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Download Download 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
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