Pattern of presentation and management outcomes of miscarriages in a rural private hospital in Enugu, south-east, Nigeria: A 5-year retrospective study

*Corresponding author: Ifeanyi Johnson Onyekpa Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Pattern of presentation and management outcomes of miscarriages in a rural private hospital in Enugu, south-east, Nigeria: A 5-year retrospective study Boniface Uwaezuoke Odugu 1, 2, Ifeanyi Johnson Onyekpa 1, 2, *, Livinus Nnanyereugo Onah 1, Sylvester Onuegbunam Nweze 1. Chidimma Akudo Omeke 1, Malachy Nwaeze Ezenwaeze 1, Chike Joachim Maduka 1, Chibunze Chukwunonso Udegbunam 1, Mekowulu Chigekwu Nwanne 1, Benedicta Ezinne Aneke 1, Godwin UgochukwuEmmanue 1, Enoch Ejiofor Ogbonna 1, Thompson Chika Ugwuanyi 1, Florence Chibuzo Egwu 3, Abigail Nneka Ude-Nebonta 3, Paul Chinwe Onah, Osmond Onyebuchi Onah 1, Francis Ugwunkanu Ugwu 1, Chinenye Sandra Onyekpa 3, Vitalis Nnamdi Udeozor 1, Calistus Obiora Nevo 1, Sunday Gabriel Mba 1, Nnanyelugo Chima Ezeora 1, Obiechina Chijioke Eze 1, Chukwuka Chude Eze 1, Fredrick Ikenna Awkadigwe 1, Kevin Emeka Ortuanya 1, Innocent Obeta 1, Chizoba Linda Chijioke 4, Bonaventure Chijioke Nwachukwu 1, Chioma Nneka Iloabachie 1, Andre Ukamaka Ezike 1, Ugochukwu Sunday Ezenyiroha 1, Pauline Odinachi Osuagwu 1, Perpetua Kelechi Enyinna 1, Ernest Ijeoma Uzoho 1, Nnabuike Chinonso Ofonere 1, Ifeanyi Anthony Ezugwu 5, Obumneme Nkemakolam Chukwubuike 1, Matthew Okoh 1, Darlington Sunday Okoh 1 and Thaddeus Ogbonna Offor 1 1 Department of Obstetrics and Gynaecology, ESUT College of Medicine/Teaching Hospital, Enugu, Nigeria. 2 Department of Maternal and Child Health, Odugu Memorial Hospital, Nkpamute, Enugu-Ezike, Igbo-Eze North, Enugu, Nigeria. 3 Department of Nursing Service, ESUT Teaching Hospital, Enugu, Nigeria. 4 MaternalHealth Unit, Advent Hospital & Maternity, Abakpa-Nike, Enugu, Nigeria. 5 Department of Medical Microbiology, ESUT College of Medicine, Enugu, Nigeria. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 Publication history: Received on 24 February 2025; revised on 05 April 2025; accepted on 08 April 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.22.1.0377 Abstract Background: Miscarriage and its related issues and complications are the commonest reasons for presentation in most gynaecological clinics and emergency rooms. They are major contributors to maternal morbidity and mortality requiring a more holistic review of our laws and the entire health system. Aim: The aim of this study was to determine the prevalence and the pattern of presentation of miscarriages in a private facility. Methodology: It was a retrospective study conducted in the above hospital over a 5-year period spanning between 31st December 2023 and 1st January, 2019. The relevant data was collated from the patients’ case files and hospital registers using a standardized proforma. The data collated were analyzed using the statistical products and services solution (SPSS) version 25.0. The mean percentages and ratios were calculated and the results presented in tables and charts. Pearson Chi-square test and student t-test were used as a test of significance for categorical and continuous variables respectively and a P-value<0.05 was considered statistically significant. Results: From the hospital records and register, a total of 293 women presented to the hospital with gynaecological conditions, out of which 78 were related to miscarriages and its complications. This gives a prevalence of 26.62%. Most of the women were aged 26-30 years 23(29.5%) while the least were 31-35 years 11(14.1%). A significant proportion was less than 20 years 12(15.4%). Fifty eight (71.8%) had secondary education and only 4(5.1%) had tertiary World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 498 education; more than half of the population 40(51.3%) were unemployed and only 4(5.1%) were civil servants. Majority of the women were multiparous 33(42.3%) and only 4(5.1%) were primiparous women; whereas only 47(60.3%) were married leaving 22(28.2%) and 9(11.5%) for single ladies and widows respectively. It further showed that 42(53.8%) were 1st trimester abortions and 51(65.4%) were induced mostly with misoprostol 32(41%) constituting the major agent of induction. Almost all of them, 74(94.9%), presented as a case of incomplete miscarriage with the most prominent features being: vaginal bleeding and abdominal pain 74(94.9%); drainage of liquor, 22(28.2%); passage of tissues per vaginam, 51(65.4%); asymptomatic, 13(16.7%). Thirty two (41%) had their cases complicated by hypovolemic shock whereas 28(35.9 had septic shock. The definitive treatments offered were medical evacuation (5.1%), MVA (94.9%). Majority of them 75.6%, had complete recovery whereas 19(24.4%) had significant morbidities and 2(2.6%) had maternal mortality from complications. There was a significant difference in the post-abortion complications between those that had spontaneous abortion and induced abortion and also the post-abortion complications between those who used misoprostol and those who had curettage or MVA; with the misoprostol group having more complications. Conclusion: There was a high prevalence of miscarriage in the hospital and most of which were induced with misoprostol. There was more post-abortion complication among those that had induced abortion; and these complications were yet more among misoprostol users than those that had surgical abortion with either D&C or MVA. Keywords: Pattern; Presentation; Outcome; Miscarriage; Rural Hospital; Enugu 1. Introduction One of the commonest reasons for presentations in most gynaecological clinics and emergency rooms is miscarriage. About 50% of first trimester miscarriages are due to chromosomal anomalies [1]. This clinical condition occurs commonly in the first trimester. About 1.25millioninduced abortions occurred in 2012 in Nigeria alone resulting from a high level of unmet need for contraceptives and restricted abortion laws in Nigeria [2-4]. However, the true incidence of spontaneous abortions is not known, but 1015% of clinically recognized pregnancy and 30 to 50% of all conceptions [5] and about 1:4 women will experience such a loss in her life time [6] In a 5-year retrospective study of all cases of miscarriage in a tertiary hospital in Abakalikki, south-east Nigeria, abortions constituted 45.5% of all gynaecological admission with a mean age of 28.4±6.4 years and the interventions offered include manual vacuum aspiration (82.2%), dilatation and curettage (9.8%) [7]. In a survey carried out in 14 countries, it was discovered that the most frequently cited reason for having an induced abortion were socioeconomic concerns or limiting childbearing while some have more than one reason [8]. Furthermore, it may be very difficult to ascertain the reason or procuring and abortion in countries with restrictive abortion laws like Nigeria. Most often patients present with abortion complications to the hospitals after an illegal abortion or following a spontaneous miscarriage. Abortion complications constituted about 41.4% of all gynaecological admission and 11.5% of all maternal mortalities in a study done in Abakalikki, south east, Nigeria [9]. This study also found that women less than 19 years were 7.1% whereas single women constituted 25.3% of the cases. In a 2024 study in Nigeria, 14.2% of all miscarriages were complicated by various morbidities whereas 2.1% were complicated by maternal death [10]. Most of these complications were associated with induced abortions. It was also found that haemorrhage was the frequent type of complication. Induced abortions were also found to be associated with about 30% of maternal deaths in Nigeria [11]. These adverse outcomes could be linked to the restrictive abortion laws in Nigeria which creates hindrances to abortion services and exposing our women to quacks [12]. This retrospective review attempted audit the experience in a rural private hospital and to proffer solutions to achieving a sustainable maternal health index in our country. Aims/Objectives The aim of this study was to determine the prevalence and the pattern of presentation of miscarriages in a private facility The objectives of the study were to determine the: • Prevalence of miscarriages • Prevalence of induced miscarriages World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 499 • Major agents of induction • Most prevalent clinical types • The correlation between clinical type and treatment outcome 1.1. Study area This study was carried out Odugu Memorial Hospital in Enugu-Ezike, Igbo-Eze North Local Government Area of Enugu State, south-East, Nigeria. It is a one of the major health facilities in the area as there is no functional public hospital in the community 2. Methodology It was a retrospective study conducted in the above hospital over a 5-year period spanning between 31st December 2023 and 1st January, 2019. The relevant data was collated from the patients case files and hospital registers using a standardized proforma. 2.1. Data analysis The data collated were analyzed using the statistical products and services solution version 25.0. The mean percentages and ratios were calculated and the results presented in tables and charts. Pearson Chi-square test and student t-test were used as a test of significance for categorical and continuous variables respectively and a P-value<0.05 was considered statistically significant 3. Result From the hospital records and register, a total of 293 women presented to the hospital with gynaecological conditions, out of which 78 were related to abortions and its complications. This gives a prevalence of 26.62%. Most of the women were aged 26-30 years 23(29.5%) while the least were 31-35 years 11(14.1%). A significant proportion was less than 20 years 12(15.4%). Fifty eight (71.8%) had secondary education and only 4(5.1%) had tertiary education; more than half of the population 40(51.3%) were unemployed and only 4(5.1%) were civil servants. Majority of the women were multiparous 33(42.3%) and only 4(5.1%) were primiparous women; whereas only 47(60.3%) were married leaving 22(28.2%) and 9(11.5%) for single ladies and widows respectively. It further showed that 42(53.8%) were 1st trimester abortions and 51(65.4%) were induced mostly with misoprostol 32(41%) constituting the major agent of induction. Almost all of them, 74(94.9%), presented as a case of incomplete miscarriage with the most prominent features being: vaginal bleeding and abdominal pain 74(94.9%); drainage of liquor, 22(28.2%); passage of tissues per vaginam, 51(65.4%); asymptomatic, 13(16.7%). Thirty two (41%) had their cases complicated by hypovolemic shock whereas 28(35.9 had septic shock. The definitive treatments offered were medical evacuation (5.1%), MVA (94.9%). Majority of them 75.6%, had complete recovery whereas 19(24.4%) had significant morbidities and 2(2.6%) had maternal mortality from complications. There was a significant difference in the post-abortion complications between those that had spontaneous abortion and induced abortion and also the post-abortion complications between those who used misoprostol and those who had curettage or MVA; with the misoprostol group having more complications Table 1 Sociodemographics Values Frequency Percentages Age group 16-20 years 12 15.4 21-25 years 16 20.5 26-30 years 23 29.5 31-35 years 11 14.1 36 and above 16 20.5 Religion Christianity 68 87.2 Traditional 10 12.8 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 500 Education No formal education 9 11.5 Primary 9 11.5 Secondary 58 71.8 Tertiary 4 5.1 Occupation Civil Servant 4 5.1 Petty trader/farmer 34 43.6 Unemployed 40 51.3 Marital Status Married 47 60.3 Single 22 28.2 Widow 9 11.5 Table 2 Clinical History Values Frequency Percentages Parity Grand-Multipara 19 24.4 Multipara 33 42.3 Nullipara 22 28.2 Primipara 4 5.1 Gestational Age 1st trimester 42 53.8 2nd trimester 36 46.2 Spontaneous abortion Yes 27 34.6 No 51 65.4 Induced abortion Yes 51 65.4 No 27 34.6 If induced , what was the agent D & C /MVA 19 24.4 Misoprostol 32 41 Not applicable 27 34.6 Clinical Types Incomplete 74 94.9 Missed 4 5.1 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 501 Table 3 Treatment given after miscarriage Values Frequency Percentages Medical Evacuation Yes 4 5.1 No 74 94.9 MVA / D & C Yes 74 94.9 No 4 5.1 Laparotomy No 78 100 Table 4 Measures taken during Miscarriage Values Frequency Percentages Analgesia Yes 74 94.9 No 4 5.1 Transfusion Yes 47 60.3 No 31 39.7 Antibiotic Yes 78 100 Table 5 Clinical presentation during Miscarriage Values Frequency Percentages Asymptomatic /Missed Yes 13 16.7 No 65 83.3 Vaginal Bleeding Yes 74 94.9 No 4 5.1 Abdominal Pain Yes Yes 94.9 No No 5.1 Drainage of Liquor Yes 22 28.2 No 56 71.8 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 502 Passage of Tissues Yes 51 65.4 No 27 34.6 Hypovolemic Shock Yes 32 41 No 46 59 Septic Shock Yes 28 35.9 No 50 64.1 Table 6 Outcomes Treatment outcome Frequency Percentages Complete recovery 59 75.6 Significant morbidity 17 21.8 Mortality 2 2.6 Table 7 Relationship between outcomes and Clinical miscarriages Outcomes Recovery (%) Post Abortion Complications %) Total X2 (p value) Spontaneous Abortion Yes 27(45.8) 0(0) 27(34.6) 11.35 (0.001)* No 32(54.2) 19(100) 51(65.4) Induced Abortion Yes 32(54.2) 19(100) 51(65.4) 11.35 (0.001)* No 27(45.8) 0(0) 27(34.6) If induced, what agent was used D&C/MVA 19(32.2) 0(0) 19(24.4) 36.11(0.001) * Misoprostol 13(22) 19(100) 32(41) 27(34.6) Not applicable 27(45.8) 0(0) Clinical types Incomplete 55(93.2) 19(100) 74(94.9) 0.32(0.57) Missed 4(6.8) 0(0) 4(5.1) 4. Discussion The aim of this study was to determine the prevalence and the pattern of presentation of miscarriages in a rural private facility. From our study, the prevalence was 26.62%. This differs from the finding from Abakalikki, Ebonyi State, where Anikwe CC et at reported a prevalence of 45.5%[7]. Even though both were retrospective studies, that of Ebonyi was in a tertiary centre which received referrals from peripheral centres and may also have better documentation and record World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 497-504 503 keeping. It can also be compared with another finding in Ogun state, western Nigeria where a prevalence of 23.0% was reported [13]. The above was a prospective cross-sectional study involving women who sought abortions in different hospital in the 4 geopolitical zones of Ogun State. The slight differences could be due to the fact that it was a multicentre prospective study as against our retrospective study in a private facility. In our study, out of the 78 abortion related cases, 51(65.4%) were induced. All cases of induced abortions were as a result of unintended pregnancies. Induced abortion is largely illegal in Nigeria;and as such, the data on it is scanty. A 2012 survey involving 772 health facilities from all over Nigeria reported an induced abortion rate of 56% prevalence [14]. This value was a little less than the finding from our study possibly due to the differences in the methodology and the national spread of data from the quoted study. From our study, 51(6.4%) of the abortions were induced and the 2 major agents/methods applied were misoprostol (41%) and D&C/MVA (24.4%). The literature is scanty on which agent is mostly employed by seekers of abortion. This could be because abortion is largely illegal in most developing nations and are clandestinely procured. This study showed that there is a significant difference in the post-abortion complications between those that had spontaneous abortions and induced abortion with a P-value of 0.001. In this study, the entire 19 patient that had significant complications had induced abortion whereas none of the patient who had spontaneous abortions had significant complications. This finding is similar to the findings by Fouedjio JH et al, who reported that the rate of complication is more with induced abortion group [15]. Even though it was a cohort study carried out in Cameroon, the results were comparable. Another study by Jeanne HF [16] reported 3.5% incidence of septic shock among the women with induced abortion whereas our study found a septic abortion rate of 35.9%. The huge difference could be due to types of study employed in each case and the differences in the setting and socio-demographic differences between the populations studied. 5. Conclusion There was a high prevalence of miscarriage in the hospital, most of which were induced with misoprostol. There was more post-abortion complication among those that had induced abortion; and these complications were even more among misoprostol users than those that had surgical abortion with either D&C or MVA. Recommendations: We recommend a review of the abortion laws in Nigeria to make abortion services more accessible. Secondly, we recommend that management of post-abortion complications and the use of MVA be incorporated into the primary health care services in all the rural areas. Finally misoprostol should be strictly regulated. Compliance with ethical standards Acknowledgment We acknowledge the cooperation of the staff of Odugu Memorial Hospital for their support in this work. 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