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ORIGINAL ARTICLE
Year : 2011  |  Volume : 10  |  Issue : 4  |  Page : 305-309  

Maternal and fetal outcome in patients with eclampsia at Murtala Muhammad specialist Hospital Kano, Nigeria


Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital Kano, Nigeria

Date of Web Publication2-Nov-2011

Correspondence Address:
Ibrahim A Yakasai
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital Kano PMB 3452 Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.87049

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   Abstract 

Background/Objectives: Eclampsia is a major contributor to maternal and perinatal mortality worldwide. It is much more common in developing countries like Nigeria where presentation is usually late and resources are scarce. The staggering figures of maternal death (46%) reported by the Society of Obstetricians and Gynaecologists of Nigeria (SOGON) in 2004 moved the Kano State government to initiate programs that will reduce maternal mortality in the state. The objectives of this report were; 1) to determine the prevalence of eclampsia at Murtala Muhammad Specialist hospital (MMSH) Kano between April 2008 and May 2009; 2) to determine maternal and fetal outcome in eclamptic patients admitted to MMSH Kano between April 2008 and May 2009.
Methods : Case records of all patients admitted to MMSH between April 2008 and May 2009 were retrieved and analyzed using Epi-info version 3.2.2 April 2004 (CDC Atlanta, USA). Information extracted includes demographic data, maternal and fetal outcome. A P value of less than 0.05 was considered significant.
Results: There were 688 eclamptic patients admitted and 13 943 women delivered during the study period giving a prevalence of 5% of total deliveries. One hundred and twenty six women died giving a maternal mortality ratio (MMR) of 904/100 000, among them 36 were eclamptics. The perinatal mortality rate for the eclamptics was 132/1 000. 81.4% of the women were primigravidas and majority (82.2%) were at term. Almost 83.3% presented within 12 hours of the onset of the fits and nearly half (44.9%) had their convulsion before the onset of labor.
Conclusion: The incidence of eclampsia is 5% of total deliveries. Delay in presentation is associated with poor outcome.

   Abstract in French 

Contexte et objectifs: Éclampsie est un contributeur majeur à la mortalité maternelle et périnatale dans le monde entier. Il est beaucoup plus courant dans les pays en développement comme le Nigeria où présentation est habituellement fin et les ressources sont rares. Les chiffres stupéfiants de décès maternels (46%) signalés par la société des obstétriciens et gynécologues du Nigéria (SOGON) en 2004 s'installe le gouvernement de l'état de Kano pour lancer des programmes qui permettront de réduire la mortalité maternelle dans l'État. Les objectifs du présent rapport ont été; 1) afin de déterminer la prévalence de l'éclampsie à Kano (MMSH) de l'hôpital de Murtala Mohammed spécialiste entre avril 2008 et mai 2009. 2) afin de déterminer les résultats maternels et fœtaux chez des patients eclamptic admis à Kano MMSH entre avril 2008 et mai 2009.
Méthodes: Dossiers de tous les patients admis à MMSH entre avril 2008 et mai 2009 ont été récupérées et analysés à l'aide d'Epi-info version 3.2.2 avril 2004 (CDC Atlanta, USA). Informations extraites comprennent des données démographiques, résultat maternel et fœtal. Une valeur de p de moins de 0,05 était considérée comme significative.
Résultats: y ont été 688 eclamptic patients hospitalisés et 13 943 femmes livrées au cours de la période d'étude donnant une prévalence de 5% du total des livraisons. Un cent vingt six femmes meurt donnant un taux de mortalité maternelle (ROR) de 904/100 000, parmi les 36 ont été eclamptics. Le taux de mortalité périnatale pour l'eclamptics était 132/1 000. 81,4% des femmes ont été primigravidas et majorité (82,2%) étaient à terme. Près de 83,3% présenté dans les 12 heures après le début de l'ajustement et près de la moitié (44,9%) avait leur convulsion avant l'apparition des labor.
Conclusion: L'incidence de l'éclampsie est 5% du total des livraisons. Délai de présentation est associé à mauvais résultat.
Mots clés: Éclampsie, maternelle, foetale, résultat

Keywords: Eclampsia, maternal, fetal, outcome


How to cite this article:
Yakasai IA, Gaya SA. Maternal and fetal outcome in patients with eclampsia at Murtala Muhammad specialist Hospital Kano, Nigeria. Ann Afr Med 2011;10:305-9

How to cite this URL:
Yakasai IA, Gaya SA. Maternal and fetal outcome in patients with eclampsia at Murtala Muhammad specialist Hospital Kano, Nigeria. Ann Afr Med [serial online] 2011 [cited 2020 Apr 7];10:305-9. Available from: http://www.annalsafrmed.org/text.asp?2011/10/4/305/87049


   Introduction Top


Eclampsia is a disease that continues to be of significant concern, and hypertensive complications of pregnancy including eclampsia remain a leading cause of maternal death. [1] It is a major contributor to maternal and perinatal morbidity and mortality worldwide and this is more so in developing countries like Nigeria where presentation is usually late and facilities for resuscitation are scarce. [1],[2] It contributed up to 31.3% by a population-based survey of maternal mortality by Adamu et al. [3] and also 46% of maternal death in Kano according to Society of Obstetricians and Gynaecologists Of Nigeria (SOGON) NEEDS assessment survey in 2004. [4] The incidence varied worldwide ranging from 1 in 100 to 1 in 3 448 pregnancies. [5] In Nigeria, rates varies between 0.3/100 deliveries in Calabar, Southern Nigeria, to as high as 9/100 deliveries in Birnin Kudu, Northern Nigeria, and in general, the rates are higher in the North than in the South. [6],[7],[8][,9],[10],[11] Eclampsia usually develop following pre-eclampsia that can be detected and managed before the onset of convulsion, except in a few cases where convulsion occur without the onset of detectable pre-eclampsia. [11]

The staggering figure of maternal mortality reported in 2004 by SOGON moved the Kano state government to initiate programs that will reduce maternal mortality in the state. Among these programs are expanding the ongoing free maternity services to include free Mgso 4 for eclamptic patients and intensive manpower recruitment posted to man strategic hospitals in the state, in order to reduce the delays in reaching the specialist hospital. This research is intended to find out the impact of these programs in terms of maternal and perinatal outcome among eclamptic patients in one of the largest maternity section in West African subregion, with average of more than 10 000 deliveries per annum and close to 1 000 cases of eclampsia per annum. The hospital receives referrals from all the local governments of the state and also from neighboring states like Jigawa, Bauchi, and parts of Katsina states. All the patients were managed using Mgso 4 . Patients with antepartum eclampsia were induced using misoprostol, except in patients with obvious indication for Caesarean section like those with cephalopelvic disproportion, fetal distress, or patients with previous scar and unfavorable cervix. There were no initial published data to compare the findings from this study, but attempt will be made to compare the findings with available figures within and outside Nigeria.

Aim / objectives

  1. To determine the prevalence of eclampsia in Murtala Muhammad Hospital, Kano.
  2. To determine the maternal and fetal outcomes among eclamptic patients admitted at Murtala Muhammad specialist Hospital (MMSH), Kano, between May 2008 and April 2009.



   Materials and Methods Top


All the cases of eclampsia admitted at the Hospital between May 2008 and April 2009 were identified and their case notes retrieved from the medical records. Information extracted include age, parity, booking status, gestational age, type of pregnancy, duration of illness before presentation, mode of delivery, maternal outcome, and fetal outcome. The data were analyzed using Epi info version 3.2.2 April, 2004 (CDC Atlanta, USA). The data were presented using tables and descriptive statistics were used as absolute numbers, measures of central tendencies, and measures of dispersion. The Chi-square test was used to test significant association. A P value of less than 0.05 was considered significant.


   Results Top


There were 688 eclamptic patients admitted during the study period and there were 13 943 deliveries during the same period, giving an incidence of 5% of total deliveries. There were 126 maternal death during the study period, giving an MMR of 904/100 000 deliveries, and eclampsia accounted for 36 maternal death among them, thus contributing 28.57% of the maternal death and a case fatality rate of 5.2%. The perinatal mortality rate for the eclamptics was 132/1 000 eclamptic deliveries. Among them, 6.2% were fresh stillbirth, 3.5% were macerated stillbirth (MSB), and 3.5% were not delivered.

Majority of the patients were teenagers (50.14%); mean age, 20.6 years; and standard deviation (SD) of 5. Primigravidae accounted for 81.4%, mean parity of about 2, and SD of about 2. These are shown in [Table 1]. Up to 48.5% of the patients had some form of antenatal care, mostly at primary health centers.

Majority of the patients (82.3%) were at term, 17.6% were preterm, and only one patient (0.1%) convulsed before fetal viability. Nearly half of the patients (44.9%) had their convulsion before the onset of labor, 35% were intrapartum, while 20.1% were postpartum.
Table 1: Age and parity of eclamptic patients at Murtala Muhammad specialist Hospital

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About 83.3% of the patients presented before 12 hours, while 8.5% and 8.2% presented between 12-24 hours and >24 hours, respectively.Up to 65.8% achieved vaginal delivery, 29.4% had Caesarean section, while 0.3% and 0.9% had forceps and vacuum deliveries, respectively. Twenty-five mothers (3.6%) died undelivered. Of the 11 mothers who died after delivery, eight had spontaneous vaginal delivery (1.8%), while three had Caesarean section (1.5). There is no significant difference in maternal outcome between those who delivered through spontaneous vaginal delivery and those who had Caesarean section (OR = 0.84, 95%CI = 0.17-3.51, P=0.5447), [Table 2]. On the other hand, of the 64 stillbirths, 33 (7.9) were delivered through spontaneous vaginal delivery, while 31 (18.1%) were delivered through Caesarean section. There was significantly higher fetal loss among those delivered by Caesarean section than those delivered by spontaneous vaginal delivery (OR = 2.31, 95%CI = 1.33-4.01, χ2 = 9.40, P=0.0022), [Table 3].
Table 2: Mode of delivery vs maternal outcome

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Table 3: Mode of delivery vs fetal outcome

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There were 51% males, 44.2% females, while sex has not been stated in the rest. There were 98.4% singleton pregnancies and 1.6% set of twins. No higher order pregnancy was reported.

Maternal death due to eclampsia is shown to worsen when presented after 12 hours from the onset of convulsion (OR = 34.45, 95%CI = 13.16-95.36, χ2 = 119.10, P=0.000), [Table 4], and similarly with perinatal mortality (OR = 57.51, 95%CI = 30.07-111.22, χ2 = 306.59, P=0.0000), [Table 5]. Maternal mortality is worst with antepartum eclampsia (OR = 0.39, 95%CI = 0.18-0.83, χ2 = 6.37, P=0.0116), but there is no significant difference in terms of maternal outcome between intrapartum eclampsia and postpartum eclampsia (OR = 1.26, 95%CI = 0.34-4.51, χ2 = 0.01, P=0.9365), [Table 6]. The fetal outcome is best with postpartum eclampsia compared with either intrapartum eclampsia (OR = 10.79, 95%CI, 2.47-66.12, χ2 = 14.27, P=0.0002) or antepartum eclampsia (OR = 15.05, 95%CI = 3.53-90.56, χ2 = 22.03, P=0.0000), but there is no significant difference between antepartum eclampsia and intrapartum eclampsia in terms of fetal outcome (OR = 072, 95%CI = 0.4-1.17, χ2 = 1.65, P=0.1995), [Table 7].
Table 4: Duration of illness vs maternal outcome

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Table 5: Duration of illness vs fetal outcome

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Table 6: Type of eclampsia vs maternal outcome

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Table 7: Type of eclampsia vs fetal outcome

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   Discussion Top


Eclampsia is one of the most dangerous conditions which those caring for pregnant woman and her fetus must deal with, especially because its onset can be dramatic, abrupt, and in many women without any warning. [12]

The incidence of 5% is lower than the incidence quoted at Birnin Kudu, [10] near the study area, and Abuja [11] (all in Northern Nigeria) but higher than the figures quoted in the Southern part of the country. [4],[6],[7],[8],[9] The lower incidence of eclampsia in this study may be attributed to the availability of competent staff at strategic general hospitals around the state, thus intercepting most of the referrals from these areas. This is commendable as it showed clearly how commitment by government can affect the incidence of fatal conditions like eclampsia. The contribution of eclampsia to maternal mortality (28.57%) has also declined considerably, compared with 46% reported in 2004 by the SOGON. [4] This decline may be due to the use of MgSO 4 in the treatment of the eclamptic patient, as shown in the Abuja study [11] and the MAGPIE Trial, a randomized controlled trial that clearly demonstrated the efficacy of MgSO4 in the control of eclamptic seizures. [13],[14],[15]

The age and parity distributions were similar to other findings in Nigeria. [6],[7],[8],[9],[10],[11] The booked patient accounting for up to 48.5% is higher than most of the studies across Nigeria. This may be explained by the fact that most of the patients were within Kano metropolis and many of them might have booked at primary health centers. Most of these primary health centers do not have sphygmomanometer to measure blood pressure as such preeclampsia will go undetected.

Delay was only established in 8.2% (presentation after 24 hours). This is in contrast to the finding at Birnin Kudu where delay was established in up to 56% of the patients. [10] This may be due to ongoing health campaign, especially about eclampsia and other causes of maternal death, as well as majority of the patients came from the city as mentioned earlier.

The Caesarean section rate of 29.4% is much lower than the rates reported in many centers in Nigeria, but similar to some centers in the United Kingdom. [16] Most of the rates in Nigeria are more than 50%. [8],[9],[10],[11] This is because most of our patients had induction of labor with misoprostol while awaiting surgery and many progress satisfactorily and had spontaneous vaginal delivery. The long period taken before the surgery was due to very high patient-doctor ratio in the hospital. This was also noted by Jamilu tukur at Birnin kudu. [10]

Multifetal pregnancy accounts for only 1.6% of the cases, which is much lower than 15.8% reported by Itam at Calabar [6] and 3.5% in the western world. [5]

Case fatality rate of 5.2% is much lower than that reported by Efetie and Okafor at Abuja (28.3%), [11] Olatunji and Sule-odu (20%) [8] and Tukur et al. at Birnin Kudu (10.6) [10] but is higher than that reported by Umezuike et al. at Aba (2.5%) [7] where MgSO 4 was used in the treatment of the eclampsia. Case fatality rate of not more than 1% is needed to achieve MDG 5.

This study showed gross reduction in overall MMR during the study period (904/100 000 births Vs >3 000/100 000 births recorded in 2004 by the SOGON NEEDS ASSESSMENT SURVEY). This may be explained by the gross reduction in the contribution of MM by eclampsia. The PNMR of 132/1 000 deliveries is similar to that found by Tukur et al. at Birnin Kudu and by Emen et al. at Uyo (130 and 137/1 000 deliveries, respectively) [9],[10] but lower than that reported from Gombe, [17] Kaduna, [14] and Aba [7] (368, 409, and 552/1 000 deliveries, respectively). The fetal outcome in this study was found to be significantly higher in intrapartum eclampsia/antepartum eclampsia compared with postpartum eclampsia; this is similar to what was found by Sinai and Anderson in America where they found the perinatal mortality remains between 75 and 85% in eclamptic patients with either antepartum/intrapartum eclampsia. [18]

From this study, it is noted that maternal outcome is made worst when patients present after 12 hours from the onset of convulsion and when they have antepartum eclampsia. This emphasizes the importance of effective antenatal care, especially at primary health centers, where early onset pre-eclampsia will be detected and managed appropriately, so that these women do not go on and develop eclampsia. According to Royal College of Obstetricians and Gynaecologists (RCOG) guidelines, it is the most effective way to prevent eclampsia. [19] There was no significant relationship between maternal mortality and mode of delivery as such; it is worth trying vaginal delivery by induction of labor using misoprostol than to rush for Caesarean section. This will also reduce our Caesarean section rate. Similarly, fetal outcome in terms of survival is made worse by late presentation (>12 hours), antepartum eclampsia, and Caesarean section. The unfavorable outcome with Caesarean section may be explained by the fact that most of those that underwent Caesarean section had other complication that necessitated the Caesarean section (cephalo pelvic disproportion or fetal distress) and there was also delay in performing the Caesarean section due to inadequate man power. Olatunji and Sule-odu also noted no significant association between mode of delivery and maternal mortality, but noted a decrease in perinatal mortality with Caesarean section. [8]


   Conclusion Top


The incidence of eclampsia at MMSH, Kano, was 5% of total deliveries. There was obvious decrease in the contribution of eclampsia to MM during the study period. Majority of the patients had successful vaginal delivery following induction of labor. Delay in presentation (after 12 hours) and antepartum eclampsia were associated with poor outcome in eclamptic patients. Mode of delivery had no effect on the outcome of the eclamptics. Remarkable reduction in maternal mortality to achieve MDG 5 is possible once Government is committed in providing proper antenatal care, especially at primary health centers.

 
   References Top

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3.Adamu YM, Salihu HM, Sarthiakumar N, Alexander R. Maternal mortality in Northern Nigeria: A population based study. Eur J Obstet Gynaecol Reprod Biol 2003;109:153-9.  Back to cited text no. 3
    
4.Status of Emergency Obstetric Services in six states of Nigeria. A Needs Assessment Report. SOGON. 2004.  Back to cited text no. 4
    
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6.Itam IH. Sociodemographic determinants of Eclampsia in Calabar; A 10 year review. Mery Slessor. J Med 2003;3:72-4.  Back to cited text no. 6
    
7.Umezuike CC, Feyi-woboso PA, Whittaker RC. Treatment of eclampsia with Magnesium Sulphate in Aba, South-Eastern Nigeria. Trop J Obstet Gynaecol 2006;23:20-2.  Back to cited text no. 7
    
8.Olatunji AO, Sule-odu AO. Presentation and outcome of eclampsia at a Nigerian University Hospital. Nigerian J Clin Pract 2007;10:1-4.  Back to cited text no. 8
    
9.Emen BA, Abasiatai AM, Umoiyoho AJ, Udoma EJ. Presentation and outcome of eclampsia in Uyo, South-South Nigeria. Trop J Med Res 2005;9:9-11.  Back to cited text no. 9
    
10.Tukur J, Umar BA, Rabiu A. Pattern of eclampsia in tertiary Health facility situated in semi-rural town in Northern Nigeria. Ann Afr Med 2007;6:164-7.  Back to cited text no. 10
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11.Efetie ER, Okafor UV. Maternal outcome in eclamptic patients in Abuja, Nigeria, A 5 year review. Niger J Clin Pract 2007;10:309-13.  Back to cited text no. 11
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12.Altam D, Carroll G, Duley L, Farrell B, Moodley J, Neilson J, et al. Do women with Pre-eclampsia and their babies benefit from magnesium sulphate? The Magpie Trial: A randomized placebo-controlled trial. Lancet 2002;357:1877-90.  Back to cited text no. 12
    
13.Which anticonvulsant for women with eclampsia? Evidence from Eclampsia Trial. Lancet 1995;345:1455-63; erratum in: Lancet 1995;346:258.  Back to cited text no. 13
    
14.Begum MR, Begum A, Quadir E. Loading dose versus standard regime of magnesium sulphate in the management of eclampsia: A randomized trial. J Obstet Gynaecol Res 2002;28:154-9.  Back to cited text no. 14
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15.Hall DR,Odendal HJ,Steyn DW,Grove D. Expectant management of early onset, severe preeclampsia: Maternal outcome. BJOG 2000;107:1252-7.  Back to cited text no. 15
    
16.Royal College of Obstetricians and Gynaecologists (RCOG). The use of Electronic Fetal. Evidence Based Clinical Guideline No8. London: RCOG Press; 2001.  Back to cited text no. 16
    
17.El-nafaty AU, Melah GS, Massa AA, Audu BM, Nelda M. The analysis of eclamptics morbidity and mortality in Specialist Hospital. Gombe. Niger J Obstet Gynaecol 2002;24:142-147.  Back to cited text no. 17
    
18.Sinai BM, Anderson GD. Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes and low platelets in severe pre-eclampsia-eclampsia. Am J Obstet Gynecol 1981;155:501-509.  Back to cited text no. 18
    
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[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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