepitte et al, 2003). Each urine sample was shaken gently, and then tipped to a slant and with sterile 0.001ml (1ui) inoculating loop the surface of the urine was touched so that the urine is sucked into the loop. The loop was never dipped into the urine. The 0.001 ml of urine was deposited on a blood agar plate and half of the plate was streaked by first making a straight line down the center (1). Followed by close passes at right angles through the original (2), and ending with oblique streaks crossing the two previous passes (3). MacConkey agar was inoculated in the same manner. The plates were incubated for 24 hours at 37 0 C (Vandepitte, et al, 2003)

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<p style="text-align: justify;">Direct Microscopy and Gram Staining

<p style="text-align: justify;">Preparation and examination of Gram-Stained smears of the urine samples were carried out, using the method described by Cheesbrough, (2000).

<p style="text-align: justify;">Bacterial Colony Count

<p style="text-align: justify;">After incubation at 37o C for 24 hours, counts >10 5colony forming unit per milliliter was taken as being significant in both symptomatic and asymptomatic pregnant women as described by Vandepitte et al, ( 2003).

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<p style="text-align: justify;"> Identification of Bacterial Isolates

<p style="text-align: justify;">A complete identification of each bacteria isolate was based on cultural examination, morphological examination, and biochemical characterization.

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<p style="text-align: justify;">Statistical Analysis

<p style="text-align: justify;"> Data collected was analyzed using Chi square test. P<0.05 was taken as being statistically significant with 95% confidence interval.

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<p style="text-align: center;">Nworie A. and  Eze U. A: Continental J. Medical Research 4: 18 -23, 2010

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<p style="text-align: justify;">RESULTS

<p style="text-align: justify;">Two hundred (200) urine samples were collected and analyzed during the study period. Ninety-six (96) samples showed significant growth, which amounted to a prevalence of 48.0/%. The prevalence of infection in relation to age are shown in table 3, individuals of the age group 21-25 years had the highest incidence of infection (41.7/ %). Followed by age group 26-30 years (34.4/%), 31-35 years (18.8/%) and 16 -20 years (3.1/%). While the age group 36-40 years had the lowest incidence of infection (2.0/%). There was no significant difference between age and rate of infection (X2 =13.432, df = 4, P>0.05). in table 4, there was higher rate of infection in the third trimester (82.3/%) compared to second trimester (17.7/%) and the difference was statistically significant (X2 = 0.0647, df = 1, P< 0.05). in table 5, there was no significant difference between parity and frequency of urinary tract infection in pregnancy (X2 = 9.8264, df 2, P> 0.05) there was a high frequency of infection occurring in those having 2 – 3 children (44.8/%). Followed by those having 0-1 children (36.4/%) while the lowest frequency of infection occurred in those with > 4 Children (18.8/%).

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<p style="text-align: justify;">Table 2 showed the frequency of various significant pathogens isolated. There were one hundred and five (105) microbiological isolates as nine (9) samples yielded double growth of microorganisms. Among the significant isolates, staphylococcus aureus had the highest frequency of isolation with a frequency of (44.8/%), while P. mirabilis has the lowest frequency of (0.9/%).

<p style="text-align: justify; text-indent: 36pt;">Table 2: Frequency of Isolation of various significant pathogens in urine of pregnant women. <p style="text-align: justify;">

<p style="text-align: justify; text-indent: 36pt;">Table 3: Prevalence of Urinary Tract infection in pregnant Women in relation to age. <p style="text-align: justify;">                                                                                                                                               X2 = 13.4321

<p style="text-align: justify; text-indent: 36pt;">Table 4: Prevalence of urinary tract infection in pregnant women in relation to gestational age. <p style="text-align: justify;">                                                                                                                                                               X2 = 0.0647

<p style="text-align: justify; text-indent: 36pt;">Table 5: Prevalence of urinary tract infection in pregnant women in relation to Parity. <p style="text-align: justify;">                                                                                                                                                               X2 = 9.8264

<p style="text-align: center;">Nworie A. and  Eze U. A: Continental J. Medical Research 4: 18 -23, 2010

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<p style="text-align: justify;">DISCUSSION

<p style="text-align: justify;">The commonly reported infections associated with pregnancy are urinary tract infection (asymptomatic bacteria, cystitis and pyelonephritis). Which are frequently encountered medical complications of pregnancy (de la Rosa et al; 1994 and Onuh et al; 2006). Although the majority of infections in pregnancy are asymptomatic, the mother is placed at high risk for low birth weight, preterm labour, hypertension, maternal anemia, thrombosis, still birth and abortion (Pfau and sacks 1992, Akerele et al, 2002, Onuh, et al 2006). For instance, pyelonephritis could cause significant maternal and fetal morbidity and mortality (Akerele et al, 2002). The earlier documented sociodemographic risk factors for urinary tract infection in pregnancy like maternal age and high parity were proven to be associated with urinary tract infection during pregnancy in this study while gestational age was not associated with urinary tract infection in pregnancy. This study does not agree with that of Onyemelukwe et al, (2003) who reported that there was no relationship of either age or parity with bacteriuria in pregnancy. The report of this study is somewhat similar to that of Leigh, (1989) who reported an increasing parity as a risk factor of developing urinary tract infection in pregnancy but no relationship to age in developing urinary tract infection in pregnancy. The report of this study is in disagreement with that of Onuh et al, (2006) who reported that there was no relationship between either age or parity and bacteriuria in pregnancy. These differences may be as a result of the different locations in which these studies were being carried out.

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<p style="text-align: justify;">In the study, ninety –six (96) urine samples gave significant growth amounting to 48. 0% prevalence. This prevalence does not agree with that of Onuh and colleagues (2006) who reported 32.7% although close to this finding. Furthermore, the prevalence in this study does not agree with that of Akinloye et al, (2006) who reported a prevalence of 21.7.0% and Onyemelukwe et al (2003) who reported a prevalence of 12.7%. also, the prevalence of this study does not agree with that of Duguid et al (1987), Leigh (1989), brook et al (2002) and Woodman, (2002) who reported a prevalence of 1 – 10%. This difference may be due to the inclusion of both symptomatic and asymptomatic pregnant woman in this study or as a result of difference socioeconomic status of the pregnant women.

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<p style="text-align: justify;">In this study, the frequency of urinary tract infection was higher in the third trimester compared to the second trimester. This is in agreement with Leigh, (1989) who reported an increased frequency of urinary tract infection in the third trimester compared to the second trimester of pregnancy. However, this report does not agree with Onuh et al, (2006) who reported a higher prevalence of urinary tract infection in the second trimester compared to the third trimester. This difference may be as a result of either change in urinary stasis and vesicoureteral reflux or decrease in urinary progestines and oestrogens in the various trimester of pregnancy.

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<p style="text-align: justify;">In this study, the commonest pathogen isolated was Staphylococcus aureus (44.8/5) followed by klebsiella pneumonia (15.2/%) and Escherichia coli (10.5%) which are not similar to literature reports, where culture from pregnant women yielded more isolates of Escherichia coli, Klebsiella species and proteus mirabilis (Abdul and Onile, 2001;; Woodman, 2002; Onyemelukwe et al; 2003 and Akinloye et al, 2006). The report of this study is similar to that of Akerele et al, (2002), who reported the common occurrence of staphylococcus aureus (24.1%) and Klabsiella pneumonia (18.2%) as the aetiologic agents of urinary tract infections pregnancy.

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<p style="text-align: justify;">From this study, there tends to be a declining percentage of E.coli in the causation of urinary tract infection and a gradual replacement by other members of the Enterobacteriaceae and Enterococci. As in some other recent studies, there tends to be shift in the proportion of aetiological agents favouring organisms like Staphylococcus aureus and Klebsiella pneumoniae (Akerele et al; 2002, Onuh etal, 2006). It has been shown that in some women, perineal bacteria gain access into the urethra and then go on to colonize the bladder or kidney causing recurrent urinary tract infection. Such women are likely to have introital colonization with bacteria manifesting bacterial adherence (Onyemelekwe et al; 2003).

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<p style="text-align: justify;">CONCLUSION

<p style="text-align: justify;">There is an abrupt decline in the frequency of E. coli as the aetiologic agent of urinary tract infection during pregnancy in our environment. In the same vein, there is gradual increase in the proportion of organisms such as Staphylococcus areus, Klebsiella pneumoniae, coagulase – negative Staphylococcus, Enterococcus faecalis and Pseudomonas aeruginosa in causing urinary tract infection in pregnant women.

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<p style="text-align: justify;">There is also association of maternal age and parity with the rate of urinary tract infection during pregnancy. These call for frequent and consistent evaluation of the prevalence, aetiologic agents and predisposing factors of urinary tract infections during pregnancy in developing countries in order to reduce the devastation effects of urinary tract infections in pregnancy on both maternal and foetal health.

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<p style="text-align: center;">Nworie A. and  Eze U. A: Continental J. Medical Research 4: 18 -23, 2010

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<p style="text-align: justify;">REFERENCES

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<p style="text-align: justify;">Akerele, J Abhlimen, P, and Okonofua, F (2002). Prevalence of asymptomatic Bacteriuria among pregnant women in Benin City, Nigeria. British Journal of Obstetrics and Gynaecology, 221 (2). 141-144

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<p style="text-align: justify;">Akinloye, O, Ogbolu, D/O, Akinloye, O, M, and Alli, O, A T (2006); Asymptomatic Bacteriuria of pregnancy in Ibadan, Nigeria; a re-assessment.

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<p style="text-align: justify;">Bonadio, M, Meini, M, Spitaleri, P and Gigli, C (2001). Current Microbiological and Clinical aspects of Urinary tract infections. European Urology; 40 (4), 439 – 445

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<p style="text-align: justify;">British Journal of Biomedical science; 63 (3); 109- 112. Woodman, P J (200@). Urinary Tract Infection in Pregnancy. Emedicine Journal, 3 (6): 61 – 71.

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<p style="text-align: justify;">Brook, G F, Butel J S, Moses, S A (2001. Jawetz Melmick and Adelberg’s Medical Microbiology, 22nd edition. McGraw-Hill, New York. Pp 637 – 638

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<p style="text-align: justify;">Duguid, J P, Marmion, B P, and Swain, R H A (1987). In Mackie and McCartney Medical Microbiology: A Guide to the Laboratory Diagnosis and Control of infections, Vo. 1. 13thedition. Churchill Livingstone, Philadelphia, PP329 – 330.

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<p style="text-align: justify;">Kass, E H (1962): Pyelonephritis and bacteriuria: A Major Problem in Preventive Medicine. ''Annals of Internal Medicine; 56: pg 46 – 53. ''

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<p style="text-align: justify;">Leigh, D (1989): Urinary Tract Infections. In: Parker, M T and Darden, B I (ends) Topple and Wilson’s Principles of bacteriology, Virology and Immunity, Vol.3, *the edition. B C Decker, Philadelphia. Pp197 – 211.

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<p style="text-align: justify;">Onuh, S O, Umeora, O U J, Igberase, Go, Azikem M E and Okpere, E E (2006). Microbiological Isolates and sensitivity pattern of urinary tract infection in pregnancy in Benin City, Nigeria, Ebonyi Medical Journal; 5(2); 48 – 52.

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<p style="text-align: justify;">Onyemelukwe, N F, Obi, S N, Ozumba, B C (2003). Significant Bacteriuria in pregnancy in Enuhun, Nigeria. Journal of College of Medicine; 8 (2): 20 – 22.

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<p style="text-align: justify;">Pfau, A, and Sacks, T CG (1992). Effective Prophylaxis for Recurrent Urinary Tract Infections During pregnancy. Clinical Practice of Infectious Diseases; 14; 820 – 814

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<p style="text-align: justify;">Sleigh, J D, Robertson, J G and Isdale, M H (1964). Asymptomatic Bacteriuria in Pregnancy. Journal of Obstetrics and Gynecology of the British Commonwealth. 71:74 -.

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<p style="text-align: justify;"> Theodor, M. (2007). Prevalence and antibiogram of urinary tract infections among prison inmates in Nigeria. The Internet Journal of Microbiology; 3(2): 12 - 23

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<p style="text-align: justify;">Ugo, C. (2003). Polytheism: the gods of Abakaliki. Handel Books Ltd., Enugu, Nigeria. PP 9 – 17.

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<p style="text-align: center;">Nworie A. and  Eze U. A: Continental J. Medical Research 4: 18 -23, 2010

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<p style="text-align: justify;">Vandepitte, J; Verhaegen, J; Engbaek, K; Rohnor, P. Piot, P; Heuk, C C(2003). Basic Laboratory Procedures in Clinical Bacteriology, 2nd edition. WHO. Geneva. pp32 – 35.

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<p style="margin: 0cm 0cm 0.0001pt; text-align: justify; line-height: normal;">Received for Publication: 17/11/2010

<p style="margin: 0cm 0cm 0.0001pt; text-align: justify; line-height: normal;">Accepted for Publication: 28/12/2010

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Corresponding Author:

Nworie A.

<p style="text-align: justify;">Amos Nworie, Department of Medical Laboratory Science, Ebonyi State University, Abakaliki, Nigeria. [mailto:nworieamos@yahoo.com nworieamos@yahoo.com].