Introduction

                Every minute a woman dies during labor or delivery. The highest maternal mortality rates are in Africa, with a lifetime risk of 1 in 16; the lowest rates are in Western nations (1:2800), with a global ratio of 400 maternal deaths per 100,000 live births.¹ Eclampsia accounts for 12% of such deaths.²

Eclampsia defined, as occurrence of seizures during pregnancy is a serious disease of pregnant females. Its complications lead to morbidity and sometimes mortality. The syndrome of pre-eclampsia develops in the second half of pregnancy, during labor, or in the immediate postnatal period within ten days. Around 585,000 women die each year of pregnancy related causes, 98% of these are in developing countries.^3,4 Thirteen percent of these maternal deaths are due to hypertensive disorders of pregnancy, particularly eclampsia.³ In developed countries, eclampsia complicates about 1 in 2000 deliveries.⁵ In developing countries,^6-8 the prevalence of eclampsia varies widely, from 1 in 100 to 1 in 1700. It is a common problem in developing countries because of illiteracy, lack of health awareness and education, poverty, and superstitious beliefs prevent women from seeking medical advice during pregnancy.

Pre-eclampsia/eclampsia affects pregnant women of all ages, but the frequency is increased in nulliparous women younger than 20 years. Women older than 40 years with pre-eclampsia have 4 times incidence of seizures compared to women in their third decade of life. Other risk factors include, pre-existing hypertension or renal disease, poor prenatal care, strong family history of pre-eclampsia/eclampsia and systemic lupus erythematous.

Pre-eclampsia/eclampsia creates a functional derangement of multiple organ systems. Its complications include permanent central nervous system damage from recurrent seizures or intracranial bleeds, hematologic, hepatic, renal, and cardiovascular systems. The severity depends on medical or obstetric factors. Causes of neonatal death include prematurity, placental infarcts, intrauterine growth retardation, abruptio placentae, and fetal hypoxia.

Being a preventable yet lethal disease, this syndrome asks for lot of interest from obstetrician and full compliance from the patient. A good, thorough and regular antenatal care can easily identify the patients at risk who can be managed on standard lines but in our circumstances the concept of antenatal care is in its infancy. Only a small number of pregnant females turn up for antenatal check ups. The bulk of the population is out side the health facilities net. On the other hand the hospital facilities are not adequate. Majority of the population is illiterate and is unaware of the importance of antenatal care. Most of the eclamptic patients present to the hospital after having fits at home in the antenatal or postnatal period. These patients are usually in a bad condition, anemic, edematous and their management needs intensive care facilities. They have long duration of hospital stay, more complications and need more attention of hospital staff. The complications at times lead to death.

In our unit eclampsia has been the major cause of maternal mortality for many years. Therefore, complications of eclampsia, their frequency, severity and outcome need evaluation for better management.

Patients and Methods

It was a prospective descriptive study conducted from July 2000 to June 2001 at gynaecology unit “A” Government Lady Reading hospital Peshawar. Institutional Review Board of the hospital gave the ethical approval for the study. The study included all pregnant females presenting with eclampsia to this unit. The study objectives were explained to the patients/relatives and their consent to participate in this study was taken. Verbal information’s were recorded on a questionnaire, which included basic information about the patient, antenatal care, present, past, family, obstetrical, drug and socio-economical status followed by general physical, systemic, obstetrical and pelvic examination. It also included progress of labor mode of delivery and any complications (visual, cerebrovascular, cardiovascular, pulmonary, hepatic, renal, haemostatic, obstetrical and minor).  Routine investigations plus liver function tests, renal function tests and fundoscopy were done in all cases. No interventions were part of this study. Data from all cases was statistically analyzed and results calculated.

Results

Out of the 3090 laboring patients presenting to this unit 96 were eclamptic (3.1%). The average age of the patients was 26.15 years (range 16 to 40 years). There were 11 mortalities in 96 eclamptic patients (11.5%). The mean age of the patients who expired was 27.27 years. In the survivors the mean age was 26 years. Average diastolic blood pressure was 107.58 mm Hg. It was 105.7 mm Hg in uncomplicated patients and 110.2 mm Hg in patients having complications. Maternal complications were seen in 46/96 cases (48%). There were many patients who had more than one complication. After excluding obstetric and minor complications the total numbers of complications were 64. Most common complications were pulmonary (43.2%), hepatic (15.5%) and haemostatic (14.5%).

Of 6 patients with visual complication, all had disc edema. One patient had blindness due to central vascular abnormalities of visual cortex on CT scan. All of them improved with conservative management.

Two patients had hemiparesis and another patient was confused and developed awkward behavior later diagnosed as perpeural psychosis.

One patient had supraventricular tachycardia and another had persistent diastolic hypertension and  expired due to it.

Five patients had acute renal failure and one had chronic renal failure. Two had severe urinary tract infections. There were 10 patients with hepatic complications. Nine patients had deranged haemostasis varying from slight gum bleeding to full blown disseminated intra vascular coagulation. One patient had Doppler proven deep venous thrombosis.

A total of 22 patients had pulmonary complications. The most common was lower respiratory infections (64%). Six (22%) patients developed pulmonary edema. Two (7%) patients had aspiration pneumonia. One (4%) had pulmonary embolism and one (4%) had bronchospasm.

Of 96 patients 11 expired (11.45%). Causes of mortality were hepatorenal syndrome with deranged homeostasis and expired due to multiple organ failure (2), disseminated intra vascular coagulation and expired due to excessive bleeding (2), acute renal failure (1),respiratory failure (2) terminal shock (2), pulmonary embolism (1). One patient presented with antenatal eclampsia, she was treated and recovered without any complication. She was discharged on seventh postnatal day. After 09 days she was brought unconscious to the hospital with hypertension and labored breathing and expired on the same day.  The diagnosis in all cases was clinical.

Discussion

In this study the frequency of eclampsia was 3.1%, which is considerably higher when compared with data from the developed countries like UK (0.072%),⁹ USA (0.028%)¹⁰ and Finland (0.024%),¹¹ but is fairly lower when compared with a study from Bangladesh,⁷ where among 32,999 obstetric patients admitted to Dhaka hospital during the years 1998 to 2000, 2956 were reported with eclampsia, yielding an incidence of 9%. A study in Adigrat zonal hospital from Ethopia reported¹² pre-eclampsia (5.2%) and eclampsia (15.6%). In a rural tertiary hospital in Nigeria,¹³ the incidence of eclampsia was 1 in 43 deliveries (2.3%). The case fatality rate was 15.4%. The figures from our study were found higher when compared with different tertiary care hospitals of Pakistan: Civil hospital Karachi (2%),¹⁴ postgraduate medical institute Hayatabad medical complex (HMC) Peshawar (1.65%),¹⁵ Nishtar hospital (1.8%),¹⁶ Faisalabad (1.7 %).¹⁷ The high frequency observed in this study is indicative of the poverty, illiteracy and ignorance regarding health care in this part of the country.

In this study the rate of maternal death from eclampsia was 11.5 %, which is similar to other studies conducted within Pakistan like civil hospital Karachi¹⁴ (9.8%), Nishtar hospital Multan¹⁶ (11%), Faisalabad¹⁷ (9%). Highest case fatality rate of 16.9% was reported from HMC, Peshawar, which accounted for 48% of total maternal mortality recorded in the unit during the study period. In Bangladesh⁷ the rate of maternal death from eclampsia was 8.6%, Development of health awareness and implementation of antenatal care for all pregnant women may reduce the incidence of eclampsia.

Complications of eclampsia are diverse, serious and need vigilant eyes and efficient management. In the present study 46 out of 96 patients had one or other complications. Many patients had more than one complication that is why the number of complications was 64 making percentage of patients having complications as 48%. Ecalmptic patients treated in the United Kingdom in 1992 had 35% complications rate¹⁸ which is less than the present study but the difference is not too much if the difference in the health facilities in both these centers are also compared. The same difference may have also effected the mortality rate which is 1.8% in the United Kingdom and 11.45 % in the present study. In another study¹⁹ from Kandang Kerbau hospital Singapore showed 31% complication rate.

Total number of complications in our study was 64. Among the complications pulmonary complications topped the list. Facilities of general intensive care unit were mostly availed for pulmonary complications. These patients need very special nursing care which is often lacking in our busy obstetrical units. Six patients had more than one pulmonary complication. In the present study it was noted that the patients who have more than one complication had a worse course than patients who had only one complication.

Visual complications are dreadful clinically but not very serious regarding course of events. The complete recovery of one patient was prolonged due to cortical blindness.

Cerebrovascular complications resolved without any contribution to the mortality. In some very serious patients central nervous system could not be properly evaluated. The diagnosis was clinical and not confirmed on CT scan due to logistic reasons. Hepatorenal complications, haemostatic complications and combination of them were associated with worse prognosis.

A study from India²⁰ has reported that 32% of women died due to eclampsia were below the age of 20 years. The most common cause of mortality in cases of pre-eclampsia was haemolysis, elevated liver enzymes, and low platelet count (HELLP) or partial HELLP syndrome (83.33%) and pulmonary edema  in eclampsia.

In the present study the average age of the patients was 26.15 years ranging from 16 to 40 years. In the survivors group it was 26 years in the present study and 23.62 in the Panama study.²¹ In the patients who expired, the average age of the patients was 27 years in our study and 26 years in the Panama study. Both these studies point towards higher mortality with increasing age. The average diastolic blood pressure was 107.58 mm Hg in the present study. It was 105.7 mm Hg in uncomplicated patients and 110.2 mm Hg in patients having complications. In Panama study the average diastolic blood pressure of survivors were 112.74 mm Hg and those of the deceased was 119 mm Hg. In both these studies the difference was not significant. Instead there is a similarity in both these studies that the patients having less diastolic blood pressure have relatively good prognosis.

In our study the mortalities were due to multiple organ failure and not due to one etiology. It is time to take a new look at this major problem in our institution. It carries a significant morbidity and mortality. There is no room for complacency. Information about this dreadful complication of pregnancy needs to be disseminated to public and women dealing with deliveries.

Acknowledgement

We are grateful to Dr. Tasleem Akhtar centre incharge Pakistan Medical Research Council research centre Khyber medical college Peshawar for her cooperation and guidance in conducting this research and writing paper.

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