INTRODUCTION
Eclampsia is defined as the occurrence of convulsions
associated with signs of pre-eclampsia (hypertension and proteinuria) during
pregnancy labor or with in 7-days of delivery and not caused by epilepsy or
other convulsive disorders. Its incidence varies widely from 1 in 100 to 1 in
2000 pregnancies.1 Eclampsia occurs in 1-2% of women with
pre-eclampsia in developed countries.2 Hypertensive disorders are a
leading cause of maternal mortality. The death rate from eclampsia in
Convulsions may occur antepartum (38%)
intrapartum (18%) or postpartum (44%).3 Primigravida are at higher
risk of convulsions and that antepartum convulsions are more dangerous then
those beginning after delivery.3,4 Magnesium Sulphate is the first
line anticonvulsive agent used in the treatment of eclampsia and has been found
to be the most effective agent in relation to a number of measures of maternal
and perinatal morbidity and in prevention of recurrent convulsion.5,7 The
other mainstay of management case of eclampsia is early delivery to improve the
prognosis in terms of reducing maternal and perinatal morbidity and
mortality. The purpose of this study was
to report the frequency of this lethal pregnancy associated disorder in terms
of age, parity, seasonal variation, associated maternal complications and fetal
outcome. Also to highlight the lapses of our setup which can be overcome to
improve the outcome and to reduce its incidence.
MATERIAL AND METHODS
This study was carried out in Department of Obs/Gynae
Ayub Teaching Hospital Abbottabad during a period of 15-months from
Inclusion criteria were patients more than
twenty weeks gestation with history (taken from attendants) of pre-eclampsia
(headache, apigastric pain, nausea, vomiting, rapidly increasing generalized
body swelling, hypertension, proteinuria, odema and superimposed convulsions.
Patients of all reproductive age group and parity ranging from teenager
primigravida to older grandmultigravida were included. Pregnant patients with
other convulsive disorders and more than 7-days postpartum were excluded. The
clinical findings on admission were recorded on note sheets including lab work
up both general and specific for eclampsia. All the patients were managed
according to basic protocol for eclampsia I.e stabilization of patients,
anticonvulsive therapy MgSO4 and/ or diazepam and early delivery. Management
was then evaluated in terms of maternal and fetal outcome. All the patients
were followed till six weeks postpartum. The data was then compiled for
frequency distribution.
RESULTS
During this period of 15-months a total of 2100 laboring
patients were admitted in labor ward and out of them 68 (3.23%) were cases of
eclampsia. The frequency of eclampsia nearly came out to be 32 patients per
1000 deliveries. Figures 1 and 2 show age and parity distribution of patients
with eclampsia respectively.
Patient’s age range was 19 years to 43 years, average 29.54 years.
Maximum cases were seen from 25-34 years age groups and at extremes of parity
i.e in primigravida and grandmultigravida. Figure-3 shows the number of cases
presenting at different period of gestation. Maximum cases were seen at term.
Frequency of cases seemed to decrease with decreasing gestation. Only three cases were seen before 28 weeks of
gestation and they were all primiparas. Another interesting feature in
primiparous patients worse clinical picture on admission with early recovery as
compared to multiparous patients in whom recovery was delayed. Another common
feature in all these patients were that they belonged to poor socio-economic
class, living in far-flung areas and never seeking proper antenatal advice even
if living in the areas nearby. Most had a preceding 1 to 7 days history of
severe pre-eclampsia especially sudden increase in generalized body swelling.
Eclampsia occurred antepartum in 32 (47.05%) cases intrapartum 30 (44.11%)
& 6 (8.82%) postpartum. Postpartum cases on an average occurred 6 to 36
hours after delivery.
Figure-1: Distributions of patients (n=68)
according to age (weeks)
Figure-2:
Distributions of patients (n=68) according to period of gestation (weeks)
Figure-3: Distributions of patients (n=68)
according to period of gestation (weeks)
Complications
were observed in 48 (70.58%) out of 68 patients. Aspiration pneumonia was seen
in 8 (11.76%), renal insufficiency in 5 (7.35%), Acute Tubular Necrosis (ATN) in
2 (2.94%) and retroplacental haemorrhage in 8 (11.76%) cases. Seven patient
died giving a death rate of 10.29%. The perinatal mortality rate was 23.52%
with prematurity being the leading cause. The preponderance of male to female
fetuses was 1.3 : 1.
Table-1: Clinical
Presentation of eclampsia (n=68)
|
Clinical Presentation |
No. of cases (%) |
|
Headache + vomiting |
68 (100%) |
|
Epigastric Pain |
55 (80.88%) |
|
Generalized body
swelling |
55 (85.29%) |
|
Hypertension |
62 (9.17%) |
|
Proteinuria |
68 (100%) |
|
Odema |
64 (94.17%) |
|
Convulsions |
68 (100%) |
Table-2:Complications
associated with eclampsia (n=68)
|
Associated Complications |
No. of Cases (%age) |
|
Aspiration
Pneumonia |
8 (11.76%) |
|
Septicemia |
2 (2.94%) |
|
Renal insufficiency |
5(7.35%) |
|
ATN |
2(2.94%) |
|
Abruptioplacentae |
8(11.76%) |
|
CCF |
2(2.94%) |
|
DIC |
3(4.41%) |
|
HELLP Syndrome |
3(4.4%) |
|
IUGR & Oligo
hydramnios |
15(22.05%) |
Table-3
Mode of delivery (n=68)
|
Mode of delivery |
No. of Cases (%age) |
|
SVD |
25(36.76%) |
|
Vaginal delivery
with epsiotomy |
4(5.88%) |
|
Vacuum delivery |
6(8.82%) |
|
Outletforceps
delivery |
1(1.47%) |
|
Caesarean
Section |
29(42.64%) |
|
Hysterotomy |
3(4.41%) |
DISCUSSION
Eclampsia is the commonest cause of convulsions during
pregnancy next being epilepsy (0.5% of pregnancies)6. It is uncommon
in
Commonest
clinical presentation was typical convulsions superimposed on hypertension and
protenuria. Only 6 cases were normotensive on admission. Two patients
hypotensive due to over dosage of diazepam prior to admission at some basic
health unit. Proteinuria was present in all the cases. Commonest associated maternal complication
was aspiration pneumonia (11.76%) in those who had countless fits before
arrival to hospital and abruptio placentae (11.76%) in whom BP was more than
180/110 mmHg. One of them required hysterectomy due to couvelaire uterus.
After preliminary management patients were
given MgSO4 +/- diazepam parenterally for control of fits followed by quick
delivery preferably vaginally or by caesarean section if the delivery was not
imminent within 6-8 hours or in cases of maternal deterioration (un controlled
fits) fetal distress or other obstetric cause for caesarean section. 47% delivered by abdominal route and rest by
vaginal route. Maternal death rate was 10.29% (7-cases) two by septicemia, two
by cerebral hemorrhage and three by pulmonary embolism. Few older multipara
with eclampsia seen six week post partum continued to have BP above base line
as compared to women with normotensive pregnancies10.
Pernatal mortality rate came out to be
23.52%. The presence of IUGR as expected was associated with reduced risk of
survival independent of other variables such as gestation and severity of
maternal disease11.
The following factors have been identified as risk
factor for maternal morbidity and mortality: late referral to tertiary hospital,
delay in hospital management, lack of transport, unbooked status of patients,
high parity, prolong state of unconsciousness and multiple seizures prior to
admission12. Patients were assessed at 6 weeks postpartum for the
presence of residual hypertension, proteinuria and for the return of renal
functions to normal, decision making regarding administration of low dose
aspirin in next pregnancy and detection of pre-eclampsia as early as possible
to reduce risk of recurrence which varies from 1.9% to 24.9% 13-15.
CONCLUSION
Eclampsia is a very common pregnancy associated
disorder in this part of the country. It can be diagnosed very easily on the
basis of history and typical clinical features i.e proteinemia, oedema, high
blood pressure with superadded fits. Most important feature of management is
its prevention by proper antenatal check ups, availability of health facilities
and prompt referral to tertiary care hospital, but once it occurs it caries a
high maternal and perinatal mortality.
REFERENCES
1.
Eclampsia Trial Collaborative group. Which anti convulsant for women
with eclampsia? Evidence from the collaborative Eclampsia Trial. Lancet 1995;345:1455-63.
2.
Drife J. Lewis G. editors. Why Mothers Die, Report on the confidential
Enquiry into Maternal Deaths in the
3.
Piercy CN. In: Handbook of Obstetric medicine.
4.
Chelsey LC. A short history of eclampsia. Obstet Gynecol 1974;43:599-602
5.
Douglous KA, Redman CWG. Eclampsia in the
6.
O’ Brien MD, Gilmour-WhiteS. Epilepsy & Pregnancy. BMJ 1993;307:492-5.
7.
Begum R, Begum A, Bullongh C, Johnson RB. Reducing maternal mortality
from Eclampsia using Magnesium Sulphate. Eur J Obstet Gynecol Reprod Biol 2000;92:223-4.
8.
Eclampsia Working Group: Eclampsia in
9.
Campbell DM, Mac Gallivray I. Pre-eclampsia in second pregnancy. Br J
Obstet Gynaecol 1985;92:131-40
10. Fisher KA, Luger A, Spargo BH,
Lindheimer MD.Hypertension in pregnancy, clinical pathological correlatioins
& remote prognosis. Medicine 1981;60:267-76.
11. Witlin AG, Saade GR, Mattar F,
Sibai BM. Predictors of neonatal outcome in women with severe pre-celampsia or
Eclampsia between 24 & 33 weeks gestation. Am J Obstet Gynecol 2000;182:607-11
12. Moodley J, Daya P. Eclampsia a
continuing problem in the developing world. Int J Gynecol Obstet 1993;44:9-14.
13. Andelusi B, Ojengbede OA.
Reproductive performance after Eclampsia. Int Obstet Gynecol 1986;24:183-9
14. Chelsey LC, Annitto JE,
Cosgrove RA. The familial factor in toxaemia of pregnancy. Obstet Gynecol
1968;32:303-5
15. Sibai BM, Sarinoglu C, Mercer
BM. Eclampsia vil. Pregnancy outcome after Eclampsia & long term prognosis.
Am J Obstet Gynecol 1992;166:1757-61.