4. DIAGNOSTICO
4.2 La estructura organizativa de la institución educativa
4.2.5 Dimensión pedagógica curricular y valores
Table VI show that early neonatal deaths constitute 66.1% of the total under-five deaths studied during the one year duration of the study. This is followed by late neonatal and infant mortality each of which accounted 11.5% of cases. Thus there is a decline in death rate from the early neonatal age group down to the pre-school age group. There were 92 males and 82 females giving a male to female ratio of 1.1:1.
Table VII show that death in under-fives is most commonly due to conditions originating in the perinatal period (60.3%). A further characterization of the conditions originating in the perinatal period show that the sub-classification of respiratory and cardiovascular disorders specific to the perinatal period under which birth asphyxia, respiratory distress syndrome, congenital pneumonia, neonatal aspiration syndromes and pulmonary haemorrhage are listed accounted for most (24.7%) under-five deaths in this study (Table VIII). Infections specific to the perinatal period accounted for 11.5% of total deaths, this combined with specific infections (6.9%) make infectious causes (18.4%) the second most common cause of under-five deaths. Other common causes of death are prematurity(14.4%), congenital malformations (12.6%), and nervous system diseases(8.0%) in decreasing frequency of occurrence. There were five cases of neoplasms seen in this study accounting for 2.9% of deaths.
5.2.1 EARLY NEONATAL DEATH
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The leading causes of Early Neonatal Death in the present study using the ICD-10 classification are respiratory and cardiovascular disorders specific to the perinatal period (birth asphyxia, respiratory distress syndrome, congenital pneumonia, neonatal aspiration syndromes, perinatal pulmonary haemorrhage) accounting for 35.6% of all early neonatal deaths. Others in decreasing order of frequency are, prematurity (21.7%), congenital malformation (13.0%), infections (8.7%), haemorrhagic/haematologic disorders (7%), {Table VII}
5.2.2 LATE NEONATAL DEATHS
Infection was the leading cause of death in this group. Infections specific to the perinatal period (neonatal sepsis) was responsible for 50% of late neonatal deaths in this study. An additional 10% of cases was due to specific infections (neonatal tetanus), making infectious causes to be responsible for 60% of late neonatal deaths. Congenital malformations involving the gastrointestinal tract dominantly were also prominent (20%).
5.2.3 INFANT MORTALITY
The leading cause of infant mortality in the study were of infectious causes. Specific infections accounted for 25% of total infant deaths. These include tetanus, cerebral malaria and paediatric AIDS. Meanwhile another 20% each of the total infant deaths were as a result of infections involving the respiratory system (bronchopneumonia) and nervous system (meningitis). The second most common cause of Infant deaths is congenital malformations (15%) involving the respiratory and cardiovascular systems mainly.
5.2.4 PRE-SCHOOL MORTALITY
Infections remained an important leading cause of death in this mortality group with specific infections accounting for 26.3% of the deaths. Infections involving particular organ systems;
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respiratory system (bronchopneumonia and lung abscess) are responsible for 21% of the deaths, while nervous system and digestive system infections together accounted for 26.3%.
Thus infectious causes of death were responsible for a majority of pre-school deaths. Also significant in this age group is the emergence of malignant causes of death (21-1%). The tumour types encountered in this study are retinoblastoma, and acute lymphoblastic leukaemia.
The 174 under-five deaths were evaluated for clinico-pathological discordance and as shown in Tables IX and X, there were nineteen cases of clinico-pathological discordance. This gives a discordance rate of 10.9%. There were ten (10) class I autopsy findings all of which related to the cause of death (Table IX) while class II major findings were seen in nine (9) cases (Table X).
TABLE I: CAUSES OF PERINATAL DEATHS IN UBTH, CLASSIFIED USING
THE TULIP PATHOPHYSIOLOGICAL CLASSIFICATION
CAUSE OF DEATH MALE FEMALE FREQUENCY (%)
CONGENITAL ANOMALY 12 14 26(10.9%)
PLACENTAL 26 23 49(20.6%)
PREMATURITY/IMMATURITY 22 16 38(16.0%)
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INFECTION 42 30 72(30.3%)
OTHER 7 10 17(7.1%)
UNKNOWN 22 14 36(15.1%)
TOTAL 131 107 238(100%)
TABLE II: AGE-SPECIFIC CAUSES OF PERINATAL DEATH IN UBTH
Age Group Cause of Death Total
CongenitalAnomaly Placental Prematurity Infection Other Unknown
FSB 5 27 1 0 9 6 48
MSB 5 17 0 21 2 30 75
ENND 16 5 37 51 6 0 115
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TOTAL 26 49 38 72 17 36 238
KEY: FSB: fresh stillbirth MSB: macerated stillbirth ENND: early neonatal death
ORGAN SYSTEM FREQUENCY PERCENTAGE(%)
Central nervous system 5 19.23
Respiratory system 5 19.23
Heart and circulatory system 4 15.38
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TABLE III:
DISTRIBUTION
OF CONGENITAL
ANOMALIES AMONGST THE PERINATAL DEATHS
Digestive system 4 15.38
Syndrome 3 11.54
Urogenital System 2 7.69
Musculoskeletal 1 3.85
Neoplasm 1 3.85
Other 1 3.85
TOTAL 26 100
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TABLE IV: WEIGHT DISTRIBUTION OF THE VARIOUS CAUSES OF PERINATAL DEATH
IN UBTH
CAUSE OF DEATH WEIGHT CATEGORIES TOTAL
<1000g 1001-1500g 1501-2000g 2001-2500g >2500g
Congenital Anomaly 0 2 5 6 13 26
Placental 1 7 10 4 27 49
Prematurity 13 14 6 5 0 38
Infection 7 18 22 13 12 72
Other 0 0 0 4 13 17
Unknown 1 6 8 3 18 36
TOTAL 22 47 51 35 83 238
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TABLE V: WEIGHT DISTRIBUTION OF THE VARIOUS PERINATAL DEATH GROUPS
GROUP WEIGHT CATEGORIES TOTAL
<1000g 1001-1500g 1501-2000g 2001-2500g >2500g
FSB 2 3 9 4 30 48
MSB 4 17 14 12 28 75
ENND 16 27 28 19 25 115
TOTAL 22 47 51 35 83 238
KEY:
FSB: fresh stillbirth
MSB: macerated stillbirth
ENND: early neonatal death
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TABLE VI: AGE AND SEX DISTRIBUTION OF UNDER-FIVE DEATHS AT THE UNIVERSITY OF BENIN TEACHING HOSPITAL.
AGE GROUPING
SEX TOTAL
MALE FEMALE (%)
Early Neonatal Death 65 50 115(66.1%)
Late Neonatal Death 12 8 20(11.5%)
Infant Mortality 4 16 20(11.5%)
Pre-School Mortality 11 8 19(10.9%)
TOTAL 92 82 174(100%)
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TABLE VII: AGE AND SEX DISTRIBUTION OF THE VARIOUS CAUSES OF UNDER-FIVE MORTALITY AS SEEN AT THE UNIVERSITY OF BENIN TEACHING HOSPITAL
DISEASE CLASS MORTALITY GROUP
TOTAL (%)
ENND Late NND Infant Pre-school
M F M F M F M F
Infections(Specific) 0 0 2 0 1 4 3 2 12(6.9%)
Conditions originating in the Perinatal Period
57 35 8 4 0 1 0 0 105(60.3%)
Congenital Malformations 4 11 2 2 1 2 0 0 22(12.6%)
Accidental Injury 0 0 0 0 0 1 0 0 1(0.6%)
Neoplasms 0 1 0 0 0 0 1 3 5(2.9%)
Diseases of Blood/ Blood Forming Organs
0 0 0 0 0 0 1 0 1(0.6%)
Nervous system diseases 2 4 1 0 0 4 1 2 14(8.0%)
Circulatory system diseases 0 0 0 0 0 1 0 0 1(0.6%)
Respiratory system diseases 0 1 0 1 2 2 4 0 10(5.7%)
Digestive system diseases 0 0 0 0 1 0 1 1 3(1.7%)
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TOTAL 63 52 13 7 5 15 11 8 100
TABLE VIII: AGE DISTRIBUTION OF THE CONDITIONS ORIGINATING IN THE PERINATAL PERIOD
SUB- CLASS
Mortality Group
TOTAL/(%) ENND Late ND Infant
Mortality
Pre-school Complications of placenta cord and
membranes
1 0 0 0 1(0.6%)
Disorders of length of
gestation(prematurity)
25 0 0 0 25(14.6%)
Birth trauma 2 0 0 0 2(1.1%)
Respiratory/cardiovascular disorders specific to the perinatal period
41 1 1 0 43(24.9%)
Infections specific to the perinatal period
10 10 0 0 20(11.5%)
Haemorrhagic/haematologic disorders 8 0 0 0 8(4.6%)
Digestive system Disorders 4 1 0 0 5(2.9%)
Others 1 0 0 0 1(0.65)
TOTAL 92 12 1 0 105(60.3%)
72 TABLE IX: CLASS I AUTOPSY FINDINGS
CLINICAL DIAGNOSIS AGE AUTOPSY DIAGNOSIS
Preterm,LBW, RDS 2days Bronchopneumonia
Severe birth asphyxia, HIE III 1 day Hypoplastic left heart syndrome
Neonatal sepsis 2 days Hyaline membrane disease
Meningitis 2 1/2yrs Ileo-ileal intussusception
Syndromic child with multiple congenital anomalies ?congenital neurosarcoma
1 day Hepatoblastoma Hydrops fetalis
Severe malaria, Uraemia 28months Bronchopneumonia Disseminated TB. ?tuberculous meningitis 14months Acute bronchopneumonia
RDS 1day Congenital pneumonia
Preterm. VLBW. SBA. RDS. 1day Complex congenital heart disease
Preterm. Fetal Ascites 1day Meconium Peritonitis. Intrauterine ileo-ileal intussusception. Intestinal Atresia.
KEY LBW: Low birth weight RDS: Respiratory distress syndrome HIE III: Hypoxic ischaemic encephalopathy grade III TB: Tuberculosis VLBW: Very low birth weight SBA: Severe birth asphyxia
73 TABLE X: CLASS II AUTOPSY FINDINGS
CLINICAL DIAGNOSIS AGE AUTOPSY DIAGNOSIS
Cerebral malaria; Septicaemia 9months Meningitis
Preterm VLBW at risk of sepsis 1day Intraventricular haemorrhage Severe birth asphyxia, HIE III 4days Pulmonary haemorrhage
Preterm, LBW, Hydrocephalus 2° stenosis 1day Hydranencephaly; Intra-uterine infection Cyanotic congenital heart disease 1day Intraventricular haemorrhage
Preterm; LBW; neonatal sepsis; meningitis 1day Congenital pneumonia; No meningitis Preterm, VLBW, Progressive sepsis 5days Meningitis.
Univentricular heart, Pulmonary stenosis 35days Hypoplastic left heart syndrome
Omphalocele major 2days Gastroschisis.
KEY: VLBW: Very low birth weight HIE III: Hpoxic ischaemic encephalopathy grade III LBW: Low birth weight
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FIGURE 1: congenital heart disease(hypoplastic left heart syndrome) in a term neonate dying within one day of life.
Atretic ascending aorta.
Enlarged pulmonary trunk draining a common ventricular cavity.
75 Single dominant ventricular cavity.
FIGURE 2: Cut surface of the kidneys in a child with acute lymphoblastic leukaemia(ALL) showing numerous areas of haemorrhage. Histology of same kidney show marked infiltration of the parenchyma by leukaemic cells.
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FIGURE 3:THANATOPHORIC DYSPLASIA in female neonate who died within hours of birth showing extremely short extremities, narrow chest, depressed nasal bridge and oedema.
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FIGURE 4: photomicrograph of a lung specimen showing marked neutrophilic infiltration of the alveolar spaces with accompanying oedema in acute bronchopneumonia.
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FIGURE 5: A case of Gastroschisis in a female neonate who died on the second day of life. The hernia sac contained oedematous small intestines which were matted together, part of the liver, spleen pancreas and caecum.
Line arrow shows the umbilical cord stump attachment Block arrow shows the paraumbilical hernia sac
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FIGURE 6: Neonatal necrotizing enterocolitis showing distension of the intestines and feacal contamination of the peritoneal cavity due to gut perforation.
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FIGURE 7: Intussusception of the ileo-ileal variety showing oedema and vascular compromise of the intussusceptum in a 30 month old male.
Intussuscipiens.
Intusscusceptum.
81 Location of intusscusception
FIGURE 8: Meningitis with purulent exudates on the surface of the brain.
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FIGURE 9: retroplacental haematoma with marked compression of the placental parenchyma from a 24years old female with severe pre-eclampsia who delivered a fresh stillbirth weighing 2.1kg
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FIGURE 10: Gross and histology of placental infarction. Histology show areas of infarction which reveals ghost outlines of villi enmeshed in fibrin. Some viable small villi are present adjacent to the infarct on the right.
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FIGURE 11: Histology of the term placenta of a stillborn showing chronic villitis with the intervillous space filled with dominantly mononuclear cell infiltrates. The mother presented with a one day history of not feeling foetal movements.
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FIGURE 12 showing left diaphragmatic hernia with herniation of left lobe of the liver, stomach as well as intestines into the left hemithorax and dextroposition of the heart. There was bilateral lung hypoplasia. The neonate died within the first 24 hours of life.
Line arrow showing hypoplastic lung in right hemithorax.
Block arrow showing part of the liver in the left hemithorax Block arrow showing dextroposition of the heart
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CHAPTER SIX