Maternal and perinatal outcome of eclampsia over a decade at a tertiary hospital in Kuwait

Aims: To determine maternal and perinatal outcome of eclampsia patients over a decade.

Methods: Analysis of case records of all eclampsia cases from January 2005 to December 2014.

Results: There were 30 cases of eclampsia. The most significant risk factors for developing pre-eclampsia are unbooked cases (97%), nulliparity, young age, marriage?≤4 months, history of pre-eclampsia in previous pregnancy, remarriage, preexisting diabetes mellitus, interval between pregnancies?≥10 years, positive family history. The incidence of eclampsia was 0.05%, antepartum eclampsia 15 (50%), intrapartum 6 (20%) and postpartum 9 (30%) with no maternal deaths, and 1 perinatal death. Perinatal mortality was 33.3/1000. 22 (73%) patients received magnesium sulphate (MgSO₄) and 8 patients (27%) received Diazepam, of which 1 had recurrence of convulsions. All 15 antepartum cases were delivered by cesarean section as were 2 intrapartum. 13 (43%) of women delivered vaginally. Only 6 (20%) patients were of low socio-economic status and were primary school educated. Severe maternal complications occurred in 8 (27%), with abruptio placentae being the most common 3 (38%).

Conclusions: Incidence of eclampsia was low, with no maternal deaths. MgSO4 was found to be highly effective. Lack of antenatal care is a major risk factor.     

Chronic hypertension in pregnancy

Hypertension is the most common medical disorder during pregnancy. Chronic hypertension is a serious medical complication in pregnancy with increased maternal and perinatal morbidity and mortality. Those who develop uncontrolled severe hypertension, those with target organ damage, and those who are poorly compliant with prenatal visits are at high risk for poor perinatal outcome. Maternal complications include abruptio placenta, stroke, and superimposed pre-eclampsia. Fetal complications include prematurity, low birth weight, and perinatal death. Careful antepartum, intrapartum and postpartum management of women with high-risk chronic hypertension in pregnancies may reduce morbidity and mortality.     

Utility of misoprostol for labor induction in severe pre-eclampsia and eclampsia

OBJECTIVES: To determine the effectiveness and safety of misoprostol in severe pre-eclampsia and eclampsia patients with unripe cervix. METHODS: A prospective observational study was carried out in 135 severe pre-eclampsia and eclampsia patients who required termination of pregnancy at the Department of Obstetrics and Gynecology, Khulna Medical College Hospital, Khulna, Bangladesh during January 2002 to October 2003. Fifty micrograms of misoprostol was used every 4 h in cases of unripe cervix (Bishop score < or = 6) in severe pre-eclampsia and eclampsia patients. Maternal and perinatal outcome as well as any complications were recorded. RESULTS: In severe pre-eclampsia and eclampsia patients vaginal delivery occurred in 79.3 and 80.5% of cases, and cesarean section was performed in 20.6 and 19.4% of cases, respectively. The maximum required responsive dose was 50-150 microg. Oxytocin augmentation was required in 29.3 and 35% of cases, respectively. Induction to delivery time was median 8 h, interquartile ranges 4.2-8.2 h in the severe pre-eclampsia group, and median 9 h, interquartile ranges 6.8-12.5 h in the eclampsia group, and average hospital stay was 3.4 +/- 1.8 and 3.7 +/- 1.7 days, respectively. The only maternal complications were hyperstimulation which occurred in 6.8 and 5.1% of cases, respectively. Neonatal death occurred in five (11.3%) and eight cases (12.1%), respectively. CONCLUSION: Intravaginal misoprostol is well tolerated and very effective for the induction of labor in severe pre-eclampsia and eclampsia patients with unripe cervix.     

Maternal and perinatal outcome of eclampsia in tertiary health institution in Southeast Nigeria

Objective: To evaluate the maternal and perinatal outcome in patients with eclampsia at Nnamdi-Azikiwe-University-Teaching-Hospital (NAUTH), Nnewi, Nigeria. Methods: A retrospective study of cases of eclampsia managed at NAUTH over a 10 year period – 1st January, 2000 to 31st December, 2009. Maternal outcome was measured in terms of complications and maternal death. Foetal outcome was assessed in terms of low birth weight, pre-term births, low apgar score, and perinatal deaths. Results: There were 57 cases of eclampsia out of a total of 6,262 deliveries within the study period, giving a prevalence of 0.91%. Majority, 71.7%, had caesarean section. There were 17.4% maternal deaths mainly from pulmonary oedema, 6 (13.0%), acute renal failure, 4 (8.7%), and coagulopathy, 3 (6.5%). Perinatal deaths were 25.5% as a result of prematurity, 42 (82.4%), and low birth weight, 36 (70.6%). Twenty-one (41.2%) of the new born had Apgar score of less than seven at 5?min while 13.0% were severely asphyxiated. Conclusion: Eclampsia was associated with high maternal and perinatal morbidity and mortality in this study. There is need to review existing protocol on eclampsia management with emphasis on appropriate health education of pregnant mothers, good antenatal care, early diagnosis of pre-eclampsia with prompt treatment.     

Eclampsia in twin pregnancy

A clinical analysis of 37 cases of twin pregnancy complicated by eclampsia showed that: (1) the incidence of twins in the total 1,030 cases of eclampsia was three times the figure in the general population, (2) the maternal mortality was slightly higher and perinatal mortality slightly lower than in unselected eclamptic patients, (3) patients with postpartum eclampsia showed significant differences in comparison with antepartum and intrapartum cases, (4) perinatal and maternal mortality were lower in cases delivered by cesarean section, (5) perinatal mortality was significantly higher in male fetuses, and (6) five of the six maternal deaths occurred in cases of male twins. In addition, the data suggest the presence of a reciprocal negative influence between maternal eclampsia and male twins and that this type of eclampsia may be the best example of essential preeclampsia.     

Reproductive performance after eclampsia

Eclampsia is a common complication of pregnancy in Ibadan, although its long term effects on subsequent pregnancies is unknown. In a prospective study of 64 women who had eclampsia in their previous pregnancies and were followed up in their current pregnancies, 15.6% of them had recurrent eclampsia, in spite of optimal antenatal care. Of the 18 patients with diastolic blood pressure of 80 mmHg 22.2% or over at booking had antepartum or intrapartum eclampsia as compared with only 2.2% of 46 patients with diastolic blood pressure of less than 80 mmHg at booking. This finding was statistically significant (P less than 0.01), showing that the diastolic blood pressure at booking can be a measure of the potential for developing eclampsia because of the possibility of residual hypertension on which pre-eclampsia may be superimposed. Similarly, there was a significant association (P less than 0.05) between the birthweight of the babies and the diastolic blood pressure at booking, and may be a measure of the effect of vascular effect of pre-eclampsia on the placenta. However, there was no difference in the perinatal mortality rate in this study and the overall hospital figures in spite of the high risk pregnancies being managed. It was concluded, therefore, that the outcome of these pregnancies would depend much on the standard of antenatal care provided for the patients.     

Implementing a facility-based maternal and perinatal health care surveillance system in Afghanistan

Afghanistan has one of the highest maternal and perinatal mortality rates in the world. Lack of a health information system presented obstacles to efforts to improve the quality of care and reduce mortality. To rapidly overcome this deficit in a large women's hospital, staff implemented a facility-based maternal and perinatal surveillance system known as "BABIES," which is specially designed for intervention and evaluation in low-resource settings. During a 12-month period, 15,509 deliveries resulted in 28 maternal deaths and a perinatal mortality rate of 56 per 1000 births. When stratified by birth weight and perinatal period of death, fetuses weighing at least 2500 g who died during the antepartum period contributed the most cases of perinatal death. This finding suggests that the greatest reduction in perinatal mortality would be realized by increasing access to high-quality antepartum care. Among fetuses weighing at least 2500 g, 93 deaths occurred during the intrapartum period. These deaths will continue to be monitored to ensure that the chosen interventions are improving intrapartum care for mothers and newborns. Because of its simplicity, flexibility, and ability to identify interventions, BABIES is a valuable tool that enables clinicians and program managers to prioritize resources.     

Anaesthetic management of patients with pre-eclampsia/eclampsia and perinatal outcome

Objective.?This study examined risk factors for perinatal mortality associated with anaesthesia for caesarean delivery in patients with pre-eclampsia/eclampsia. The study is apt because perinatal mortality rate is one of the indicators of health status of pregnant women, new mothers and their newborns. The information obtained may help to assess changes in public health policy and practise amongst women of child-bearing age.

Aim.?The role of anaesthesia in perinatal outcome in pre-eclamptics.

Methods and materials.?The hospital records (cases notes, labour ward and newborn special care unit and theatre records) of patients with pre-eclampsia/eclampsia, which had caesarean delivery and their babies at the University of Nigeria Teaching hospital (UNTH), Enugu, Nigeria from July 1998 to June 2006, were retrospectively reviewed. The term perinatal mortality refers to stillbirths and neonatal deaths within 7 days of birth.

Results.?There were a total of 6798 deliveries and 1579 women delivered through caesarean section. Of these, 196 were patients with pre-eclampsia/eclampsia. There were a total of 19 stillbirths (9%) and 19 (9%) early neonatal deaths in the pre-eclampsia/eclampsia group going a perinatal mortality of 180/1000 births. Amongst these women, 157 delivered under general anaesthesia, 34 under spinal anaesthesia and five under epidural block. Of the 38 perinatal deaths, 30 delivered by general anaesthesia and eight by regional anaesthesia.

Conclusion.?Pre-eclampsia/eclampsia continues to be a cause of foetal loss in the developing world even where essential obstetric services are available. Early onset management of severe pre-eclampsia with maintenance of adequate placental perfusion during anaesthesia may result in lower perinatal deaths.     

Central nervous system lupus and pregnancy: 11-year experience at a single center

Objective: To describe the pregnancy outcomes in women with central nervous system (CNS) manifestations of lupus. Methods: Between 1991 and 2002, the outcome of five pregnancies in four patients with CNS lupus were retrospectively reviewed. All patients had an established history of systemic lupus erythematosus (SLE), and either a history of CNS lupus or active CNS lupus. Pregnancy outcomes assessed included term and preterm birth, intrauterine growth restriction, abnormal antepartum testing, perinatal mortality, pre-eclampsia and other maternal morbidities. Results: Evidence of active CNS lupus symptoms developed in three of the five pregnancies. Two pregnancies were complicated by early onset pre-eclampsia, abnormal antepartum testing and extreme prematurity, with one subsequent neonatal death. The remaining three pregnancies had good neonatal outcomes, but were complicated by severe maternal post-pregnancy exacerbations, and the eventual death of one patient. Conclusions: CNS lupus in pregnancy represents an especially severe manifestation of SLE, and may involve great maternal and fetal risks.     

Prediction of adverse outcomes by common definitions of hypertension in pregnancy

OBJECTIVE: To examine the ability of five common definitions of hypertension in pregnancy to predict adverse maternal and perinatal outcomes. METHODS: We studied 9133 singleton nulliparous pregnancies with early prenatal care from the Collaborative Perinatal Project, a large cohort study conducted between 1959 and 1965. Definitions from five different groups were evaluated. Severe maternal and perinatal morbidity and mortality were used as the outcome measurements. Sensitivity, specificity, and positive predictive value for outcomes were compared across various definitions. RESULTS: Blood pressure alone had very poor discriminatory power to predict adverse outcomes. Positive predictive values of adverse outcomes by the diagnosis of preeclampsia were 18-20% based on antepartum and intrapartum blood pressures and 22-36% based on antepartum blood pressure only. Mild hypertension occurring for the first time in labor and isolated mild systolic hypertension were not associated with adverse outcomes. Similarly, an increase in diastolic blood pressure of 15 mmHg that did not achieve an absolute value of 90 mmHg did not predict adverse outcome. CONCLUSION: Neither blood pressure nor blood pressure and proteinuria are accurate predictors of severe adverse maternal and perinatal outcomes. Mild hypertension occurring for the first time in labor and isolated mild systolic hypertension should not be considered indicators for hypertensive disorders in pregnancy in a research definition.     

Severe pre-eclampsia and eclampsia in Abha, the south west region of Saudi Arabia.

A retrospective study was conducted over a 10-year period on 32,000 maternities at Abha General Hospital, Abha, Saudi Arabia, to estimate the contribution of eclampsia and severe pre-eclampsia to maternal mortality and morbidity and also fetal wastage. It included 18 cases of eclampsia and 297 cases of severe pre-eclampsia. Multiple regression analysis revealed that only the presence of prodromal symptoms significantly affected the occurrence of eclampsia, p < 0.05, while nulliparous patients were a high risk group for eclampsia. Maternal complications including eight cases of massive ascites occurred exclusively in severe pre-eclamptics. Although no maternal deaths were reported, the perinatal mortality rate was 16.6% and 14.1% among the eclamptics and severe pre-eclamptic patients, mainly from prematurity. Regarding the eclamptic patients, 17(94.4%) had the first fit before arrival at the hospital, 13(72.2%) before labour, while 3(16.6%) had fits before and during labour and 1(5.6%) had the fits after delivery. Suggestions are proffered to reducing maternal morbidity and perinatal mortality and morbidity.     

Relationship between prenatal care and maternal complications in women with preeclampsia: Implications for continuity and discontinuity of prenatal care

ObjectivePrenatal care is associated with better pregnancy outcome and may be a patient safety issue. However, no studies have investigated the types and quality of prenatal care provided in northern Taiwan. This retrospective study assessed whether the hospital-based continuous prenatal care model at tertiary hospitals reduced the risk of perinatal morbidity and maternal complications in pre-eclampsia patients.Materials and MethodsOf 385 pre-eclampsia patients recruited from among 23,665 deliveries, 198 were classified as patients with little or no prenatal care who received traditional, individualized, and physician-based discontinuous prenatal care (community-based model), and 187 were classified as control patients who received tertiary hospital-based continuous prenatal care.ResultsThe effects on perinatal outcome were significantly different between the two groups. The cases in the hospital-based care group were less likely to be associated with preterm delivery, low birth weight, very low birth weight, and intrauterine growth restriction. After adjustment of confounding factors, the factors associated with pregnant women who received little or no prenatal care by individualized physician groups were diastolic blood pressure ≥105 mmHg, serum aspartate transaminase level ≥150 IU/L, and low-birth-weight deliveries. This study also demonstrated the dose–response effect of inadequate, intermediate, adequate, and intensive prenatal care status on fetal birth weight and gestational periods (weeks to delivery).ConclusionThe types of prenatal care may be associated with different pregnancy outcomes and neonatal morbidity. Factors associated with inadequate prenatal care may be predictors of pregnancy outcome in pregnant women with pre-eclampsia.     

Lessons for low-income regions following the reduction in hypertension-related maternal mortality in high-income countries

Objectives

To evaluate pre-eclampsia/eclampsia-associated maternal mortality in high-income countries to understand better the potential improvements in pre-eclampsia/eclampsia-related mortality in low-income countries.

Methods

We searched Medline, PubMed, and the Cochrane Database (1900-2010) using relevant search terms. Studies of the incidence of pre-eclampsia/eclampsia and case fatality rates in various geographic regions were included. The incidence of pre-eclampsia/eclampsia and the pre-eclampsia/eclampsia-associated case fatality rates are presented by location and year.

Results

Most declines in maternal mortality associated with pre-eclampsia/eclampsia in high-income countries occurred between 1940 and 1970 and were associated with a 90% reduction in the incidence of eclampsia and a 90% reduction in the case fatality rate in women with eclampsia. The most important interventions were widespread use of prenatal care with blood pressure and urine protein measurement, and increased access to hospital care for timely induction of labor or cesarean delivery for women with severe pre-eclampsia or seizures.

Conclusions

A substantial reduction in pre-eclampsia/eclampsia-related mortality could be made in low-income countries by widespread hypertension and proteinuria screening and early delivery of women with severe disease. Magnesium sulfate may reduce mortality, but should not be the cornerstone of maternal mortality reduction programs.     

The effects of maternal weight and age on pre-eclampsia and eclampsia in Haiti

Objective: Patient data from Maison de Naissance (MN), a rural maternity clinic in Haiti, were analyzed to determine the prevalence of pregnancy-related hypertensive disorders and the extent to which maternal weight and age are associated with these disorders in the MN population.

Methods: A case-control study design was used with cases defined as pregnant women who were presented at MN with pregnancy-related hypertensive disorders (pregnancy-induced hypertension, pre-eclampsia or eclampsia) and controls defined as those women who delivered babies at MN and were not diagnosed with a pregnancy-related hypertensive disorder. The final cohort size was 622 controls and 67 cases. Odds ratios were calculated using multivariate logistic regression.

Results: The incidence of pre-eclampsia and eclampsia was 7.0%. Older maternal age at delivery (OR?=?3.18; 95%CI: 1.31, 7.76) and higher maternal weight (OR?=?3.24; 95%CI: 1.76, 5.98) measured during prenatal care were significantly associated with pregnancy-related hypertensive disorders. Prenatal care was not significantly associated with reduced risk of pre-eclampsia/eclampsia.

Conclusions: The prevalence of pregnancy-related hypertensive disorders was high relative to rates in other developing countries. More is required to reduce the rate of pre-eclampsia perhaps by targeting older and women with high weight for preconception and more intensive prenatal care.     

Timeliness of care for eclampsia and pre-eclampsia in Benin, Ecuador, and Jamaica.

OBJECTIVE: Cases meeting diagnostic criteria for severe pre-eclampsia or eclampsia were reviewed in three countries to determine timeliness and effectiveness of care. METHOD: Cases were retrospectively selected from 11 emergency obstetric care facilities and medical records reviewed by trained obstetricians. RESULT: Of 91 cases (Benin, 28; Ecuador, 25; Jamaica, 38), 74% were correctly treated with anticonvulsant and 77% with antihypertensive therapy. The median interval to treat eclampsia (anticonvulsant, 28 min; antihypertensive, 77 min) was shorter than for severe pre-eclampsia (anticonvulsant, 45 min; antihypertensive, 85 min). Two in three cases (65%) received anticonvulsant but only 41% received antihypertensive therapy within 60 min of diagnosis. While 74% of eclamptics had been delivered within 12 h, only 39% of severe pre-eclamptics were delivered within 24 h. CONCLUSION: Timeliness can be studied in developing countries. Its objective measurement is a first step towards improving this component of care.     

Acute myocardial infarction in pregnancy and the puerperium: a population-based study

OBJECTIVE: To estimate the population-based incidence and pregnancy outcomes of acute myocardial infarction (MI) in pregnancy. METHODS: Maternal and newborn hospital discharge records were linked to birth/death certificates for the 10-year period January 1, 1991, to December 30, 2000, for the majority (98%) of deliveries in California. This database was searched for the diagnosis of acute MI, demographic characteristics, and pregnancy outcomes. Patients were divided into 4 groups: antenatal diagnosis, intrapartum diagnosis, up to 6-week postpartum diagnosis, and those without the diagnosis of acute MI. All groups were compared by Student t test or chi(2) or both, where appropriate. RESULTS: A total of 151 women had an acute MI during the antepartum (38%), intrapartum (21%), or 6-week postpartum (41%) period, giving an incidence rate of 1 in 35,700 deliveries. The incidence rate increased over the study period. The maternal mortality rate was 7.3%, and maternal death only occurred in women with an acute MI before or at delivery (P < .01). Compared with women who did not have an acute MI, those with one were more likely to be older (30% were older than 35 years compared with 10%), multiparous (78% compared with 61%), non-Hispanic white (40% compared with 35%) or African Americans (15% compared with 7%). All measures of maternal and neonatal morbidity were increased in the acute MI group compared with those without an acute MI. Multivariate analysis identified chronic hypertension, diabetes, advancing maternal age, eclampsia, and severe preeclampsia as independent risk factors for acute MI. CONCLUSION: Acute MI during pregnancy remains a rare event, with significant maternal, fetal, and neonatal morbidity and mortality and maternal mortality limited to the antepartum and intrapartum period.     

Adverse maternal and fetal outcomes and deaths related to preeclampsia and eclampsia in Haiti

ObjectiveThe purpose of this study was to define the prevalence and clinical characteristics of preeclampsia and eclampsia at a hospital in rural Haiti.MethodsThis is a retrospective review of women presenting to Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti with singleton pregnancy and diagnosis of preeclampsia or eclampsia from January 1, 2011 through December 31, 2012. Hospital charts were reviewed to obtain medical and prenatal history, hospital course, delivery information, and fetal/neonatal outcomes. The outcomes included placental abruption, antepartum eclampsia, postpartum eclampsia, maternal death, birthweight <2500 g and stillbirth. Data are presented as median (quartile 1, quartile 3) or n (%) and risk ratios.ResultsDuring the study period, 1743 women were admitted to the maternity service at HAS and 290 (16.6%) were diagnosed with preeclampsia or eclampsia. Only singleton pregnancies were analyzed (N = 270). Nearly all (95.0%) patients admitted with preeclampsia had severe preeclampsia. There were 83 patients with eclampsia (30.7%) of which 61 (73.4%) had antepartum eclampsia. There were 48 stillbirths (17.8%) and 5 maternal deaths (1.9%). Patients with antepartum eclampsia were younger, more likely to be nulliparous and had less prenatal care compared to women with antepartum preeclampsia. Antepartum eclampsia was associated with placental abruption and maternal death.ConclusionsThe rates of preeclampsia and its associated complications, such as eclampsia, placental abruption, maternal death and stillbirth, are high at this facility in Haiti. Such data are essential to developing region-specific systems to prevent preeclampsia-related complications.     

Eclampsia in Finland in 1990-1994

BACKGROUND: Eclampsia is a serious threat to both maternal and fetal well-being. We started the present study because no recent data are available on the incidence of eclampsia and the outcome of patients with this serious disorder in Finland. METHODS: The incidence of eclampsia in Finland in 1990-1994 was studied retrospectively. The data were retrieved from the National Birth Register and the Finnish Hospital Discharge Register. Patient records were reviewed. RESULTS: Seventy-seven cases of eclampsia were found in the hospital records, which gave an eclampsia incidence of 2.4 per 10,000 deliveries (95% confidence intervals 1.9 to 2.9). Eclampsia was preceded by severe pre-eclampsia in 84% and by mild pre-eclampsia in 8% of the patients. Ten mothers suffered from severe eclampsia-related complications but, fortunately, none of the mothers died. Perinatal mortality was 5%, and 33% of the newborns were small for gestational age. CONCLUSIONS: Eclampsia is rare in Finland. Its low incidence is probably due to improved neonatal care that allows earlier deliveries before the progress of preeclampsia to eclampsia.