Category: Miscellaneous

A “New Nigeria,” What Will It Take?

Nigeria is a nation that is in desperate need of visionary leadership. For decades, we have depended on leaders who have no clear understanding of the depth of our problems as a nation, and lack the vision necessary to create impact. Our leaders make promises and fail because they are unwilling to undergo due process and carry out feasibility studies on how proposed projects can be implemented and sustained, as well as the supporting structures that must be in place to ensure long-term success.

We are left with a country that is broken from top to bottom, and a social service system that cannot meet the needs of its people. Our roads need improvement, our educational system needs to be updated to meet the demands of the 21sth century, and we need more creativity in our teaching methods to ensure that our graduates are well prepared for the work-force. We need quality improvements in our healthcare system, as well as some form of subsidized health services to ensure better outcomes for many Nigerians who would otherwise not access healthcare because of the cost.

We need leaders who understand that what we choose to ignore today will continue to cripple our nation, leaving our children and grandchildren to pay the price of our negligence. In the past, we accepted empty campaign promises along with all the gifts they distribute as a campaign tool to solicit our support. We have allowed tribalism and political affiliations direct how we vote. As a result, we have created recycled politicians who are well versed in sustaining a corrupt system, as long they are compensated and do not suffer the social ills experienced by the average Nigerian.

Thanks to the “Not Too Young to Run” policy, we now have several candidates with diverse backgrounds who may be able to turn the tide for Nigeria in 2019. We know that most people change once they have power and are corrupted by the existing influences within the system. However, we must remain hopeful that among the 2019 candidates, we may finally have leaders who can identify with Nigerians and will not bow to the wills of greedy political “God fathers.” We need leaders who are passionate about Nigeria and understand the importance of investing in our most valuable resource, the people.

We need leaders who understand the value of maintenance, as we have had multiple projects initiated in the past, while incoming leaders ignore projects by previous administrations and allow it to decay. This a waste of our nation’s resources, and we must find ways to improve and sustain projects that are making a positive impact in the society, while consolidating investments that no longer serve us. For example, if a governor builds a facility that was unable to meet the purpose for which it was built, the government should look to sell it to private institutions and utilize the funds for other valuable projects instead of allowing the building to decay.

We are desperate for leaders who are willing to establish standards and work hard to maintain it in all levels of public service. We can no longer continue to watch our leaders defect from one political party to another during the election season, with the hopes of building coalitions and continuing to perpetuate the status quo. We have had enough, and must join forces to make our voices heard in 2019. We need to consider young political parties like Alliance For New Nigeria whose vision is founded on bringing tangible change to Nigerians.

We need hope in our nation’s future and musts start now to reverse the ills of the past; to let go of corruption and misappropriation of public funds, and the mockery which we have allowed in our political offices. We must understand that public service is a call of destiny, and what we do with that opportunity can impact a generation. Therefore, we must not waste our political leadership opportunities on frivolous living and gross negligence, but we must commit our tenures to improving the lives of Nigerians and giving them a future that is brighter than yesterday.

 

Written By:

Dr. Idongesit Udoh Bassey

INTRODUCTION TO PRECLAMPSIA/ECLAMPSIA

Preeclampsia/eclampsia is one of the most common complications of pregnancy that affects approximately 5-10% of pregnant women and causes approximately 14% of maternal death worldwide. Available data from Nigeria points to preeclampsia/eclampsia affecting approximately 163/10000 deliveries, and causing several maternal deaths in the process (Danmusa, Coeytaux, Potts, & Wells, 2016). Preeclampsia/eclampsia treatment and management has evolved over the years, however more people need to be aware of this condition and seek appropriate care when suspected. This paper explains preeclampsia and its complications including eclampsia.

Preeclampsia

Preeclampsia describes a condition where a woman’s blood pressure becomes abnormally high after 20 weeks of pregnancy. With this condition, a woman who was previously normotensive (normal blood pressures) is diagnosed with hypertension and her urine when tested also shows the presence of excess protein (proteinuria). The condition can develop without any symptoms and is detected during routine pre-natal checkup. However, depending on the severity of the condition, a woman may present with symptoms including severe headaches, visual changes such as blurry vision and increased light sensitivity, excess protein in urine, low urine output, abdominal pain particularly near the ribcage and towards the right side, liver dysfunction on lab test, nausea and vomiting, shortness of breath, and sudden swelling/weight gain (edema) most noticeable in face and hands (Salam, Das, Ali, Bhaumik, & Lassi, 2015).

Diagnostic Criteria for Preeclampsia

Preeclampsia

  • Systolic Blood Pressure (SBP) > 140 mm Hg or Diastolic Blood Pressure (DBP) > 90 mm Hg in a pregnant woman at rest after 20 weeks of pregnancy
  • Proteinuria (Protein in urine) > 0.3g in 24-hour urine collection or 1+ protein in urine dipstick test

Severe Preeclampsia

  •  Systolic Blood Pressure > 160 mm Hg or Diastolic Blood Pressure > 110 mm Hg on two occasions at least six hours apart in a woman at rest
  • Proteinuria > 5g in 24-hour urine collection or 3+ protein in urine dipstick test
  • Other presenting symptoms could include: low urine output (< 500ml per day), visual disturbances, right sided abdominal or epigastric pain, low platelets, difficulty breathing, edema, and abnormal liver function etc (Wagner, 2004).

The cause of preeclampsia is unknown. However, studies have shown that pregnancy causes growth of new blood vessels with placental development and implantation. These blood vessels are supposed to supply the placenta. In women with preeclampsia, these vessels are not well developed or functional, leading to impairment in placental blood flow and blood vessel spasms (vasopasm), which interferes with blood supply to multiple organs including the kidneys (Wagner, 2004). The sequela of this condition is intra-uterine growth restriction and severe hypertension for the mother. Some women who were diagnosed with hypertension before pregnancy can also have worsening hypertension and new protein in urine indicating the development of preeclampsia superimposed on prior hypertension. It is important to note that there are other types of hypertension during pregnancy that are different from preeclampsia, and these include Gestational Hypertension which describes high blood pressure first diagnosed during pregnancy without protein in urine, and Chronic Hypertension which classifies those patients who were already diagnosed with hypertension before pregnancy. There are many risk factors for preeclampsia, and they include:

  • History of hypertension
  • Family history of preeclampsia
  • First pregnancy (primigravity)
  • Teenage pregnancies or women > 35 years
  • Obesity
  • Multifetal pregnancies (pregnancy with multiples: twins, triplets etc)
  • In-vitro fertilization
  • Renal disease
  • Thrombophilia
  • Gestational diabetes
  • Systemic lupus erythematous

Complications of Preeclampsia

Preeclampsia causes several complications including intra-uterine growth restriction and low birth weight, preterm birth, placental infarcts and abruption, HELLP syndrome, and Eclampsia etc.

Intra-uterine Growth Restriction: Preeclampsia affects arteries that supply oxygenated blood to the placenta. Therefore, a decrease in oxygenated blood flow throw the placenta decreases blood supply to the baby resulting in slower growth, small for gestational age, and possible preterm birth.

Preterm Birth: Depending on the severity of preeclampsia, the baby may need to be delivered early to decrease the risk of intrauterine death or possible death of the mother. Unfortunately, premature delivery has its own problems as the baby’s lungs may be immature, resulting in respiratory distress and other complications after delivery.

Placental Abruption: As mentioned earlier, preeclampsia affects the blood vessels supplying oxygenated blood to the placenta. A decrease in oxygen supply to the placenta can cause placental infarcts and separation from the wall of the uterus. Placental separation is usually indicated by bleeding, and the degree of separation determines the severity of bleeding. However, placental separation requires immediate medical attention as the life of the baby and mother are at stake.

HELLP Syndrome (Hemolysis (destruction of red blood cells), Elevated Liver Enzymes, Low Platelets): This condition is one of the most severe end-organ complications of preeclampsia. It describes a set of clinical signs signaling a dire situation that is potentially fatal if not identified early and properly managed. HELLP syndrome is diagnosed with laboratory results which would point to red blood cell hemolysis, abnormal liver enzymes, and low platelets which result from platelet destruction. Immediate medical attention is needed to avoid fatal outcomes. Symptoms of HELLP syndrome include nausea and vomiting, headaches, and right upper abdominal pain (likely related to liver dysfunction).

Eclampsia: This describes the presence of grand-mal seizures or coma in a pregnant woman with no prior neurologic history or post-partum woman with preeclampsia. Eclampsia is one of the most dangerous complications of preeclampsia and necessitates emergent delivery of the baby to avoid death of both mother and child, as well as complex treatment and management to prevent further seizures in the immediate postpartum period. In some parts of Nigeria particularly northern Nigeria, Eclampsia contributed to approximately 33% of maternal deaths (Esike et al., 2017). Approximately 80% of cases of eclampsia occur in the 3rd trimester, during labor, or within 48 hours after delivery. There has been a few reports of cases occurring even up to 23 days post-partum but these are extremely rare (Ross & Ramus, 2017).

Treatment and Management of Preeclampsia

Preeclampsia has no direct cure except delivery of the baby. Depending on gestational age of the fetus, the mother may be managed primarily with anti-hypertensives (medications to control blood pressure) to allow time for adequate fetal development. Arising complications including liver dysfunction are also monitored closely, and she is followed up more frequently by the obstetrician to assess need for emergent delivery. Apart from anti-hypertensives such as Labetalol and Hydralazine used to control blood pressure throughout pregnancy, Magnesium Sulfate has become a must in the management of women with preeclampsia. The medication is primarily used during labor and in the post-partum period to reduce the risk of seizures in women with preeclampsia, and to treat seizures in those who have already developed eclampsia.  The use of magnesium sulfate has been shown to reduce the risk of eclampsia by 58% and mortality by up to 45%. The value of magnesium sulfate cannot be understated, and in 2007 the MacArthur Foundation began to fund programs to improve availability of Magnesium sulfate in Nigerian healthcare centers, as part of an initiative to reduce maternal mortality (Danmusa et al., 2016).

As stated earlier, the only cure for preeclampsia is delivery of the baby. However, several factors influence the timing at which the baby is delivered, and the gestational age and maternal/fetal well-being are primary considerations. Most healthcare providers will focus on blood pressure control and symptom management to allow time for fetal development, and carry out emergent delivery if the fetal or maternal well-being is severely compromised. Factors influencing timing of emergent delivery include severe intrauterine growth restriction, non-assuring fetal vital signs, deficiency in amniotic fluid (Oligohydramnios), platelet counts < 100,000, worsening liver function, suspected placental abruption, and eclampsia etc. Once the baby is delivered, the woman must be monitored closely with proper treatment to ensure recovery from the complications that developed over the course of pregnancy.

Till date, there is no available information on ways to prevent preeclampsia. Therefore, it is imperative for healthcare providers to educate pregnant women and carryout timely assessments and tests once they present with symptoms suspicious for preeclampsia. In addition, there is need for more public education on this condition, as public awareness can possibly improve health seeking behaviors and encourage pregnant women in places like Nigeria to obtain pre-natal healthcare from skilled healthcare providers, learn to monitor themselves for signs of complications, and report immediately to their obstetricians if any of these arises. With such concerted efforts, we stand a chance of reducing the rates of maternal and perinatal mortality in Nigeria.

Written by Dr. Idongesit  Udoh  Bassey

References

Danmusa, S., Coeytaux, F., Potts, J., & Wells, E. (2016). Scale-up of magnesium sulfate for treatment of pre-eclampsia and eclampsia in Nigeria. International Journal of Gynecology and Obstetrics, 134, 233-236. doi: http://dx.doi.org/10.1016/j.ijgo.2016.06.001
Esike, C. O. U., Chukwuemeka, U. I., Anozie, O. B., Eze, J. N., Aluka, O. C., & twomney, D., E. (2017). Eclampsia in rural Nigeria: the unmitigating catastrophe. Annals of African Medicine, 16(4), 175-180.
Ross, M. G. & Ramus, R. M. (2017). Eclampsia. Retrieved from https://emedicine.medscape.com/article/253960-overview.
Wagner, L. K. (2004). Diagnosis and management of preeclampsia. American Family Physician, 70(12), 2317 – 2324.

Meningitis Outbreak In Nigeria

Statistics: The outbreak began in March 2016, approximately 15 States have been affected, almost 2000 Suspected Cases. Approximately 300 deaths so far. The states with the largest number of cases include: Kebbi, Katsina, Niger, Sokoto, Zamfara State.

Who Is In Charge of Managing The Outbreak? 

  • Nigeria’s Centre for Disease Control  is leading outbreak control in coordination with the World Health Organization (WHO), UNICEF, US Centers for Disease Control (CDC), Medecins Sans Frontieres, and Ehealth Africa
  • NPHCDA is leading vaccination in Zamfara state, similar efforts are being coordinated in other affected states
  • WHO is working to ensure the availability of vaccines.

What Are The Risk Factors?

  • Outbreak tends to occur in dry season because of low humidity and dusty conditions
  • The northern part of Nigeria seems to have a higher perdisposition because of their environment
  • Overcrowding and poor sanitation can contribute to outbreaks
  • Living in Dormitories, military bases, child facilities
  • Lack of Vaccination
  • Compromised immune system
  • Pregnancy increases risk of Listeria meningitis.

What Is Meningitis? 

  • It is an Infection of the brain and spinal cord. Organisms can enter the blood stream and travel to the brain and spinal cord, or invade the meninges directly through an ear or sinus infection, skull fracture, or after surgeries in the brain or spinal area
  • Can be caused by bacteria, virus, or fungus
  • Bacterial meningitis most common in teenagers and young adults, it is very severe and can lead to death
  • Viral meningitis are most common in children <5 years, but often mild, can clear on its own
  • Fungal meningitis is rare, usually chronic, it is not contagious, and may be seen in people with immunodeficiency such as AIDS.

Bacterial Meningitis

  • Could be caused by multiple organisms including Streptococus Pneumonia, Haemophilus Influenzae, Listeria Monocytogenes, and most commonly Neisseria Meningitidis (N. meningitidis).
  • Nigeria’s current outbreak is of N. meningitidis (C serogroup), affects mostly teenagers and young adults.
  • Bacterial Meningitis is highly contagious, can lead to death with 24 to 48 hours if untreated.

How Bacterial Meningitis Spreads

  • It spreads through the respiratory system via droplets. Exposure to kissing, coughs, sneezes, shared cutlery, or sharing items that were in contact with an affected person’s saliva such as toothbrush, cigarettes etc.
  • Can contact meningitis by staying in an enclosed environment or room with an affected person.
  • Spreads very quickly in a crowded environment.

Symptoms Of Meningitis

  • Severe Headache that’s different from your usual
  • Difficulty concentrating or Confusion
  • Sudden high fever
  • Stiff neck
  • Sensitivity to light
  • Sleepiness or difficulty waking up
  • seizures
  • Poor appetite
  • Skin rash
  • Muscle and joint aches

Symptoms Of Meningitis In Infants

  • High fever
  • Irritability or Constant Crying
  • Poor feeding
  • Excessive sleepiness
  • Inactivity or sluggishness
  • Stiff neck or body
  • A bulge in the soft spot on the baby’s head

What To Do If You Suspect Meningitis

  • Prompt response and treatment can save lives and prevent complications
  • Avoid exposing others, wear mask and isolate yourself if possible
  • Go to the nearest hospital immediately
  • Tell the Doctor all your symptoms

Evaluation And Management Of Bacterial Meningitis

  • Bacterial meningitis is a medical emergency. Treatment must be initiated immediately to reduce the risk of death
  • Evaluate Patient for:
    • Recent exposure to persons with meningitis
    • Otorrhea (leaking ears) or rhinorrhea (runny nose)
    • Recent travel to areas with endemic meningitis
    • Recent or remote head injury
    • Recent infection (especially ear infection)
    • Immunocompromised conditions
    • Intravenous drug use
  • Obtain blood cultures and Cerobrospinal (CSF) fluid through lumbar puncture if no contraindications
  • Initiate empiric intravenous antibiotics immediately, can use third-generation cephalosporin like cefotaxime (2grams every 4 to 6 hours) and ceftriaxone (2grams every 12 hours), or fourth-generation cephalosporin such as cefepime (2 grams every 8 hours). These drugs can consistently penetrate the cerebrospinal fluid to kill the causative organism
  • Chloramphenicol is preferred for N. meningitides during epidemics. Ceftriaxone can be used as an alternative if Chloramphenicol is not available or contraindicated. The World Health Organization recommends the use of chloramphenicol as the empiric antibiotic of choice in treatment of patients with N. Meningitidis in Sub-Saharan Africa. 1 or 2 injections of the long-acting formula is acceptable.
  • Add vancomycin (15 to 20 mg/kg every 8 to 12 hours) for empiric gram positive coverage until culture results indicate the absence of other infections
  • Can use dexamethasone as an adjunct to decrease brain inflammation, risk of hearing loss, and other complications
  • Antibiotic dosing should be adjusted for patients with poor renal function.

Complications Of Meningitis

  • Complications usually occurs if a person is left untreated for a long time, and includes:
  • Brain damage
  • Hearing loss
  • Seizures
  • Gait problems
  • Shock
  • Death
  • Memory problems and learning disabilities

Prevention of Meningitis

  • Vaccination of high risk populations is the best option for prevention
  • Vaccination against meningitis should be provided as part of the routine childhood vaccination
    • Haemophilus Influenzae type B (Hib) vaccine prevents infections that cause meningitis and pneumonia
    • MMR (measles-mumps-rubella) vaccine prevents meningitis caused by measles and mumps
    • Pneumococcal vaccines also prevent bacterial meningitis especially in those older than 65, immunodeficient persons, or those with some chronic diseases
    • Varicella (chickenpox) vaccine and shingles vaccine prevent viral meningitis
  • Vaccination with the Haemophilus Influenzae type B (Hib) is recommended for boarding school students or new college students
  • Avoid traveling to areas with meningitis outbreaks or epidemics

Written by Dr. Idongesit Udoh

 

References
BellaNaija (March 30, 2017). Meningtis: 1966 suspected cases reported in five states. Article obtained from http://www.bellanaija.com.
Mayo Clinic Staff. Meningitis symptoms and causes. Article obtained from http://www.mayoclinic.org/diseases-conditions/meningitis
Stephanie Busari (March 31, 2017). Meningitis outbreak in Nigeria kills nearly 300. Article obtained from http://www.cnn.com.
Tunkel, A. R., Calderwood, S. B., Thorner, A. R. (2017). Initial therapy and prognosis of bacterial meningitis in adults. Article obtained from http://www.uptodate.com
Waure, C. D., Miglietta, A., Nedovic, D., Mereu, G., & Ricciardu, W. (2016). Reduction in Neisseria meningitides infection in Italy after meningococcal C. conjugate vaccine introduction: a time trend analysis of 1994-2012 series. Human Vaccines & Immunotherapeutics, 12(2), 467-473.
World Health Organization (March 13, 2015). Meningococcal disease – Nigeria. Article obtained from http://www.who.inte/csr.