BACTERIOLOGICAL PROFILE AND SENSITIVITY
PATTERN OF SEPTIC ABORTION.
IN
LAGOS ISLAND MATERNITY HOSPITAL,
LAGOS, NIGERIA.
A Dissertation submitted to the National Postgraduate Medical College
of Nigeria. In partial fulfillment of the requirement for the Award
of the Fellow of the National Postgraduate Medical College in
Obstetrics and Gynaecology.
BY
DR. OLAKUNLE ALFRED KUSEMIJU
LAGOS ISLAND MATERNITY HOSPITAL.
LAGOS, NIGERIA.
MAY, 2013. 1 CERTIFICATION
The work was carried out under the supervision of:
DR. A.S. SOYINKA
FWACS, FMCOG, DMIS (Germany)
Lagos Island Maternity Hospital, Lagos.
SIGNED:
DR. W.B. MUTIU.
MBBS - FMCPATH (Medical Microbiology)
Lecturer/ Honorary Consultant Microbiologist
Lagos State University College of Medicine/Teaching Hospital
(LASUCOM/LASUTH)
Ikeja. Lagos.
SIGNED:
DR. TEMITOPE OJO.
FWACS, FMCOG.
HOD. Obs & Gyn.
Lagos Island Maternity Hospital, Lagos.
SIGNED: 2
DECLARATION
I, Dr. OLAKUNLE ALFRED KUSEMIJU hereby declare that the dissertation entitled: BACTERIOLOGICAL PRIFILE AND SENSITIVITY
PATTERN OF SEPTIC ABORTION in Lagos Island Maternity Hospital,
Lagos, which was submitted to the National Postgraduate Medical College of
Nigeria (NPMCN); in partial fulfillment of the requirement of the Award of the Fellow of the National Postgraduate Medical College in Obstetrics and
Gynaecology, comprises only my original work and due acknowledgment has been made in the text to all other materials used.
NAME OF CANDIDATE: DR. OLAKUNLE ALFRED KUSEMIJU
DATE:
SIGNATURE:
3 ACKNOWLEDGEMENT
My gratitude goes to the entire Consultant staff of Lagos Island Maternity
Hospital, Lagos, for their support and guidance in the preparation of this book.
I acknowledge with profound gratitude the help of Mr. Lewis O. Ojomgbede the
Principal Laboratory Scientist and the entire staff of the Microbiology Research
Laboratory of the Lagos State University Teaching Hospital, Ikeja.
Finally, my appreciation goes to my wife, Folake and my children for their prayers and patience.
4 ABSTRACT
Objective: The study aims to determine the bacteriological profile and sensitivity pattern of endocervical isolates in septic abortion patients at the Lagos Island Maternity Hospital, with a view of recommending appropriate 1st-line antibiotic regimen for the management of Septic abortion cases.
Design: This was be a prospective cross sectional study.
Materials and Methods: A standard questionnaire was administered to a total of 234 consenting patients (with signs and symptoms suggestive of septic abortion), who were recruited for the study between 1st February 2011 and 31st January, 2012. Endocervical swabs obtained before commencement of antibiotics were transported in peptone broth to the laboratory; isolates were identified by standard microbiology techniques and were subjected to antibiotic sensitivity tests.
Results: 46.2% of the patients were 30 years and above, 34.6% were petty traders and 55.6% had up to secondary education. 68.4% were married; 41.4% have had 1 or 2 previous abortions, 71.3% of the abortions were in the 1st trimester, 59.7% presented more than 7 days after procuring abortion. 46.5% had abortion done in hospitals (especially Private Hospitals) and 49.1% were performed by nurses. 70.8% had dilation and curettage or MVA done. Only 11% of all the patients were using contraceptives before index abortion and condom was the commonest method. Of the 234 endocervical specimens, 210 yielded significant growth of bacterial pathogens; 8 revealed no growth, 10 had mixed growth and 6 were viewed as contaminants.
Escherichia coli was the most predominant organism isolated, while other isolates were Staphylococcus aureus, Pseudomonas aeroginosa, Enterobacter agglomerans, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganni, Pseudomonas stuartii and Staphylococcus epidermidis. Levofloxacin was found to be the most effective antibiotic agent.
Conclusion: Endocervical isolates from septic abortion patients were polymicrobial in nature. Escherichia coli was the commonest organism isolated. Levofloxacin was the most effective antibiotic. Levofloxacin is hereby recommended as 1st-line drug regimen. 5 TABLE OF CONTENTS
PAGES
Abstract … … … viii
Introduction … … … 1
Justification for the Study … … 5
Literature Review … … … 7
Statements of Objectives … … 24
Materials and Methods … … 25
Data Collection Method … … 28
Data Processing & Statistical Analysis … … 36
Results … … … 37
Discussion … … … 53
References … … … 61
Data Collection Form … … … 77 6 INTRODUCTION
Septic abortion is an infected abortion complicated by fever, endometritis and parametritis1, and remains one of the most serious threats to women’s health worldwide. Deaths from induced abortion are disproportionately due to infection2,3. Various studies in developing countries have shown, that abortion deaths are primarily from sepsis4,5,6,7,8. Delay in treatment allows progress to bacteraemia, pelvic abscess, septic pelvic thrombophlebitis, disseminated intravascular coagulopathy, septic shock, renal failure and death9,10,11. While morbidity and mortality from septic abortion are infrequent in countries in which induced abortion is legal12, suffering and death from this process are widespread in many developing countries in which abortion is either illegal or inaccessible13,14. Septic abortion is a paradigm of preventive medicine, relating all levels of prevention –primary, secondary and tertiary15,16,17.
Maternal mortality remains unacceptably high across many of the developing countries and little has changed from the often-quoted dismal statistics of the 1990s where half a million maternal deaths occurred annually; 97% of which are from Sub-Saharan Africa18.
About 75 million unwanted pregnancies occur annually worldwide, accounting for 4 in every 10 pregnancies19. An estimated 46 million induced abortions (legal or illegal) are performed annually20, of which about 20 million are unsafe with 95% of them occurring in developing countries21. Complications from spontaneous abortion and unsafely induced abortions pose serious global threat to women’s health and lives 22. Unsafe abortions account for an estimated 13% of maternal deaths (representing about 67,000-80,000 women) and serious complications in many others18,21,23. 7 The World Health Organization (WHO) defines unsafe abortion as any procedure for termination of an unwanted pregnancy, either by persons lacking the necessary skills, or is conducted in an environment lacking the minimal medical standards, or both20. Tragically, unsafe abortion is the most easily preventable cause of maternal mortality24. Barriers to addressing the challenges of unsafe abortion vary in different parts of the world, but cluster around restrictive abortion laws; restrictive access to contraception, limited resources, restrictions to mid-level providers’ (i.e. non- doctors) performance of uterine evacuation; and political and religious sensitivities about abortion related issues22.
In Nigeria, the abortion law prohibits induced abortion except for medical reasons, in order to save the life of the woman. In spite of the law, it has been estimated that 610,000 induced abortions occur yearly in Nigeria18, 23 .Prevalence of induced abortion has been quoted as ranging from 25-55% among adolescents (12-18 years) in schools and 85-94% among out-of - school single women18, 25. High sexuality and low contraceptive use is what results in unplanned pregnancy in many Nigerian women who seeks abortion 26, 27.
Strategies for reducing abortion complications include health education and implementation of post-abortion care strategy as published by IPAS in 199422. The original model comprised three elements: Emergency treatment services for complications of spontaneous or unsafely induced abortion; post-abortion family planning counseling and services and links between emergency abortion treatment services and comprehensive reproductive health care 28. The preventable morbidity and mortality from septic abortion are staggering and well documented 29. The American Medical Association’s Council on Scientific Affairs has attributed the marked decline in abortion deaths in the last century to the
8 introduction of antibiotics to treat sepsis; the widespread use of effective contraception and more recently, the shift from illegal to legal abortion30.
A 1992 report of Guinea, West Africa, showed that abortion constituted 17% of maternal deaths; 80% of the abortion deaths were from induced abortion and sepsis was the most common cause of death31. A study from 5 hospitals in Kampala, Uganda (1980-1986) found 20% of maternal deaths to be abortion – related32. A Nigerian study reported 35% of hospital maternal mortality was from abortion, with sepsis the most common cause of death4. A 7-year review of abortion at the University College Hospital, Ibadan, Nigeria, revealed that abortion complications represented 76.7% of all emergency gynaecological admissions 33. A 10-year review from Rio de Janeiro found maternal mortality to have increased almost four fold (1978-1987), where abortion related deaths accounted for 47% of the total mortality7. More recent reports from many countries echo the same dismal findings. A 10-year study from rural India (2001), found that 41.9% of all maternal deaths were from septic abortion6. A hospital-based study(2007) in Ayinke House, Lagos, Nigeria, a major hub for the management of post-abortion complications, reported that abortion related deaths constituted 25% of maternal deaths in that hospital34. As shown in all these studies, abortion deaths are primarily from sepsis.
The bacteriology of septic abortion is usually polymicrobial, derived from the normal flora of vagina and endocervix, with the important addition of sexually transmitted pathogens35. The necessity for investigation before therapy cannot be over-emphasized, since the result of sensitivity reactions may be the all-important factor in determining the most suitable antibiotic agent(s). Haphazard trials of various antibiotics is not only unscientific but may lead to complications as a result
9 of development of resistance to antibiotics36. It was therefore considered appropriate to study the bacteriological profile (endocervical isolates) and their antibiotic sensitivity pattern in septic abortion patients at the Lagos Island Maternity Hospital (LIMH). This can be instituted as 1st-line treatment regimen promptly enough to prevent undue spread of infection and delay in management, instead of waiting till laboratory results are available, (which usually takes 4-7 days in most public hospitals in the state). Such antibiotics could be made readily available and highly subsidized to reduce short and long-term morbidities and maternal deaths.
Lagos Island Maternity Hospital (LIMH) is one of the largest and busiest gynaecological centres in Nigeria (and indeed West Africa) and a major referral centre in the management of post-abortion complications receiving referrals from primary and secondary (tier) health institutions in all local government areas of the state.
The outcome of this study could be used as a template for more comprehensive research, to postulate an evidence-based antimicrobial treatment of septic abortion for residents of Lagos state.
10 JUSTIFICATION FOR THE STUDY
Septic abortion remains one of the most serious threats to women’s health worldwide. Induced abortion deaths are disproportionately due to infections2, 3. Various studies in developing countries have shown that abortion deaths are primarily from sepsis4 , 5, 6, 7, 8. Delay in treatment allows progress to more serious complications and death9, 10.
Complications from spontaneous abortion and unsafely induced abortions pose serious global threat to the health and lives of women22, accounting for an estimated 13% of maternal death; Unsafe abortion is also a significant cause of long-term morbidity in women in developing countries, including chronic pelvic pain or pelvic inflammatory diseases, secondary infertility, ectopic pregnancy and recurrent pregnancy loss5, 37.
The preventable morbidity and mortality from septic abortion are staggering and well documented29. A common theme in reported deaths from septic abortion is delay; young or unmarried women often conceal the abortion and delay seeking help until they are moribund. Management of severe sepsis requires eradication of the infection and supportive care for cardiovascular system and other involved organs9.
The American Medical Association’s Council on Scientific Affairs has attributed the marked decline in abortion deaths in that country to the introduction of antibiotics to treat sepsis, which should be instituted as early as possible in the course of management.
11 Abortion related studies are scanty in LIMH, despite the high frequency of presentation at the emergency unit of the hospital (about 83% of total emergency gynaecological admissions).
The necessity for this study cannot be over-emphasized; the result of sensitivity reactions is the all-important factor in determining the most suitable antibiotic regimen(s) for patients.
Haphazard trials of various “strong” or “powerful” antibiotics is not only unscientific, but expensive, patients may not be able to afford the cost, causing further delay, and this may lead to more complications. If the bacteriological profile and antibiotic sensitivity pattern of a community is known, as this study will attempt to highlight, such drugs can promptly be instituted as 1st-line treatment regimen to prevent undue spread of infections, thereby reducing morbidity and mortality.
12 LITERATURE REVIEW
Abortion is the termination of pregnancy before fetal viability. It may be spontaneous or induced 38. The definition of fetal viability varies from country to country, but the World Health Organization (WHO) defines viability as 22 completed weeks from date of onset of the last menstrual period (LMP). In Nigeria, miscarriage is defined as termination of pregnancy before 28 completed weeks from the LMP, or expulsion of a fetus weighing less than 1000gm39. Most countries, including the USA, define viability as 20 completed weeks 38. Induced abortion is the termination of pregnancy by artificial means before the pregnancy becomes viable38, 39. Medically induced abortion is defined as termination of pregnancy using drugs (Mifepristone plus Misoprostol) or by surgical intervention after implantation and before fetal viability 38, 40, 41.
INCIDENCE
The incidence of spontaneous abortion may be difficult to ascertain for several reasons 42. Spontaneous abortion is recognized easily only when the fetus is already well developed. Early ones are difficult because most may appear like late periods and some infertile women may report irregular late periods as abortions42. Probable estimate of incidence of spontaneous abortion is 10 – 20%, most (80%) of which occur in the 1st trimester43.
Causes of early (1st trimester) spontaneous abortion include chromosomal abnormalities, fetal damage from drugs, lower genital tract infections, febrile illnesses and antiphospholipid syndrome 42e.t.c.
13 Causes of late (2nd trimester) miscarriage may be due to uterine anomalies, cervical incompetence, lower genital tract infections, endocrine factors and thrombophylias42.
After 12 weeks the abortion process resembles labour; membrane rupture occurs first before expulsion of the fetus and placenta, and incomplete abortion is more common with consequent vaginal bleeding and infection 42, 44.
Each year, an estimated 210 million women throughout the world become pregnant, and 1 in 5 of them resort to abortion20. Out of 46 million abortions performed annually, 19 million are estimated to be unsafe20, 45.
There are an estimated 330 abortion-related deaths per 100,000 abortions in developing countries as a whole, compared to a ratio of only 0.7 per 100,000 abortions in developed countries20. Africa has the highest ratio of 680 per 100,000 abortions, followed by South Central and South-East Asia, with a ratio of 283 per 100,000 abortions, and Latin America with a ratio of 119 per 100,000 abortions20. The risk of dying from unsafe abortion is highest in Africa with a ratio of 1 in 150, compared with rates of 1 in 250 and 1 in 900 respectively in Asia and Latin America and the Caribbean respectively; while the rate in Europe is as low as 1 in 1,90046. In Africa, an estimated 5 million induced abortions (mostly illegal) are performed annually; (1.9; 0.6; 0.8 and 1.6 million in East; North; South and West Africa respectively)47, 48. It is estimated that 610,000 induced abortions occur yearly in Nigeria (40% of West Africa) 22, 23. The prevalence of induced abortion has been quoted as ranging from 25-55% among adolescents in school and 85- 94% among out-of-school single women25.
14 Worldwide estimates for 1995 indicated that 26 million legal and 20 million illegal abortions took place48. Almost all unsafe abortion (97%) are in developing countries and over half (55%) are in Asia (mostly South-Central Asia) 49. Reliable data for the prevalence of unsafe abortion are generally scarce, especially in countries where access to abortion is legally restricted50. Whether legal or illegal, induced abortion is usually stigmatized and frequently censured by political, religious, or other leaders. Hence, under-reporting is routine even in countries where abortion is legally available50, 51. The use of varying terms, such as induced miscarriages, menstrual regulation, mini-abortion, and regulation of delayed or suspended menstruation, further compound the problem of producing reliable and comparable estimates of the prevalence of unsafe abortion52. Community studies around the World indicates a higher magnitude of unsafe abortion than do health statistics53, 54, 55. Estimates show that women in South America, East Africa and West Africa are more likely to have an unsafe abortion than are women in other regions20. Unsafe abortion rates per 1000 women aged 15-44 years provide a more comparable measure of unsafe abortion by region. In Asia, South- Central and South- Eastern regions have similar unsafe abortion rates (22 and 21 per 1000 women respectively) whereas the rate is about half (12 per 1000) in Western Asia and negligible in Eastern Asia (where abortion is legal on request and easily available)20.
Unsafe abortions vary substantially by age across regions; adolescents (13-19 years) account for 25% of all unsafe abortion in Africa; whereas the percentage in Asia, Latin America, and the Caribbean is much lower. By contrast, 42% and 33% of all unsafe abortions in Asia and Latin America, respectively, are in women aged 30-44 years, compared with 23% in Africa56. For the developing regions as a whole, unsafe abortions peak in women aged 20-29 years. Temporal trends in 15 unsafe abortion have been inconsistent internationally. Between 1995 and 2000, a decline of 5 or more percentage point took place in Eastern, Middle and West Africa, the Caribbean and Central America. Other developing areas had no appreciable change in the rate of unsafe abortion49.
On the basis of WHO estimates, if current rates prevail, throughout women’s reproductive life-times, women in the developing world will have an average of about one unsafe abortion by age 45 years56.
Reasons for seeking abortion are varied; socio-economic concerns (including poverty, no support from partner, and disruption of education and employment); family-building preferences (including the need to postpone child-bearing or achieve a healthy spacing between births), relationship problems with the husband or partner, risk to maternal or fetal health; and pregnancy resulting from rape or incest57. More proximate causes include poor access to contraceptives and contraceptive failures57.
Methods used for Inducing Abortion.
Nearly 5000 years ago, the Chinese Emperor Shen Nung described the use of mercury for inducing abortion58. Although one publication20, lists over 100 traditional methods used for inducing abortions, unsafe methods today can be divided into several broad classes; oral and injectable medicines, vaginal preparations, intrauterine foreign bodies, and trauma to the abdomen. Other agents documented to have been used by women to procure abortion include detergents, solvents, and bleach. Some women in developing countries rely on teas and concoctions made from local plants or animal products, including dung29. Foreign bodies inserted into the uterus to disrupt the pregnancy often damage the
16 uterus and internal organs including bowel29. In setting as diverse as the Pacific and Equatorial Africa, abortion by abdominal massage is still used by traditional practitioners59. The vigorous pummeling of the woman’s lower abdomen is designed to disrupt the pregnancy but sometimes burst the uterus and kills the women instead59.
The primitive methods used for unsafe abortion show the desperation of the women. Surveys done in New York City before the legalization of abortion on request documented the techniques in common use 60. Of these reported abortion attempts, 80% tried to do the abortion themselves and nearly 40% of women used a combination of approaches. In general, the more invasive the technique the more dangerous it was to the women and the more likely it was to disrupt the pregnancy58. Invasive methods such as insertion of tubes or liquids into the uterus were more successful than were other approaches 61. Coat hangers, knitting needles, and slippery elm bark were common methods60, 61. The bark would expand when moistened, causing the cervix to open. Another widely used method was to place a flexible rubber into the uterus to stimulate labour. Surveys suggest that miscellaneous methods and oral medications such as laundry bleach, turpentine, and massive doses of quinine, were most commonly used in New York60.
Injection of toxic solutions into the uterus with double bags or turkey basters was common. Absorption of soap solutions into the woman’s circulation could cause renal toxicity and death62. Potassium permanganate tablets placed in the vagina were also common; these did not induced abortion but could cause severe chemical burns to the vagina, sometimes eroding through to the bowel63.
17 Legalization.
The most important public health effect of the legalization of abortion was the near elimination of deaths from illegal abortions in the United States3. Illegal abortion deaths are disproportionately due to infection 3, 4. In a 1994 U.S. review, 62% of illegal abortion deaths and 51% of spontaneous abortion deaths were from infection; whereas only 21% of legal abortion deaths were from infection64. The risk of death from post-abortion sepsis is greatest for younger women and unmarried women, and it is more likely with procedures that do not directly evacuate the uterine content9. With more advanced gestations, the risk of perforation and retained tissue increases9. Delay in the treatment allows progress to bacteraemia, pelvic abscess, septic shock, renal failure and death9, 10, 11. United States maternal deaths from all causes have declined rapidly since 194065; while non- abortion maternal mortality declined steadily, abortion mortality exhibited three phases; an initial decline until 1950, a plateau from 1951 to 1965, and then a very rapid decline from 1965 to 1976 (more rapid than that of maternal mortality from other causes); as legal abortion became increasingly available. In 2003, the last year for which complete data were available, 10 deaths were reported of 1,287,000 legally induced abortions for a case fatality rate of 0.8 per 100,000 legal abortions 66, 67. By comparison, in the 1940s, over 1000 women per year were known to have died from abortion in the United States 3. The American Medical Association’s Council on Scientific Affairs has attributed the marked decline in abortion deaths in that country to the introduction of antibiotics to treat sepsis, the widespread use of effective contraception beginning in the 1960s, which reduced the numbers of unwanted pregnancies and more recently, the shift from illegal to legal abortion30.
18 The experience in Western Europe has been very similar to that in the United States. With legal abortion becoming widely available and very low rates of abortion mortality currently reported 48. Overall, maternal mortality from legal abortion in Europe is less than 1.0 per 100,000 procedures. Death rates are somewhat higher in the former Soviet Union, where the special problem of illegal abortion with a markedly higher risk of death has emerged 68.
In the 3rd World Countries, abortion remains a major cause of maternal death. The WHO estimates that 68,000 deaths from unsafe abortion occur in the world every year, about 13% of all maternal deaths 21, 29. A WHO working paper summarizing the world literature after 1960 lists almost 400 published reports of abortion morbidity and mortality and concludes that “unsafe abortion is one of the greatest neglected problems of health care in developing countries” 69.The proportion of maternal deaths that result from unsafe abortion is probably considerably larger than reported. Where abortion is illegal, women and health care professionals are reluctant to report that abortion was induced 70. Private personal dialogue with women by trained, empathetic case workers reveals a higher proportion of induced abortions 71.
Abortion-Related Death Statistics.
The preventable morbidity and mortality from septic abortion are staggering and well-documented 29. A 1992 report of Guinea in West Africa, reported an investigation of all maternal deaths in the capital from July 1, 1989 to June 30 1990, found that abortion constituted 17% of maternal deaths 21, 80% of the abortion deaths were known to be from induced abortion; and sepsis was the most common cause of death31. A study from 5 hospitals in Kampala, Uganda, in East Africa, for the period 1980 to 1986 found 20% of maternal deaths to be 19 abortion-related 32. A Nigerian study reported that 35% of hospital maternal mortality was from abortion, and sepsis was the most common cause of death 4. A 7- year review of abortion at the University College Hospital in Ibadan, Nigeria, reported that abortion complications represented 76.7% of all emergency gynaecological admissions33. A population based survey in rural Bangladesh identified 387 maternal deaths from 1976 to 1985 (555 per 100,000 live birth) 72, abortion constituted 18%. In 1990, 36 hospitals and medical schools from 4 Latin American countries participated in a multinational survey of all women attending for abortion during a 6-month period 73. During this time, 14,501 abortion admissions were recorded and 8,871 were investigated (113,714 births); 15% of the abortions were classified as “Septic” on admission; 43 women of the 8,871 required hysterectomy and 36 women died, producing an abortion maternal mortality ratio of 406 per 100,000 women admitted for abortion. Although hemorrhage was the most common abortion complication, 75% of the deaths were in women admitted as “septic”. The problem may actually be escalating in some areas as shown by a 10-year review from Rio de Janeiro which found maternal mortality to have increased almost 4-fold from 1978 to 1987 (128 per 100,000 to 462 per 100,000). Abortion related deaths accounted for 47% of the total mortality7.
More recent reports from many countries echo the same dismal findings. A report of a 10-year study from rural India, published in 2001, found that 41.9% of all maternal deaths were from septic abortion and the total maternal mortality rate was extra-ordinary (785 per 100,000 live births) approximately 100-fold greater than maternal mortality in developed countries 6.
20 As shown in all these studies, abortion deaths are primarily from sepsis. Complications of unsafe abortion that may cause a woman’s death include haemorrhage, genital tract sepsis, trauma to the cervix, uterine perforation and trauma to the surrounding organs such as urinary bladder and intestine, acute renal failure, etc 5,15,21. When women suffer these complications, the lack of appropriate information and local negative attitudes towards abortion, coupled with fragile health and social infrastructure in many of these countries often prevent women from receiving quality post-abortion care that could save their lives. Unsafe abortion is also a significant cause of long-term morbidity in women in developing countries, including chronic pelvic pain, secondary infertility, ectopic pregnancy and recurrent pregnancy loss 5, 37.
Socio- economic, Religious, Political and Medico-Legal Factors.
Although women die from complications of induced abortion, it is the social, legal (restrictive abortion laws), cultural and economic contexts under which abortion takes place and under which women lead their lives in developing countries, that pave the way for these complications and eventual mortality. Of the 107 countries around the world that either prohibit or strongly restrict access to safe abortion services, Poland and Republic of Ireland are the only industrialized countries74. The rest are developing and low-income countries in Africa, South-East and Central Asia and South America and the Caribbean. Abortion laws in developing countries were derived from laws of European colonizers. While these European countries notably Britain, France, Portugal and Spain have modernized their laws, many of the colonized countries have continued to maintain the old laws despite years of independence and freedom 55. However, contrary to the expectation of protagonists of these laws, restrictive abortion have not prevented abortion in
21 these countries. The laws have merely commercialized and driven the practice of abortion underground. Available data indicate that more than 30% women seeking termination of pregnancy in countries with restrictive abortion laws may experience moderate to severe complications 53.
Socio-economic, cultural and religious factors also militate. In countries with restrictive abortion laws, abortion services provided by skilled providers are often expensive and not affordable and accessible to women of low socio-economic status. Even when abortion laws are more liberal, adverse socio-economic, cultural and religious factors may prevent women from seeking services. As a result of pervading religious and cultural views, women with unwanted pregnancies fail to seek services in public health institutions even when the law allows the provision of such services. A classic example is India 75,76, where religious sentiments prevent women from seeking legal and safe abortion services provided in public health institutions. By contrast, women with unwanted pregnancies in India continue to patronize illegal back-street abortionists despite the fact that the law permits abortion on broad social grounds. This situation makes India one country with continuing high rate of abortion-related maternal mortality in the developing world. Women with complications are more likely to be adolescents or poor, since poverty and being young increase the likelihood that women will seek inexperienced back-street abortionist or use dangerous methods for procurement of abortion. When such women suffer complications they are less likely to seek treatment with skilled providers in public health institutions because of perceptions relating to high cost of treatment in such institutions 77. By contrast, data from sub-Saharan Africa indicate that women tend to seek the same inexperienced providers that procured unsafe abortion for treatment of the complications, with resulting delayed appropriate treatment and high mortality 77. 22 Service delivery systems that investigate the prevention and management of abortion complications are often lacking in developing countries. In Zambia and Ghana, two countries with liberal abortion laws in Africa, the lack of strong service delivery systems that integrate abortion and post- abortion care is the major reason why women still suffer complications of unsafe abortion in both countries 55,78,79. Women and many providers in these countries are not even familiar with opportunities provided to them under the law to terminate unwanted pregnancies safely, and policy-makers do not regularly provide and disseminate clear guidelines and procedures for abortion and post- abortion care in the two countries. In Indonesia, the negative attitudes of providers often prevent women from seeking “menstrual regulation” that is provided by the Ministry of Health 80. These negative attitudes by health providers are also carried over to women who suffer complications of induced abortion and are referred to public hospitals for treatment.
PREVENTION
Strategies for reducing abortion mortality include health education and the implementation of post-abortion care 22. The term ‘Post-abortion care’ (PAC) was proposed by IPAS in its 1991 strategic planning document which sought to encourage the integration of post-abortion care and unwanted pregnancy and improving the overall health status of the women in the developing world 81. In 1994, IPAS published the original post-abortion care model, which comprised three elements; (a) emergency treatment services for complications of spontaneous or unsafely induced abortion, (b) post – abortion family planning counseling and services; and (c) links between emergency abortion treatment services and comprehensive reproductive health care 28.
23 The problems of abortion mortality in developing countries would be best addressed at the levels of primary prevention; secondary prevention and tertiary prevention 17.
Primary prevention avoids the occurrence of disease or injury. Primary prevention of septic abortion includes access to effective and acceptable contraception (to prevent unwanted pregnancies that lead to induced and unsafe abortion); access to safe, legal abortion in case of contraception failure, and appropriate medical management of abortion. Pregnancy places women at risk of illness and death. Unwanted pregnancy places a woman at additional risk if she seeks abortion and safe services are not available 82, 83.
Reducing unwanted pregnancies is a goal to which both sides in the abortion controversy can agree, although the means to that end diverge. A prerequisite to preventing unwanted pregnancy in all nations, is social equality; the elevation of woman’s status so that they can avoid coercive sexual relationship and use contraceptive methods that they regard as safe and free of side effects 83,84. In the United States, age-specific abortion ratios make it clear that women at greatest risks for unwanted pregnancy are adolescents and young adults 85. National Surveys consistently shows 11 – 12% of reproductive age women to be sexually active with no contraception 86. The continued low contraceptive prevalence rates in developing countries accounts for the high rate of unwanted pregnancies that lead to unsafe and induced abortion-related mortality 87. Data from United Nations Family planning Agency (UNFPA) 88 , indicate that the prevalence of modern contraceptive use is currently around 55% for Asia, 49% for Latin America and the Caribbean, and only 15% for Sub-Saharan Africa, with large unmet needs for contraception in many of these countries89.
24 The need for safe legal abortion is nowhere more clearly shown than in the Romanian experience. When abortion was outlawed in the 1960s, the abortion- related maternal mortality rose 10-fold. An estimated 10,000 women died from this policy over the 23 years of its imposition90. The death rate fell only when abortion was legalized. The public health message of this bizarre natural experience is clear. When abortion is legal and accessible, women’s health improves and vice-versa. No evidence supports the claim that restricting abortion reduces the number performed. Abortion rates and ratios are as high or higher in countries in which it is legal and readily available 91. The risk from abortion rises with gestational age, increasing in the second trimester 64, 92. Therefore, safe services are needed early in pregnancy. Access is especially a problem for disadvantaged women, including the young, who in many jurisdictions must seek consent from their parents for abortion, but who may continue a pregnancy, a far- more dangerous course, on their own 93.
The technology for first trimester abortion is not complicated. In the first trimester and early mid-trimester, abortion is readily performed by vacuum curettage in an out-patient or office setting 94,95 . Prophylactic antibiotics reduces the risk of febrile morbidity after abortion 96.
Secondary prevention requires early detection and treatment, with the goal of halting the disease process 16. Secondary prevention of septic abortion entails prompt diagnosis and effective treatment of endometritis to avoid more serious infection. The diagnosis of septic abortion must be suspected when any reproductive age woman presents with vaginal bleeding, lower abdominal pain and fever. A common theme in reported deaths from septic abortion is delay; young or unmarried women often conceal the abortion and delay seeking help
25 until moribund. With more advanced gestations, there is greater risk of perforation and of retained tissue. Perforation markedly increases the risk of serious sepsis 9. Illegal abortion by insertion of rigid foreign objects increases the risk of perforation 60. Intrauterine instillation of soaps poses a special hazard for uterine necrosis and renal failure 62. Disseminated sepsis is suggested by high fever and prostration; tachycardia, tachypnoea, respiratory difficulty and low blood pressure 9, 97.
The bacteriology of septic abortion is usually polymicrobial, derived from the normal flora of the vagina and endocervix with the important addition of sexually transmitted pathogens 35. Gram-positive and gram-negative aerobes and facultative or obligate anaerobes, Neisseria gonorrhoeae and Chlamydia trachomatis are all possible pathogens 9. In the United States, infection with Clostridium perfringens – is largely associated with illegal abortion 9, 97. Recently Clostridium sordellii has been the cause of death in small number of women treated with Mifepristone and vaginal Misoprostol for early medical abortion 98. In the third world countries, tetanus contributes to septic abortion deaths 29. Because of the variety of bacterial agents found in infected abortions, no one antibiotic agent is ideal. The recommended regimens of the Centres for Disease Control and Prevention for out-patient management of Pelvic Inflammatory Disease (PID) are appropriate for patients with early post-abortal infection limited to the uterine cavity. One such regimen is ceftriaxone 250mg by intramuscular injection (or other third generation cephalosporin such as cefoxitim, ceftizoxime or cefotaxime) plus doxycycline 100mg orally twice a day for 14 days, with or without metronidazole 500mg orally twice a day for 14 days 99 .Because of the spread of quinolone resistant gonococcus, quinolone regimens are no longer first choice for
26 out-patient management of PID in the US 100. Evaluation of the patient at 48 hours is essential, with hospitalization if fever and pain persist.
Tertiary prevention minimizes the harm done by the disease and avoids disability 16. Tertiary prevention of septic abortion seeks to avoid serious consequences of infection including hysterectomy and death. Patients with more established infections as indicated by temperature elevations (arbitrarily defined as > 38oc), pelvic peritonitis, or more severe disease, should be hospitalized for parenteral antibiotic therapy and prompt uterine evacuation. Bacteraemia is more common with septic abortion than with other pelvic infections; septic shock and adult respiratory distress syndrome (ARDS) may result 60. Management of severe sepsis requires eradication of the infection and supportive care for the cardiovascular system and other involved organs systems 9,101.
Management
Urine, blood and cervical cultures should be ordered, and high dose broad spectrum antibiotics are begun intravenously. Cervical swab has been shown to be the best specimen for the laboratory diagnosis of septic abortion 36, 102. Examination of the Gram-stained material can guide early management. One – time-honored regimen for severe pelvic sepsis is penicillin (5m units intravenously (iv) every 6 hours) or Ampicillin (2-3g IV every 6 hours) combined with an aminoglycoside, either Gentamycin or Tobramycin (2mg/kg) loading dose, followed by 1.5mg/kg every 8-hours depending on blood levels or renal status. Either metronidazole (15mg/kg initially followed by 7.5mg/kg every 8 hours) or clindamycin 900mg IV every 8 hours is added103.
27 Remaining products of conception must be evacuated without delay as soon as antibiotics therapy and fluid resuscitation are begun. Hesitation of physicians to evacuate the uterus because of the poor condition of the patient is a common theme in fatal septic abortion in the United States 9. Vacuum curettage is readily accomplished with patient under local anaesthesia with minimal intravenous sedation.104
A retained fetus from mid – trimester abortion poses a special challenge. Evacuation by a curettage procedure may cause serious complications, that is, damage to uterus and other pelvic organs through perforation. Hence a medical means for uterine evacuation is preferred using Misoprostol, a postalglandin E1 analogue. Mistoprostol has fewer side effects than the older prostaglandins and is inexpensive, stable at room temperature and widely available 105. Vaginal or sublingual doses of 400µg at 3 – hourly intervals are highly effective for inducing abortion in the mid-trimester 106,107.
Alternatively, high-dose oxytocin can be used. 50 units of oxytocin is given in 500ml of 5% dextrose in normal saline over a 3-hour period (approximately 278.u/min). This is followed by a 1 – hour rest and repeated, adding 50 additional units to the next 500ml infusion, and continuing with 3 hours of infusion and 1 hour of rest. This is repeated until the patient aborts or a final solution of 300 unit oxytocin in 500ml is reached (1667m.u/min) 108.
Another option is a metreurynter: a Foley catheter with a 50 – cm3 balloon is placed in the lower uterus and the balloon inflated to 50 – 70cm3. One kilogram of traction at the foot of the bed is then attached to the catheter. This dilates the cervix and facilitates expulsion109.
28 Laparotomy will be needed if the patient does not respond to uterine evacuation and adequate medical therapy. Other indications are uterine perforation with suspected bowel injury, pelvic abscess, and clostridial myometritis 97. Although ultrasound – guided percutaneous needle aspiration of pelvic abscesses is practiced, the technique is still new, and in critically ill women with severe post- abortal sepsis, hysterectomy will likely be needed in addition to drainage of any abscess. A discoloured, woody appearance of the uterus and adnexa, suspected clostridial sepsis, crepitations in the pelvic tissues, and radiographic evidence of air within the uterine wall, are indications for total hysterectomy and possible removal of both uterine adnexae. 97.
Death and serious complications from abortion – related infection are almost entirely avoidable. Unfortunately, prevention of death from abortion remains more a political than a medical problem. Although leaders in international health have repeatedly drawn attention to abortion complications and maternal mortality, many government and health care agencies still lack the moral courage to confront the problem 110.
29
STATEMENT OF OBJECTIVES
1. To determine the bacteriological profile and sensitivity pattern of endocervical isolates in patients with post-abortal sepsis at the LIMH.
2. To give recommendations on the choice of antibiotic agent(s) for immediate use as 1st line regimen.
30 MATERIALS AND METHODS
STUDY SITE
The study was carried out at the Emergency Department of Lagos Island Maternity Hospital, (LIMH), Lagos. Lagos, a metropolitan city in Southwestern Nigeria, in Lagos State, is located on the Bight of Benin (an arm of the Atlantic Ocean). Lagos is Nigeria’s largest city, chief port and principal economic and cultural centre; and former Nigerian Capital until 1991. LIMH is the oldest and largest maternity centre in Lagos State and indeed in Nigeria and the West African Sub-region. It is a major referral centre in the management of post-abortion complications, receiving referrals from private, primary and secondary (tier) health institutions in all local government areas of the state.
STUDY DURATION The study was conducted from 1st of February 2011, to 31st of January 2012.
STUDY DESIGN This was a prospective cross sectional study.
STUDY POPULATION Patients presenting with complications of abortion (induced or spontaneous) at the emergency room of the Lagos Island Maternity Hospital (LIMH), who satisfied the inclusion criteria were recruited for the study.
31 ETHICAL CONSIDERATION The study was carried out after obtaining approval from the Ethics and Research Committee of Lagos Island Maternity Hospital, that the study shall be used only for research purpose, would be safe and would not expose the patients to any risk (patient would not be made worse by the study). A condition of complete confidentiality (anonymity) was guaranteed to minimize stigmatization by using coded questionnaires and laboratory samples were serially code labeled.
INCLUSION CRITERIA.
Patients with history of spontaneous miscarriage or induced abortion (legal or illegal); patients with symptoms suggestive of sepsis such as abdominal pain, fever, bleeding per vaginum with offensive vaginal discharge; patients who had not commenced antibiotics on admission, and patients who had consented to participate in the study after being duly informed and counseled were recruited.
EXCLUSION CRITERIA
Patients with initial wrong diagnosis of septic abortion and later found to be having pelvic inflammatory disease, endometritis ( following normal delivery or operative delivery) patients who had dilation and curettage done before diagnosis of ectopic pregnancy was made, patients with multiple organ damage such uterine perforation involving the guts, damage to urinary bladder, retroviral-positive patients, unconscious patients, and patients already on antibiotic treatment following admission were excluded from the study.
32 SAMPLE SIZE DETERMINATION
The sample size for single proportion was determined using the formula 111
N = Z2 P (1-P)
D2
Where N = minimum sample size required for the study.
Z= standard deviation usually 1.96 at 95% confidence level
P= prevalence rate in the population based on literature (15%)* 73
D= margin of sample error acceptable or precision rate (5%) degree of accuracy required:
N = (1.96)2 x 0.15 x (1 - 0.15)
(0.05)2
=195.9
In order to increase the confidence interval, power of the study and have adequate data for sub-cell analysis for relative risk determination and make up for loss of subjects, a sample size of 250 was projected.
SAMPLING TECHNIQUE
Consecutive patients presenting with post-abortal sepsis, (i.e. using convenience sampling method), were recruited for the study, following the inclusion and exclusion criteria.
33 DATA COLLECTION METHOD
This will be divided into BIO-DATA collection, sample collection and laboratory processing of specimen.
BIO -DATA COLLECTION
Questionnaires were administered to the patients by the researcher/registrars in the emergency room. Information obtained from the patients included their age, parity/past obstetric history, occupation, marital status, gestational age at termination/miscarriage, number of previous termination/miscarriages, methods of termination, location: at home or hospital, personnel performing abortion, reasons for termination, drug usage post termination, contraceptive history, awareness of legality or illegality of abortion, view on legalization, interval between termination and presentation.
SAMPLE COLLECTION AND LABORATORY PROCESSING OF SPECIMEN
The sample size of 234 patients was collected over 12-month period. Each patients either coming directly from home or following referral from private hospitals or sister public health facilities in the state, admitted into the emergency room, were informed about the study. Detailed history was obtained and thorough physical examinations were carried out by the researcher or the registrar on duty, on women admitted for suspected septic abortion. A questionnaire was administered to each eligible patient. Endocervical swabs and blood samples were obtained at the point of admission before commencement of antibiotics.
34 ENDOCERVICAL SAMPLING:
Having obtained informed consent for the procedure the patient was placed in dorsal position. Using aseptic technique, the labia were patted with the thumb and index fingers of the left hand and the right hand used to clean the vagina from anterior to posterior, using sterile cotton wool balls soaked with water. A sterile bivalve (Cusco) speculum was introduced into the vagina, and opened to expose the cervix. A sterile swab stick was introduced into and rotated inside the endocervix to collect endocervical sample.. The swab end of the stick was cut short with a sterile scissors and the stump dropped into peptone water broth in a Bijou bottle, to preserve, and as transport medium to the Microbiology Research Laboratory at LASUTH, Ikeja, within 24 hours of collection.
Blood agar or MacConkey agar made from sheep blood was used to culture the organisms. The various media used in this study were manufactured by OXOID LTD 112. The media were prepared according to the manufacturer’s instructions. They were poured into sterile Petri – dishes and allowed to set.
On getting to the lab, each endocervical sample was immediately plated out on blood agar viz:
A sterile loop was used to smear a loop-full of the sample on the medium in the Petri-dish. The inoculated agars were incubated (Memmerat Incubator) aerobically at 370c for 18-24hours. After incubation, isolates were observed, read morphologically and gram stained for identification of organisms
BLOOD SAMPLING
A patch of skin approximately 7.5cm in diameter over a convenient peripheral vein was prepared by cleaning thoroughly with methylated spirit followed by povidone 35 – iodine, followed again by methylated spirit. Application of povidone iodine was done in concentric circles moving outwards from the centre. The skin was allowed to dry for 1-2 minutes before samples were collected.
20.0mls of venous blood was collected by the researcher or the registrar on duty from the prepared peripheral vein and was inoculated into Oxoid Signal blood culture broth (Oxoid Basingstoke UK, batch numbers BC0102M – 779346, 773416, 765892 and 759931)
Samples were immediately taken to the Microbiology laboratory in LASUTH, for processing according to the manufacturer’s specification. The cap of the Oxoid Signal Bottle was cleaned thoroughly with methylated spirit before applying the Oxoid Growth Indicator.
The Oxoid Signal System is a one-bottle system. After blood is inoculated into the bottle, a clear plastic cylindrical signal device is attached to the top of the bottle. A long needle from the lower end of the device extends below the surface of the blood – broth mixture creating a closed system. Samples were mixed intermittently for an hour and incubated (Memmerat incubator) at 37oC for seven days. Gases produced as a bye-product of microbial growth increase the pressure in the headspace and force some of the blood-broth mixture through the needle into the cylinder thereby “signaling” a positive culture.
Sample growth indicators were examined on daily basis for positive growths. Those with suspected microbial growth were sub-cultured into blood agar or MacConkey agar made from sheep blood. The microbial agars were incubated in the incubator at 37oc for 24 hours and isolates were gram stained for identification.
36 GRAM STAINING
A loop of distilled water was transferred to the centre of a previously labeled, clean and grease- free glass slide. A sterile wire loop was used to pick a discrete colony and emulsified with a drop of distilled water in a circular manner to make a thin smear. The smear was allowed to dry at room temperature and then fixed by passing the slide over gentle Bunsen burner flame,3 or 4 times, to prevent the material from washing off during the staining procedure.
Placed on a staining rack, the slide was then flooded with Crystal Violet solution for about one minute, then washed with free flowing tap water for about 5 seconds. The slide was then flooded with Lugol’s iodine solution for about one minute after which it was washed with tap water for another 5 seconds. Holding the slide between the thumb and index fingers, decolorization was carried out by flooding the slide with plain Acetone ( or Methylated Spirit) for 1-3 seconds or until such time as no more blue colour runs out of the smear. The acetone was then washed off with tap water, after which the smear was counterstained by flooding the slide with Neutral red or Saffranin for about one minute and then washed off with water. The slide was then placed upright on a staining rack to allow excess water to drain off and the smear to dry at room temperature.
MICROSCOPY
A drop of immersion oil was placed on each slide, which was then viewed under the microscope with X100 objective (High power magnification). Organisms that stained blue or purple on microscopy were categorized as Gram-Positive, while those that stained pink or red were categorized as Gram-Negatives. Spherical or
37 round shaped organisms were taken as Cocci, while rod-shaped organisms were taken as Bacilli.
BIOCHEMICAL TESTS
GRAM POSITIVES
1. Catalase test The catalase test was performed on Gram positive organisms to differentiate between staphylococci that are catalase positive and streptococci that are
catalase negative. A drop of 3% Hydrogen peroxide (H202) solution was placed at the centre of a clean and grease free slide. With a sterile wire loop, a colony of suspected pure growth was picked and emulsified with the
3% H202 solution. An immediate reaction with the appearance of bubbles confirmed the organisms to be catalase positive, absence of bubbles signifies catalase negative.
COAGULASE TEST The coagulate test is used to differentiate between staphylococcus aureus and other species of staphylococcus. Staphylococcus aureus is coagulase positive while others are not. Catalase positive isolates were subjected to coagulase test using plasma from sheep blood. A drop of sterile distilled water was placed at the centre of a clean and grease-free slide. A colony of the suspected pure isolate was picked with a sterile wire loop and emulsified with the distilled water. A drop of plasma from sheep blood was then added to it and mixed carefully. The appearance of agglutination signifies coagulase positive which indicates Staphylococcus aureus. Such isolates were later confirmed with Staphaurex 38 test. Agglutination of cells with staphaurex indicates Staphylococcus aureus while absence of agglutination of cells indicates other Staphylococcus species. Absence of agglutination of bacterial cells in the plasma from sheep blood in the coagulase test signifies coagulase negative which indicate other species of Staphylococcus, which were later subjected to Novobiocin sensitivity test.
NOVOBIOCIN TEST
The Novobiocin test was used to differentiate between Staphylococcus epidermidis and Staphylococcus sapophyticus. Pure isolate of Staphylococcus was plated on Muetter – Hinton agar using the swab techniques. Novobiocin antibiotics disc was placed on the preparation and incubated for 18-24 hours. Zone of inhibition of growth of 17mm and above signifies Novobiocin positive test, which indicates Staphylococcus epidermidis, while zone of inhibition less than 17mm signifies novobiocin negative, which indicates Staphylococcus saprophyticus.
GRAM NEGATIVES
OXIDASE TEST
The oxidase test was used to differentiate Pseudomonas aeroginosa from other Gram negative organisms. Gram negative rods were subjected to oxidase test using oxidase strips from Oxoid Basingstoke, U.K. This was done by flaming a non- toothed dissecting forceps. This was used to pick up an oxidase strip which was placed on an agar plate. Sterile tooth-pick was used to pick a suspected colony of pure isolate, which was rubbed or spread on the surface of the oxidase strip and left for about 5 seconds. The appearance of a blue – black coloration 39 indicates oxidase positive organism, usually Pseudomonas aeroginosa while absence of blue-black coloration after 5 seconds indicates oxidase negative.
Pseudomonas was further confirmed by passing a loopful of the isolate through ultraviolet light when florescence occurs.
MICROBACT 12A &12B Kits were used for further differentiation of the organisms present in the endocervical sample. These kits have wells which contain different types of sugar which react with the bacteria to produce different colours in the wells ,Colonies of oxidase positive and oxidase negative isolates were transferred from the agar to labeled peptone broth, mixtures shaken and kept in the incubator for an hour. Using a sterile syringe, four drops of the oxidase positive isolates were introduced into each well of the Oxoid microbact for identification of enteric organisms (Microbact 12A & 12B, batch number 1067670 and 1067178 respectively) for oxidase positive Gram negative organisms; microbact 12A, batch number 1067670 for oxidase negative Gram negative organisms. A drop of mineral oil was placed into each of the black coloured wells to prevent the enzymes from drying up. The impregnanted microbact were incubated in the incubator for 24hours. After 24 hours, the wells were inspected and the colours produced from sugar fermentation by the bacteria in the wells, were compared with the Oxoid microbact colour chart and each colour was given a corresponding code/score. The scores imputed into the Oxoid microbact software for the identification of the Gram negative organisms. With the codes imputed into the software, the software produces the name of the organisms.
40 SENSITIVITY
24-hours pure isolates were inoculated into peptone water and incubated at 370c for an hour and the growth turbidity was compared with 0.5 % concentration of Mcfarland Equivalence standard for turbidmetric comparison of bacterial suspension. The preparation was then streaked onto the surface of the plate using swab stick in a uniform manner. Antibiotic discs for Clindamycin, (DA); Ciprofloxacin (CIP); Levofloxacin (LEV), Amikacin (AK); Amoksiklav, (Augmentin) (AMC); Erythromycin (ERY) and Ceftazadime (CAZ)manufactured by Oxoid Ltd, were used together with Mueller-Hinton broth and Mueller-Hinton Agar to test the antibiotic sensitivity of the microorganisms present in the samples of endocervical swab. Single discs of the antibiotic discs were then placed on the surface of the Mueller-Hinton Agar plate following the WHO recommended way of setting up sensitivity. The plates were incubated at 370C for 24 hours and observed for zones of inhibition. After 24hours incubation, zones of inhibition of growth were read using a metric ruler to measure the diameter of the zones of inhibition of growth created by the antibiotic disc. The sensitivity results were interpreted according to clinical and laboratory standard (CLSI), 2008 113. Only single isolates were taken as significant in this study. Mixed isolates were disregarded.
41
DATA PROCESSING AND STATISTICAL ANALYSIS.
The data obtained was processed and analysed using Statistical Package for Social Sciences version 16.0 (SPSS, Inc 2001, Chicago III), a statistical computer programme .
Frequency tables were presented for all variables (age of patients, occupation, parity, Gram reaction, distribution of organisms, antibiogram, etc).
Susceptibility patterns of all isolated organism were determined by running a cross- tabulation between the isolates and antibiotics.
Susceptibility patterns of Gram – ve rods and Gram +ve Cocci were also determined by running a cross –tabulation between the results of Gram stain reactions and the antibiotics.
Descriptive statistics (minimum, maximum, mean, and standard deviation) were calculated for continuous variables. Percentages were used to assess proportions in categorical variables.
Pearson’s Chi-sphere (a non- parametric inferential statistical procedure) was used to assess relationship between categories variables.
P-value less than 0.05 was considered to be statistically significant. (Confidence level = 95%).
42 RESULTS
AGE DISTRIBUTION
TABLE 1: The age distribution amongst septic abortion patients.
Age (in years) No. of Patients Percentage (%) 15 – 19 17 7.3 20 – 24 57 24.4 25 – 29 52 22.2 30 and above 108 46.1 TOTAL 234 100 The minimum age recorded among the patients suffering from septic abortion was 16 years, while the maximum age was 35 years. The median age was observed to be 26 years. Majority of the patient with post-abortal sepsis, that is, 108 (46.2%) were 30 years and above. Seventeen (7.3%) of the patients were 15-19 years of age, 57 (24.4%) of the patients were 20-24years, and 52(22.2%) were 25-29 years.
MARIAL STATUS
TABLE II: The marital status of the patients.
Marital status No. of Patients Percentage (%) Single 66 28.2 Married 160 68.4 Co – habiting 8 3.4 TOTAL 234 100 Table II reveals that about two-third of the patients 160 (68.4%) were married; 66(28.2%) were single, while 8 (3.4%) were co-habiting.
43
OCCUPATION
TABLE III: Occupation of the patients
Occupation No. of patients Percentage (%) Unemployed 28 11.9 Student 23 9.8 Artisan/craftsman 28 12.0 Petty trader 81 34.6 Salaried worker 54 23.1 Others 20 8.6 TOTAL 234 100.0
Table III shows that 28(11.9%) of the patients were unemployed, 23(9.8%) were students; 28(12.0%) were artisans or craftmen; 81(34.6%) were petty traders; 54(23.1%) were salaried workers, while 20 (8.6%) had other forms of occupation.
EDUCATIONAL STATUS
TABLE IV: The educational status of the patients.
Educational level No. of Patients Percentage (%) None 9 3.8 Primary 32 13.7 Secondary 130 55.6 Tertiary 63 26.9 TOTAL 234 100.0 Table IV reveals that 32(13.7%) of the patients had only primary school education; 130 (55.6%) of the patients had up to secondary school education; 63(26.9%) had tertiary while 9(3.8%) of them had no formal education.
44 PARITY/PAST OBSTETRICS HISTORY
TABLE V: Past obstetric history of the patients.
Characteristics No. of Patients Percentage No. of Previous Pregnancies 0 (None) 106 45.3 1 – 2 97 41.5 3 – 4 29 12.4 5* and above 2 0.8 TOTAL 234 100.0 No. of deliveries No. of Patients Percentage 0 (Nil) 96 41.0 1 – 2 86 36.8 3 – 4 46 19.7 5 and above 6 2.5 TOTAL 234 100 No. of living Children No. of patients Percentage 0 none 117 50.0 1 – 2 65 27.8 3 – 4 49 20.9 5 and above 3 1.3
TOTAL 234 100.0
45 No. of previous abortion No. of Patients Percentage 0 112 47.9 1 70 29.9 2 27 11.5 3 15 6.4 4 9 3.9 5 1 0.4 TOTAL 234 100
One hundred and six (45.3%) had never been pregnant before; 97 (41.5%) have had 1 or 2 previous pregnancies. Eighty-Six (36.8%) have had 1-2 deliveries. The maximum number of living children recorded amongst the respondents was 5. Sixty-Five (27.8%) had 1-2 living children. Half of the patients 117(50%) had no living children.
The maximum number of previous induced abortion or miscarriages recorded was 6. Ninety-Seven (41.4%) have had 1-2 previous induced abortions, while 25 (10.7%) have had more than 2 previous abortions. One hundred and twelve (47.9%) of the patients never had a previous abortion.
In the index abortion, 178(76.1%) of the patients had induced abortion, while 56(23.9) were said to be spontaneous abortion.
The minimum estimated gestational age (EGA) when abortion was performed was 4 weeks, while the maximum EGA was 26weeks. The modal estimated gestation age was 12 weeks. One hundred and thirty-nine (71.3%) of the patients
46 performed their abortion in the 1st trimester (<13 weeks), while 56(28.7%) had their abortion in the 2nd trimester.
PROCUREMENT OF ABORTION
TABLE VI: Interval between procurement of abortion and presentation.
Duration (Days) No. of patients Percentage %
1 – 3 5 2.2
4 –6 88 38.1
7 and above 138 59.7
TOTAL 231 100.0
Table VI show that 5 (2.2%) of the patients presented at the clinic 3 days after procurement of abortion, 88 (38.1%) presented 4-6 days while 138 (59.7%) presented after 7 days.
47 REASONS FOR INDEX ABORTION
TABLE VII: Reasons for Index abortion
Reasons for abortion No. of patients Percentage % Not ready to be a parent 61 26.5 Because of school/ Job 17 7.4 Denial by partner 21 9.1 Wants small sized family 29 12.6 Health problems 10 4.4 Not financially ready to 92 40.0 care for baby TOTAL 230 100.0
Table VII shows the reasons why the respondents opted for the Index abortion that necessitated their current presentation. 61(26.5%) were not ready to be parents; 17(7.4%) , because of school/job; 21(9.1%), because of denial by partner, 29 (12.6%) wanted a small sized family, 10(4.4%), Health problems and 92 (40.0%) for other reasons like short pregnancy interval, financial constraints and contraceptive failure in 2 respondents.
48 Table VIII: Abortion process by location, service provider and methods employed.
Abortion details No. of patients Percentage % Location Private hospital 80 35.7 Government hospital 25 11.2 Chemist shop 11 4.9 Nursing home 60 26.8 TBA place 15 6.7 Home 33 14.7 TOTAL 224 100.0 Service provider Doctor 85 39.0 Nurse 107 49.1 Chemist 15 6.9 Native doctors 3 1.4 Self 8 3.6 TOTAL 218 100.0 Methods employed Native herbs 5 2.3 Oral tablets 12 5.6 Vaginal pessaries 7 3.2 Injections 39 18.1 Dilatation & Curettage 153 70.8 TOTAL 216 100.0
Table VIII : Almost half of the patients 105 (46.9%) had their abortion in a hospital; (Private hospital (35.7%) & Government 11.2%); and Nursing home (26.8%). (14.7%) of respondents had their abortion carried out at home either by a nurse or self administered drugs/native concoctions; while 15(6.7%) and 11 (4.9%) had it performed at TBA place and chemist shop respectively. 107 (49.1%) of the abortions were performed by nurses, 85 (39.0%) by doctors,
49 15(6.9%) by chemist attendants and 8 (3.7%) patients performed the abortion on themselves.
More than two-third of the patients 153 (70.8%) had dilatation and curettage or manual vacuum aspiration (MVA). Most patients did not differentiate between the two: 18.1% had injections; 5.6% used oral tablets, & 3.2%/ were given vaginal pessaries and 2.3% used native herbs.
POST ABORTION TREATMENT
TABLE IX: Post abortion treatment
Post abortion treatment Number No drugs 36 (16.1)
Unknown 35 (15.6)
Analgesics 146 (65.2)
Table IX shows that 36 (16.1%) of the patients did not take any drugs, while 35(15.6%) of the patients took drugs, but the drugs were unknown to them and 146 (65.2%) had analgesics only.
50 CONTRACEPTIVE USE.
TABLE X: Contraceptive use before Index abortion
Contraceptive use Using Before index abortion 25 (11.0) Type of contraceptive OCP 7 (28.0) Injectable 6 (24.0) IUCD - Condom 12 (48.0)
None 202 (84.0)
Reason for stopping Side effect 9 (36.0) Contraceptive failure 2 (8.0) Non – availability 8 (32.0) Cost 6(24.0)
Table X shows that only 25(11.0%) of all the patients were using contraceptives before the index abortion. Analysis of the forms of contraceptive used before abortion revealed that the condom was the most used method by 12(48.0%) of contracepting clients; OCP used by 7(28.0%) and 6(24.0%) claimed to have used injectables while none of the respondents was using IUCD.
51 A few 2(8.0%) of the respondents were still using a form of contraceptive when the pregnancy occurred and claimed contraceptive failure was the cause. 36% of the respondents had stopped using contraceptives because of side effects; 32.0% stopped because of non-availability and 24.0% stopped because of cost.
Growth observed on culture
Of the 234 endocervical specimens processed, 4 yielded no bacterial growth, 3 were viewed as contaminants and 31 revealed mixed bacterial growths (i.e. 2 or more bacteria from same swab sample). The commonest combination of mixed growths were Escherichia coli/Staphylococcus aureus (16), Escherichia coli/Pseudomonas aeroginosa (9) and Staphylococcus aureus/Enterobacter/Klebsiella oxytoca (6) in that order.
Blood culture
Of the 30 blood samples processed, only 2 yielded growths of Staphylococcus aureus, after extended incubation periods of more than 7 days and these were regarded as contaminants. The blood cultures were abandoned because of cost, poor yield, time factor and clotting in the syringe during inoculation of the blood culture bottle.
52
TABLE XI: Gram reaction of isolates.
GRAM REACTIONS
Gram reaction Frequency Percentage (%) Gram –ve Rods 157 74.8
Gram +ve Cocci 53 25.2
TOTAL 210 100.0
Table XI depicts the Gram reactions of the bacterial pathogens, of the 210 endocervical samples with significant bacterial growth, about three-quarters 157(74.8%) were observed to be Gram negative rods, while 53(25.2%) were Gram positive Cocci.
53
Table XII: Distribution of Organisms
Name of organism Frequency Percentage %
Escherichia coli 65 31.0 Staphylococcus aureus 48 22.8 Pseudomonas aeruginosa 41 19.5 Enterobacter agglomerans 12 5.7 Klebsiella oxytoca 12 5.7 Klebsiella pneumoniae 9 4.3 Proteus mirabilis 8 3.8 Morganella morganii 5 2.4 Pseudomonas stuartii 5 2.4 Staphylococcus 5 2.4 epidermidis TOTAL 210 100.0
Table XII shows the bacteriological profile; the most common organisms cultured were Escherichia coli 65(31.0%) followed by Staphylococcus aureus 48(22.8%); Pseudomonas aeroginosa 41(19.5%); Enterobacter agglomerans 12(5.7%), Klebsiella oxytoca 12 (5.7%), Klebsiella pneumoniae 9(4.3%) Proteus mirabilis 8(3.8%); Morganella morganii, Pseudomonas stuartii and Staph. epidermidis 5(2.4%) respectively.
54 Table XIII: SUSCEPTABILITY (SENSITIVITY) PATTERN OF ISOLATED ORGANISMS
ANTIBIOTICS Organisms DA CIP AK LEV CAZ AMC ERY
S S S S S S S
Enterobacter 0 (0%) 8 (66.7%) 8 (66.7%) 8 (66.7%) 0 (0%) 0 (0%) 0 (0%) agglomerans Escherichia coli 0 (0%) 61 (93.8%) 20 (30.8%) 61 (93.8%) 0 (0%) 4 (6.2%) 4 (6.2%)
Klebsiella 0 (0%) 0 (0%) 12 4 (33.3%) 0 (0%) 0 (0%) 0 (0%) oxytoca (100.0%)
Klebsiella 0 (0%) 9 (100.0%) 4 (44.4%) 9 (100.0%) 0 (0%) 0 (0%) 0 (0%) pneumoniae M. morganii 0 (0%) 5 (100.0%) 5 (100.0%) 5 (100.0%) 5 (100.0%) 0 (0%) 0 (0%)
Pseudomonas. 0 (0%) 5 (100.0%) 0 (0%) 5 (100.0%) 0 (0%) 0 (0%) 0 (0%) stuartii Proteus mirabilis 0 (0%) 8 (100.0%) 8 (100.0%) 8 (100.0%) 0 (0%) 0 (0%) 0 (0%)
Pseudomonas 0 (0%) 33 (80.5%) 12 (29.3%) 24 (58.5%) 4 (9.8%) 0 (0%) 0 (0%) aeruginosa Staphylococcus 4 (8.3%) 40 (83.3%) 32 (66.7%) 44 (91.7%) 0 (0%) 4 (8.3%) 0 (0%) aureus Staphylococcus 0 (0%) 0 (0%) 5 (100.0%) 5 (100.0%) 0 (0%) 0 (0%) 0 (0%) epidermidis KEY: DA (Clindamycin); CIP (Ciprofloxacin); AK (Amikacin); LEV (Levofloxacin); CAZ (Ceftazadime); AMC (Amoksiktav, Augmentin); ERY (Erythromycin).
55
Table XIII: Shows the sensitivity pattern of isolated organisms – Viz:-
Enterobacter agglomerans; CIP, AK and LEV, 66.7% each
Escherichia coli: LEV, 93.8%, CIP; 93.8%; AK; 30.8%; AMC; 6.2% and ERY; 6.2%
Klebsiella oxytoca: - AK; 100%, LEV; 33.3%
Klebsiella pneumoniae: CIP: 100%; AKA:44.4%; LEV:100%
Morganella morganii; CIP;AK,LEV, CAZ, 100% each
Pseudomonas stuartii: CIP, LEV, 100% each
Proteus mirabilis: CIP, AK, LEV: 100% each
Pseudomonas aeruginosa: CIP; 80.5%, LEV. 58.5%, AK:29.3%, CAZ; 9.8%.
Staph. aeureus; LEV, 91.7%; CIP; 83.3%; AK; 66.7%; DA; 8.3% and AMC 8.3%
Staph. epidermidis; AK; LEV; 100% each.
Table XIV: Antibiogram of various organisms isolated from septic abortion patients.
ANTIBIOTICS SUSCEPTIBLE RESISTANT p-values
LEV 173 (82.4%) 37 (17.6%) < 0.001**
CIP 169 (80.5%) 41 (19.5%) < 0.001**
AK 106 (50.5%) 104 (49.5%) 0.890
CAZ 9 (4.3%) 201 (95.7%) < 0.001**
AMC 8 (3.8%) 202 (96.2%) < 0.001**
DA 4 (1.9%) 206 (98.1%) < 0.001**
ERY 4 (1.9%) 206 (98.1%) < 0.001**
**Significant at 95% confidence level with Chi-Square Test (Goodness of fit), (²)
Table XIV: Reveals the antibiogram of the various organisms isolated from septic abortion patients. LEV (173, 82.4%) was found to be the most effective antibiotics for septic abortion patients, followed by CIP; (169, 80.5%). Susceptibility of AK was found to be 50.5% (i.e in 106 isolates). CAZ; 9 (4.3%), AMC; 8 (3.8%). DA and ERY were found to be the least effective antibiotics to use for septic abortion patients. In general, over 82% of the isolates were susceptible to quinolones while over 95% were resistant to cephalosporins. This is statistically significant and not due to chance variation.
57
Table XV: Susceptibility Patterns of Gram –ve rods and Gram +ve Cocci.
Gram DA CIP AK LEV CAZ AMC ERY stain
Gram –ve 0(0%) 129 69 (43.9%) 124(79.0%) 9 4(2.5%) 4(2.5%) rods (82.2%) (5.7%)
Gram +ve 4(7.5%) 40(75.5%) 37(69.8%) 49(92.5%) 0(0%) 4(7.5%) 0(0%) Cocci
P-Value 0.004 0.318 0.001 0.035 0.116 0.113 0.574
** Significant at 95% confidence level with Chi-square Test (Test of Association), (x2).
GRAM NEGATIVE RODS:
The most effective antibiotics for Gram – ve rods were found to be CIP; 82.2% followed by LEV; 79.0%; AK; 43.89%; CAZ 5.7%, AMC; 2.5% and ERY 2.5%. DA was found to be completely ineffective against Gram –ve rods.
GRAM POSITIVE COCCI:
The most effective antibiotics for Gram +ve Cocci was LEV. 92.5%, followed by CIP; 75.5%, AK, 69.8% DA and AMC were the least effective antibiotics against Gram +ve Cocci.
Overall, Levofloxacin (a quinolone), was found to be the most effective
broadspectrum antibiotic against both Gram +ve and Gram –ve isolates in septic
abortion in Lagos.
58 DISCUSSION
Although hemorrhage is the most common abortion complication, about 75% of the deaths are from sepsis 4,5,7,9,73. The preventable morbidity and mortality from septic abortion are staggering and well documented.29 Guinea in West Africa31, Kampala, Uganda32, Ile-Ife, Nigeria4, Bangladesh72, Latin America, Multinational survey on abortion73, India6etc. The contribution of unsafe abortion to the maternal mortality rate in Nigeria remains unacceptably high34.
The mean age of the patients in this study was 26.7 years, with 53.9% between the ages of 16 and 29 years. This is in agreement with the work of Emuveyan and Agboola (1997), who noted ages 19-30 years to be a period of intense sexuality which encompasses late adolescence and the single, out-of-school period25.
It is significant to note that patients between ages 30 and 35 alone constituted about (46.2%), and majority (34.6%) of the respondents were petty traders. This is agreement with the figures quoted for Asia where 42% of unsafe abortion occur in women aged 30-44 years but higher than the 23% quoted for Africa and the developing region as a whole where unsafe abortion peak in women aged between 20 and 29 years56.
It is important to note that 89% of the patients presenting with complications of abortion, were not using any form of contraception before the index abortion. This is in agreement with earlier findings, Starrs (1997) 24, and WHO regional estimates (1998) 21, and these non-contracepting patients according to Adewole et al114 constitute a significant proportion of abortion seekers in the country.
59 It is also significant to note that 82.5% of the patients have had at least secondary education and 68.4% were married. This might be an indirect corroboration of earlier findings that though education and marital status are strong influences on the use of contraceptives 27,115, the educated women are more likely to have an abortion if their contraceptives fail, and terminate a pregnancy which might interfere with their schooling, or joining the work force77.
Almost all the reasons given to justify the abortion are distinct indications for contraception and an indication of the unmet post abortion care needs in the community.
About 26.3% of the patients had their abortions performed at home, TBA and chemist shops. This is in agreement with the Alan Guttmacher Institute (AGI) findings, where one publication listed over 100 traditional methods used for inducing abortion, such as oral and injectable medicines, vaginal preparations, etc20. Some women in developing countries rely on teas and concoctions made from local plants or animal products20. This is also similar to experience in the “Bad Old Days” in the USA, where surveys done in New York City before the legalization of abortion documented the techniques in common use; 80% tried to do the abortions themselves (at home) and nearly 40% of women used a combination of approaches60. There is the need to intensify the counseling component of PAC, both to the provider and clients to reduce such risk taking and further propagate the advantage of MVA over curettage whenever the need arises. Counseling will also allay the fears that kept women from utilizing contraceptive services.
The preference for condom as the method of choice in 48.0% of those who practiced contraception before their last pregnancy is a shift from earlier reports20 60 where in Nigeria contraception prevalence is as low as 15% and percentage of married women of reproductive age (MWRA), relying on condoms in various countries, is 2% for Africa116. This preference for condom is in agreement with the findings of Oye-Adeniran et al27, and as they explained, probably reflecting the response to the educational campaigns and social marketing of condoms in response to the HIV/AIDS epidemic27. It also might be a pointer to potential benefits of enhanced post-abortion care efforts.
Septicaemia is a recognized complication of septic abortion4,5. When blood cultures yield clinically important micro-organisms, it is a sign that host defences have failed to contain an infection at its primary site or that the clinician has failed to adequately eradicate the infectious process117.
Many studies have been carried out concerning yield from blood cultures. Moritz and Thompson (1966), reported on 118 cases of septic abortion, out of which only two had positive blood culture118, Washington (1975), reported the cumulative yield from three 20ml blood samples obtained in sequence and cultured with use of conventional manual methods119.
More recently, Weinstein and Colleagues (1996) using the BacT/Alert continuous- monitoring blood culture system evaluated the yield of clinically important micro- organisms from three consecutive 20ml blood samples obtained and cultured during a 24-hour period120. During a 15-month period, three blood cultures were performed for 218 patients; the 3rd blood culture was the only one positive on only six occasions, and only one of these positive cultures represented true sepsis120. The conclusion drawn from this study was that for the great majority of patients, two blood cultures should be sufficient to detect septicaemia.
61 On the other hand, single blood cultures should be discouraged, if not forbidden altogether121. Not only will single blood cultures be insufficiently sensitive for detecting some bacteraemia, but they also may be difficult to interprete. For example, a single blood culture that yields a coagulase negative Staphylococcus may represent contamination or clinically important infection. However, if two samples obtained in sequence by separate venepunctures yield the same coagulase negative Staphylococcal species with the same antibiogram, the probability is high that the isolates represent true bacteraemia122.
Many technical factors affect the sensitivity of blood culture systems. Of these factors, the most important are probably the volume of blood used and the broth medium used for the culture, the number and timing of culture for each patient within 24 hours117. Other important factors include the ratio of blood to broth; agitation during incubation, length of incubation, atmosphere of incubation and additives to the media (e.g. those that neutralize the effects of antimicrobial agents present in the blood at the time the sample is drawn) 117,118.
This researcher had only one contact with the patients before antibiotics were commenced, thus making it impossible to obtain multiple samples; because these were septic and some, critically-ill patients, from whom specimens should be obtained quickly before initiating therapy. The recommended 20mls of blood per culture, was associated with clotting in the syringe, in 12 (40%) of the 30 blood samples, thereby making it impossible to inoculate the blood culture bottles.
Several studies in which instrumented blood culture systems were used have shown that 5-day incubation periods are sufficient for detecting the majority of pathogens123,124,125. In this study, of the 30 samples analyzed, only 2 yielded growths of Staphylococcus aureus, after extended incubation periods of more 62 than 7 days and these were regarded as contaminants. This is in agreement with the findings of Witson et al that after 5 days, most newly positive cultures represent contaminants125.
This study has highlighted the polymicrobial nature of the bacteriology of septic abortion, and this is in agreement with the work of Stublefield and Grimes, (2008)109 Das Vnita et al (2004)126, Rotimi and Abudu (1986)127, and similar studies6,9,33,36.
This study has also brought to the fore the antibiogram (antibiotic sensitivity pattern) of the various micro- organisms, thereby making it possible to postulate an appropriate antibiotics regimen (1st line regimen) in the management of septic abortion, in this community. This will indirectly support the American Medical Association Council on Scientific Affairs’ observation that attributed the marked decline in abortion deaths in that country (between 1974 – 1991) to the introduction of antibiotics to treat sepsis 30.
As this study has shown, the predominant micro- organisms isolated are Escherichia Coli (31%), followed by Staphylococcus aureus (22.9%), Pseudomonas aeroginosa (19.5%) and Enterobacter agglomerans (5.7%). This is similar to the findings of Das Vnita et al in the Indian study of 2004126, Rotimi & Abudu (1986)127.
The overall antibiogram of the various microbes in this study showed that Levofloxacin is the most effective antibiotic, followed by ciprofloxacin.
This study also highlight the susceptibility pattern according to Gram reactions. Levofloxacin was found to be the most effective antibiotic against Gram-negative rods and Gram-positive Cocci. Therefore, in the absence of sophisticated
63 laboratory (as in rural communities) but where a quick Gram staining reaction can be carried out, the appropriate antibiotics can be selected. (Table XV).
It is significant to note that susceptibility of endocervical isolates to 3rd generation cephalosporin, (CAZ) is very low CAZ (4.3%) and 5.7% against Gram-negative pathogens; compared to the cheaper quinolones, Levofloxacin (LEV), Ciprofloxacin (CIP), 82.4% and 80.5% respectively and greater than 80% each against Gram- negative and Gram-positive isolates. Resistance to quinolones in this study (17.6% and to cephalosporin CAZ 95.7%). This is in agreement with the study of Kesah et al128 who found resistance to quinolones very low < 1% compared to < 50% for 3rd generation cephalosporins and concluded that the blind prescription of multiple drugs or ‘powerful’ antibiotics with the aim of eliminating the pathogens, is not only disadvantageous to the patient but also an economic loss.
64 CONCLUSION
The need of the day is prevention, mainly by stepping up contraceptive usage to prevent unwanted pregnancy that leads to unsafely induced abortion.
This study has confirmed the polymicrobial nature of the cervical isolates. Escherichia coli was the commonest micro-organism cultured in patients with post-abortal sepsis and was found to be highly sensitive to Levofloxacin, a quinolone.
RECOMMENDATION
Levofloxacin (or in the alternative, Ciprofloxacin), a quinolone, is hereby recommended as 1st line broadspectrum antibiotic agent in the treatment of patients with post-abortal sepsis in Lagos Island Maternity Hospital, Lagos.
LIMITATIONS 65 Limitations encountered during the course of this study included the prohibitive cost of materials/reagents; scarcity of patients meeting the inclusion criteria; limited time frame for the study, difficulties in co-ordinating collection of samples.
Blood culture broths are very expensive; the 20-30mls volume of blood suggested in many studies as ideal, were associated with clotting while being injected into the blood culture bottles.
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82 DATA COLLECTION FORM
BACTERIOLOGICAL PROFILE AND SENSITIVITY PATTERN OF SEPTIC ABORTION IN LIMH, LAGOS, NIGERIA.
Dear Madam,
This study is designed to identify the bacteriological profile and determine the antibiotic sensitivity pattern in women with post-abortal sepsis; and thus give recommendations to improve on treatment outcome.
I humbly request that you fill in your responses as appropriate. The report of the study shall be used only for research purpose and a condition of complete anonymity is guaranteed.
Thank you.
83 SECTION 1
1. Age:
[ ] 15-19yrs [ ] 20-24 yrs [ ] 25-29yrs. [ ] > 30yrs
[ ] Other (Please Specify).
2. Occupation:
[ ] Unemployed [ ] Student [ ] Artisan/Craftwork [ ] [ ] Petty Trader [ ] Salaried Worker [ ] Others(Please Specify)
3. Educational Status:
[ ] Part Primary School [ ] Finish primary school
[ ] Part secondary school [ ] Finish secondary school [ ] NCE [ ] Polytechnic/University
4. Marital Status:
[ ] Single [ ] Married [ ] Divorced or Separated [ ] co-habiting [ ] Others (Please Specify) [
5. Parity: 84 [ ] Number of living children
[ ] Number of dead children
[ ] None
6. Last Menstrual Period (LMP) [ ]
7. Gestational age when abortion was performed in weeks [ ]
8. Number of previous abortions/miscarriages [ ]
How many were induced? [ ]
How many were spontaneous [ ]
9. Interval between procurement of abortion and presentation:
[ ] 1-3 days [ ] 4-6 days [ ]
[ ] > 7 days
10. Reason(s) for abortion:
[ ] Not ready to be a parent
[ ] Because of school/job
85 [ ] Denial by partner
[ ] Wants small sized family
[ ] Health problem
[ ] Others (please specify)
11. Location, where abortion was performed:
[ ] Government Hospital [ ] Private Hospital
[ ] Chemist shop
[ ] Nursing home
[ ] TBA place
[ ] Home
12. Level of service provider:
[ ] Doctor
[ ] Nurse
[ ] Chemist Attendant
[ ] Native Doctor
[ ] Self
86 [ ] Others (Please specify)
13. Method(s) employed:
[ ] Native herbs
[ ] Oral tablets
[ ] Vaginal pessaries
[ ] Injections
[ ] Dilatation & Curettage/MVA
[ ] Others (Please Specify)
14. Post-abortion treatment given:
[ ] Unknown
[ ] Analgesics
[ ] Antibiotics
[ ] No drugs
[ ] Others (Please Specify)
15. Contraceptive use before last pregnancy:
[ ] Yes [ ] No
87 If Yes, what type
[ ] OCP
[ ] Injectable
[ ] IUCD
[ ] Condom
[ ] Others (Please specify)
16. If Yes, reason(s) for discontinuing contraceptive use
[ ] Side effects
[ ] Contraceptive failure
[ ] Non-availability
[ ] Cost
88