ObjectiveTo investigate the burden and causes of life‐threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.DesignNationwide cross‐sectional study.SettingForty‐two tertiary hospitals.PopulationWomen admitted for pregnancy, childbirth and puerperal complications.MethodsAll cases of severe maternal outcome (SMO: maternal near‐miss or maternal death) were prospectively identified using the WHO criteria over a 1‐year period.Main outcome measuresIncidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).ResultsParticipating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near‐misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre‐eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life‐threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21–215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non‐availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care.ConclusionsImproving the chances of maternal survival would not only require timely application of life‐saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care.Tweetable abstractOf 998 maternal deaths and 1451 near‐misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.

Objective To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals.Design Nationwide cross-sectional study.Setting Forty-two tertiary hospitals.Population Women admitted for pregnancy, childbirth and puerperal complications.Methods All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period.Main outcome measures Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO).Results Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were preeclampsia/eclampsia (23.4%) and postpartum haemorrhage †The members of Nigeria Near-miss and Maternal Death Surveillance Network are in Appendix 1.

Hyoscine butyl-bromide was effective in shortening the duration of the active phase of labor. It was also associated with significantly less postpartum blood loss.

Objective To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to lifethreatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals.Design Secondary analysis of a nationwide cross-sectional study.Setting Forty-two tertiary hospitals.Population Women admitted for pregnancy, childbirth or puerperal complications.Methods All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period.Main outcome measures Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/ SMO).Results Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/ 100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH.Conclusions Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH. Tweetable abstract One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year. Please cite this paper as: Sotunsa JO, Adeniyi AA, Imaralu JO, Fawole B, Adegbola O, Aimakhu CO, Adeyemi AS, Hunyinbo K, Dada OA, Adetoro OO, Oladapo OT. Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey. BJOG 2019; 126 (S3): 19-25.

Aim: To highlight the potential for misdiagnosis of ovarian fibromas and need for careful evaluation especially when fertility altering decisions need to be taken in the young adolescent. Presentation of Case: The authors here review literature and present the case of a 15 year old pre-menarchal patient with bilateral, solid hard ovarian tumors with marked ascites, who had bilateral salpingo-oophorectomy, in whom the tumors turned out to be bilateral calcific ovarian fibromas. Discussion: Ovarian neoplasia are often misdiagnosed because of their non-specific symptoms and similarities to other pathologies on radiological imaging. The management of adolescents with ovarian tumors poses peculiar challenges as there is need for a balance between the risk of malignancy and the need to preserve fertility. About 1/3 of pelvic masses in pre-pubertal girls are malignant. This fact in addition to the non-specific features of malignancy in this patient such as weight loss, ascites, necessitated further evaluation which included laparotomy. Conclusion: Ovarian fibromas occur in adolescents and can pose a diagnostic dilemma; a high index of suspicion is required to plan fertility-sparing and cancer-limiting management.