Abstract
Introduction
Preeclampsia with severe features and eclampsia has remained a serious challenge in tropical obstetric practice. It is a major cause of maternal and perinatal morbidity and mortality in Nigeria.
Aim
This study was aimed at determining the prevalence, the risk factors and feto-maternal outcome of preeclampsia with severe features and eclampsia in Abakaliki.
Materials and Methods
This was a 5-year retrospective case-control study of preeclampsia with severe features and eclampsia at the Federal Teaching Hospital, Abakaliki. Case notes of preeclampsia with severe features and eclampsia between January 2008 and December, 2012 were retrieved. Similarly, the case file of next parturient that did not have any medical disease was included in the study. The cases and controls were selected at the ratio of 1:1. The data assessed were information on maternal age, parity, booking status, diagnosis, mode of delivery, complications, maternal and perinatal outcomes.
Results
A total of 13,750 deliveries were recorded within the study period. The prevalence of preeclampsia with severe features and eclampsia were 136(0.99%) and 104(0.76%) respectively. Preeclampsia with severe features and eclampsia was more common among adolescents, rural dwellers, poorly educated, unemployed, unbooked and nulliparous women. It was more associated with preterm delivery, caesarean section, low birth weight babies, maternal and perinatal mortality.
Conclusion
Preeclampsia with severe features and eclampsia is common among the adolescents, unbooked, rural, and low socio-economic group of women in this study. It has also contributed to high maternal and perinatal morbidity and mortality. There is need for policy makers to formulate policies toward female education, women empowerment and provision of social amenities in rural areas. These policies may reverse the current ugly trend in this environment.
Keywords: Hypertension, Obstetric practice, Proteinuria
Introduction
Preeclampsia is a multi systemic disorder characterized by hypertension and new-onset proteinuria which develops after the 20th week of pregnancy [1,2]. However, even when there is no proteinuria which meets or exceeds the diagnostic threshold, any of the following conditions can be diagnostic: new-onset thrombocytopenia, impaired liver function, renal insufficiency, pulmonary oedema, or visual or cerebral disturbances [2].
Preeclampsia with severe features can occur in any of the following conditions: the systolic blood pressure of at least 160 mm Hg, or diastolic blood pressure of at least 110 mmHg when measured on two occasions at least 4 hours apart while the patient is on bed rest. The other conditions comprise thrombocytopenia (platelet count less than 100,000/microliter), impaired liver function indicated by abnormally elevated blood concentrations of liver enzymes, severe persistent epigastric or right upper quadrant pain that is not responsive to medication and not accounted for by alternative diagnoses, or both, progressive renal insufficiency (serum creatinine concentration greater than 1.1mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease), pulmonary oedema and new-onset cerebral or visual disturbances [2].
Eclampsia is one of the serious obstetric emergencies seen in our sub-region and it is defined as new onset of grand mal seizure activity and/or unexplained coma during pregnancy or postpartum in a woman with signs or symptoms of preeclampsia [2–4]. It often presents with few warning signs and might occur in a patient with previously mild disease and therefore predicting its occurrence is as difficult as predicting the timing [5]. The incidence of preeclampsia/eclampsia varies from one part of the world to another. The incidence is low in the western countries where there is excellent antenatal care [5,6]. The incidence however remains high in the developing countries like Nigeria, because of poor antenatal care attendance especially in the rural areas [5]. The incidences of 0.42%, 1.32% and 1.66% were reported in Zaria, Benin and Lagos, respectively [5,7,8]. Studies carried out in Ibadan and Zaria showed that the incidence was higher among primigravidae and young women less than 25 years of age [5,9]. It has also been reported as a leading cause of maternal mortality in Kano, Sokoto, Jos and other Nigerian cities [10–12]. The fetal complications of preeclampsia with severe features and eclampsia comprise placental abruption, intrauterine growth restriction, premature delivery and intrauterine fetal death [13]. Moreso, the maternal complications of preeclampsia with severe features and eclampsia consist of Haemolysis, Elevated Liver enzymes, Low platelet count (HELLP) syndrome, Disseminated Intravascular Coagulation (DIC), acute kidney injury, cerebrovascular hemorrhage, cortical blindness, focal motor deficit and adult respiratory distress syndrome [13–15].
Abakaliki is the capital of Ebonyi State, South-East Nigeria. This state has a preponderance of poor rural women who are subjected to early marriage, teenage pregnancy, ignorance, poor health-seeking behaviour and high parity. These low socio-economic risk factors have been shown to be common among preeclamptics with severe features and eclamptics [16,17]. Similarly, these low socio-economic risk factors are associated with the high maternal mortality ratio previously reported in this environment [18]. Therefore, the finding from this study may help policy makers in formulating programmes aimed at reversing this ugly trend. It was based on this that the study on the incidence and feto-maternal outcome of preeclampsia with severe features and eclampsia in Abakaliki, South-East Nigeria, was embarked upon. This study was aimed at determining the prevalence, the risk factors and feto-maternal outcome of preeclampsia with severe features and eclampsia in this environment.
Materials and Methods
A 5-year retrospective case-control study of preeclampsia with severe features and eclampsia at the Federal Teaching Hospital, Abakaliki, from 1st January 2008 to 31st December 2012, was undertaken. Labour ward and Emergency unit records were used to extract file numbers of patients with preeclampsia with severe features and eclampsia and their case notes were retrieved from the medical records department of the hospital. Similarly, the file number and case note of the next obstetric patient after each preeclampsia with severe features and/ or eclampsia was consecutively retrieved and used as control. A proforma was used to collect information on maternal age, parity, booking status, diagnosis, mode of delivery, complications, maternal and perinatal outcomes. All the case files of preeclampsia with severe features and eclampsia were included in the study. Similarly, the case file of next parturient that did not have any medical disease was included in the study. The cases and controls were selected at the ratio of 1:1. The case files of the controls excluded were those of parturients who suffered from medical diseases like anaemia, haemoglobinopathy, diabetes mellitus, hypertensive disorders, mental illness and renal disease.
Statistical Analysis
The statistical analysis was done using the Statistical Package for Social Sciences version 17.0 software (SPSS Inc., Chicago IL, USA). The chi-square test and t-test were used for the discrete and continuous variables respectively. p-value ≤ 0.05 was considered to be statistically significant.
Ethical clearance for the study was obtained from the Ethics Committee of the Federal Teaching Hospital, Abakaliki.
Results
A total of 13,750 deliveries were recorded within the study period, among which 240 patients were found to have preeclampsia with severe features and eclampsia. There were 136 and 104 preeclampsia with severe features and eclampsia cases respectively. So, the prevalence of preeclampsia with severe features and eclampsia recorded in this study were 0.99% and 0.76% respectively. Out of the 240 case notes of the preeclampsia with severe features and eclampsia, only 207 case notes were retrieved giving the retrieval rate of 86.3%. These 207 case notes comprised 118 and 89 preeclampsia with severe features and eclampsia, respectively. The analysis was therefore solely based on the number of the retrieved case files.
[Table/Fig-1] shows the socio-demographic variables of the patients. Preeclampsia with severe features and eclampsia was significantly commoner among adolescents, rural dwellers, poorly educated, unemployed, unbooked and nulliparous women when compared with controls. The maternal and perinatal characteristics and complications are summarized in [Table/Fig-2]. Preeclampsia with severe features and eclampsia was significantly common among parturients with preterm delivery, caesarean section, low birth weight, maternal and perinatal mortality. [Table/Fig-3] contains the various types of eclampsia. It showed that antepartum eclampsia was the most common type recorded within the study period.
[Table/Fig-1]:
The sociodemographic variables of the patients.
| Sociodemographic data | Cases(%).N=207 | Controls(%).N=207 | p-value |
|---|---|---|---|
| Age (years) | |||
| <20 | 102(49.3) | 15(7.2) | <0.0001* |
| ≥20 | 105(50.7) | 192(92.8) | |
| Residential address | |||
| Rural | 181(87.4) | 45(21.7) | <0.0001* |
| Urban | 26(12.6) | 162(78.3) | |
| Educational Qualification | |||
| ≤ Primary Education | 145(70.0) | 54(26.1) | <0.0001* |
| ≥Secondary Education | 62(30.0) | 153(73.9) | |
| Booking status | |||
| Booked | 35(16.9) | 175(84.5) | <0.0001* |
| Unbooked | 172(83.1) | 32(15.6) | |
| Parity | |||
| 0 | 123(59.4) | 26(12.6) | <0.0001* |
| ≥1 | 84(40.6) | 181(87.4) | |
| Occupation | |||
| Unemployed | 126 | 39 | <0.0001* |
| Employed | 81 | 168 | |
| Form of marriage | |||
| Monogamy | 192 | 199 | 0.20 |
| Polygamy | 15 | 8 | |
*=Statistically significant
[Table/Fig-2]:
Maternal and perinatal characteristics and complications.
| Characteristics | Cases(%). N=207 |
Controls(%). N=207 |
p-value |
|---|---|---|---|
| Mean gestational age of delivery (weeks) | 34±2 | 38±1 | <0.0001* |
| Mode of delivery | |||
| Vaginal delivery | 100(48.3) | 185(89.4) | <0.0001* |
| Caesarean section | 107(51.7) | 22(10.6) | |
| Birth weight (kg) | |||
| <2.5 | 93(44.9) | 2(1.0) | <0.0001* |
| ≥2.5 | 114(55.1) | 205(99.0) | |
| Maternal mortality rate | |||
| Yes | 25(12.1) | 2(1) | <0.0001* |
| No | 182(87.9) | 205(99.0) | |
| Causes of maternal mortality | |||
| Aspiration pneumonitis /respiratory distress | 12(5.8) | 0(0) | <0.0001* |
| Acute renal failure | 5(2.4) | 0(0) | |
| Abruptio placentae | 1(0.5) | 0(0) | |
| Disseminated Intravascular Coagulopathy (DIC) | 5(2.4) | 1(0.5) | |
| Postpartum Haemorrage | 0(0) | 1(0.5) | |
| None | 2(1) | 0(0) | |
| 182(87.9) | 205(99.0) | ||
| Perinatal outcome | |||
| Alive | 160(77.3) | 199(96.1) | <0.0001* |
| Death | 47(22.7) | 8(3.9) | |
*=Statistically significant
[Table/Fig-3]:
Types of eclampsia.
| Types of Eclampsia | N=89 | % |
|---|---|---|
| Antepartum | 41 | 46.1 |
| Intrapartum | 28 | 31.5 |
| Postpartum | 20 | 22.5 |
Discussion
The prevalence of eclampsia of 0.76% recorded in this study was found to be higher than 0.42% and 0.44% previously reported in Kaduna and Enugu, respectively [5,19]. However, it was lower than 1.66%, 2.52% and 4.4% reported in Lagos, Benin and Sokoto respectively [7,8,11]. This study showed that low maternal socio-economic status was more common among patients with preeclampsia with severe features and eclampsia and it was similar to previous reports in other centres [17,20]. This may be due to the social deprivation of this group of women thereby increasing their risk of ignorance and poor-health seeking behaviour. This poor health–seeking behaviour may have been responsible for 83.1% of the patients being unbooked. The high unbooked status of these preeclamptics with severe features and eclamptics recorded in this study is similar to the previous reports in Irrua, Ibadan and Enugu, Nigeria [4,7,8].
More so, preeclampsia with severe features and eclampsia significantly found among adolescents in this study was similar to the report in Irrua [7]. However, this is contrary to the report in the developed world where severe preeclampsia with severe features and eclampsia is significantly commoner among women older than 40 years [1]. The reason may be because of higher rate of early marriage and teenage pregnancy in our environment when compared with the developed countries. This may further be explained by preeclampsia and eclampsia being more common among the blacks than the Caucasians [21]. Nulliparity strongly associated with preeclampsia with severe features and eclampsia in this study is supported by previous reports in other centres [7,8,22]. Although the proportion of women involved in polygamous marriage in this study was small, the absence of any strong association between preeclampsia with severe features and eclampsia and polygamy was similar to the report in Northern Nigeria [23].
The higher risk of preterm delivery among the preeclamptics with severe features and eclamptics may have been due to the interventional care and early delivery usually given to these patients after stabilization in the study centre. The significantly higher proportion of preeclamptics with severe features and eclamptics being delivered through caesarean section when compared with the control may have been due to the emergency delivery approach usually required to avert further maternal and perinatal complications from this disease especially when the cervix is unfavourable. More so, the 51.69% of cases who were delivered through caesarean section was similar to the findings in Ibadan and Ethiopia [9,24]. The 44.9% low birth weight reported in this study is lower than 58.54% and 71.43% reported in Tanzania and India respectively [25,26]. The strong association between preeclampsia with severe features and eclampsia and low birth weight in this study may have been due to the interventional delivery being carried out, irrespective of the gestational age, especially on eclamptics to forestall further maternal and perinatal morbidity and mortality. It may also be due to intrauterine growth restriction commoner among the preeclamptics with severe features and eclamptics. Antepartum eclampsia accounting for 46.1% in this study is higher than 36.8% reported in Lagos but lower than 61.6%, 84% and 85% reported in Ethiopia, Enugu and Ibadan respectively [4,8,9,24].
The maternal mortality rate of 12.1% reported in this study was higher than 7.9%, 8% and 9% reported from Tanzania, India and Ibadan, Nigeria respectively [9,25,26]. It is however lower than 15.6% and 23% reported from Enugu and Irrua [4,7]. The causes of maternal mortality rate among the preeclamptics with severe features and eclamptics in this study were similar to the reports in Ibadan, Lagos and Sokoto [8,9,11]. The high maternal mortality in this study may not only be due to the complications from preeclampsia with severe features and eclampsia but the high caesarean section rate among the women with its consequences.
The 22.7% perinatal mortality rate in this study is higher than 10% reported from Ibadan, but lower than 29% and 40.9% reported from Ethiopia and Kaduna, Nigeria respectively [5,9,27]. The high perinatal mortality in this study may also be adduced to the high incidence of low birth weight among the preeclamptics with severe features and eclamptics in this study. The positive association between low birth weight and perinatal mortality has previously been reported in Bangladesh [28]. Furthermore, the significant association between preeclampsia with severe features and eclampsia and maternal/ perinatal mortality rates when compared with the controls in this study may be due to not only the disease and its complications but the capability of the hospital to manage some of these complications.
Limitation
The limitation of this study was the retrospective design in which all the confounding variables were not taken care of between the cases and the controls.
Conclusion
Preeclampsia with severe features and eclampsia was common among the adolescents, unbooked, rural, and low socio-economic group of women in this study. It has contributed to high maternal and perinatal morbidity and mortality in Nigeria. Therefore, there is need for policy makers to formulate policies toward female education, women empowerment and provision of social amenities especially in Nigerian rural areas. The healthcare centers have to be provided and equipped so that they will have the capacity to manage the complications due to preeclampsia with severe features and eclampsia. These salvage measures may reduce early marriage, teenage pregnancy, poverty, poor health-seeking behaviour among the patients and maternal and/or perinatal mortality from this disease.
Financial or Other Competing Interests
None.
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