Eclampsia in rural Nigeria: The unmitigating catastrophe.

INTRODUCTION: Eclampsia is one of the most dreaded causes of adverse outcomes of pregnancy worldwide. It is one of the greatest causes of maternal and perinatal morbidity and mortality world over. We do not know the prevalence, management outcome, and the devastation caused by this dreaded disease in our center hence the need for this work.
MATERIALS AND METHODS: This is a 7-year retrospective review of all cases of eclampsia managed in Mater Misericordiae Hospital Afikpo, a rural secondary cum referral Catholic Mission Hospital in Afikpo, Ebonyi State in Southeastern Nigeria.
RESULTS: The prevalence of eclampsia in our center is 1.12% or one case of eclampsia for every 89 women that delivered in our facility. The majority of the women that had eclampsia in our center 56 (71.8%) were primigravidae. Seventeen women (21.8%) had various antenatal complications with 4 or 23.6% presenting with intrauterine fetal deaths and two (11.8%) each with intrauterine growth restriction, and domestic violence, respectively. Thirty-five or 44.9% of the women were delivered by emergency lower segment cesarean section. Fifteen or 17.9% babies were dead giving a perinatal mortality rate of 174 per 1,000After delivery, and 3 (3.8%) of the women had postpartum hemorrhage. Two women (2.6%) died giving a maternal mortality ratio of 2564 per 100,000 deliveries.
CONCLUSION: Eclampsia is a dreaded obstetric disease with adverse fetal and maternal consequences that are not mitigating, and no effort should be spared in managing it effectively including public enlightenment.

INTRODUCTION

Eclampsia is one of the most dreaded causes of adverse outcomes of pregnancy worldwide[1] constituting one of the greatest causes of maternal and perinatal morbidity and mortality in the world.[23] It is estimated that preeclampsia and eclampsia account for almost up to 63,000 maternal deaths annually worldwide.[4] This grim situation is anticipated to worsen given the increasing prevalence of obesity and metabolic syndrome among women of child-bearing age.[56]

Eclampsia which is considered as a complication of preeclampsia[7] is defined as the onset of convulsions described as the grand mal type of seizure first appearing before, during labor or within 48 h from delivery, and/or coma unrelated to other cerebral conditions in women with preeclamptic signs and symptoms.[8] Despite the seemingly lack of understanding of eclampsia and its causation, it has been recognized for years.[9] Hippocrates as early as the 5th century noted that headache, convulsion, and drowsiness were ominous signs associated with pregnancy[10] and in 1619 Varandaenus coined the term eclampsia in a treatise in gynecology.[711]

Maternal deaths from preeclampsia mainly result from eclampsia.[12] Eclampsia causes still births, increased interventions with cesarean sections at deliveries, increased intensive care unit admissions and neonates that have more respiratory distress syndrome and lower birth weights.[1213] Placental infarcts, abruption placentae, intrauterine growth restriction, and fetal hypoxia also contribute to fetal demise.[7]

Risk factors for eclampsia include, family history of preeclampsia and eclampsia, multifetal gestation, primigravidity, patients older than 35 years, teenage pregnancies, lower socioeconomic class,[714] preexisting medical conditions such as obesity, chronic hypertension, renal disease, thrombophilias, antiphospholipid antibody syndrome, gestational diabetes mellitus, and systemic lupus erythematosus.[15]

While nowadays eclampsia is rare in developed countries, it is still occurring in the developing countries, and its mortality in these countries is up to 15%.[2] High-income countries have been able to reduce both the incidence and case fatality rates associated with eclampsia by about 90% using a combination of early detection during antenatal care and increased access to hospital care for women who developed severe preeclampsia.[16]

The prevalence of eclampsia is reported to be 0.08% in the United States,[12] 0.02% in the United Kingdom[13] and 1.03% in India.[19] Eclampsia accounts for a significant number of maternal deaths in Africa and Asia and about a quarter of maternal deaths in Latin America and the Caribbean.[1718] In some parts of Northern Nigeria, eclampsia alone contributed to almost one-third of maternal deaths.[1920]

In Northern Nigeria, the incidence of eclampsia was 9.42% in Birnin kudu in Jigawa State[21] 1.02% in Kano,[22] and 7.6 per one thousand deliveries in Abuja.[23]

The prevalence of eclampsia appears to have strong variations in different countries[24] and even in different regions and indeed in different health institutions of the same country. The above, in addition to the fact that the prevalence and outcome of eclampsia had not been studied in our institution before and given the fact that sound information has been found to be a prerequisite for sound health actions[25] made our undertaking this work imperative.

MATERIALS AND METHODS

This is a retrospective study of all the cases of eclampsia managed over a 7-year period (from 2008 to 2014) at Mater Misericordiae Hospital, Afikpo. The cases were got from the casualty department, antenatal, labor and postnatal ward registers. The case notes were retrieved from the Hospital Records Department. Relevant information such as the biodata, booking status, of the patients, the gestational age at delivery, state of the baby on mother's arrival to our facility, mode of delivery, the birth weights, and Apgar scores, etc., were extracted and analyzed using numbers and percentages.

Mater Misericordiae Hospital, Afikpo where this work was done is a Roman Catholic secondary/referral Mission hospital in Afikpo, Afikpo North Local Government Area of Ebonyi State, one of the 36 states that make up Nigeria. It is located in the Southeast Geopolitical zone of Nigeria. The Hospital was founded in 1948 by the Medical Missionaries of Mary congregation of the Roman Catholic Church and has a general section where all other cases except maternity cases are managed and a maternity section. The maternity section has 150 beds, it is semiautonomous from the main hospital and handles the full range of maternity services.

According to the 2006 National population census conducted in Nigeria, Afikpo is the second largest town in Ebonyi state after the state capital, Abakaliki. The hospital has a school of Nursing, a school of Midwifery and is accredited by the National Postgraduate Medical College of Nigeria, the West African College of Surgeons and the Royal College of Obstetricians and Gynecologists England for training of resident doctors in Obstetrics and Gynecology. It is also a training center for residents in family medicine. The hospital offers, among other services, secondary and referral health services and full gynecological and obstetric services to her immediate environ of Afikpo and other neighboring communities in Ebonyi state and the surrounding Cross River, Abia, Imo, and Enugu States.

RESULTS

Out of 83 cases notes that were retrieved, 78 (94%) had complete information and were used for the study. Out of the 6938 deliveries conducted over the 7-year period, 78 women had eclampsia giving the prevalence of eclampsia in our center as 1.12% or one case of eclampsia for every 89 women that delivered in the hospital.

As can be seen from Table 1, the majority of the women that had eclampsia in our center 56 (71.8%) were primigravidae. The majority (69.3%) were in the 20–30 years age bracket and 11 (14.1%) were 19 years or below with an age range of 15–40 years and an average age of 27.5 years. Forty-seven or 60.3% of the women were booked while 31 (39.7%) were unbooked. The majority of the babies 42 (53.8%) were delivered at term while 31 (39.7%) were preterm. Eight (10.3%) of the pregnancies were multiple pregnancies (twins), and 3 or 3.8% of the women had comorbidities with two of them having HIV/AIDS and one gestational diabetes. Seventeen women (21.8%) as seen in Table 2 had various antenatal complications. Four or 23.6% presented with intrauterine fetal deaths, 3 (17.7%) had previous cesarean delivery and two (11.8%) intrauterine growth restriction, and domestic violence, respectively. One of the women that were beaten up was said to have been beaten up when she had the fit to make her stop fitting. The other was beaten up shortly before she had the fit and was rushed to the hospital. Thirty-five (44.9%) of the women were delivered by emergency lower segment cesarean section and the majority, 43 (55.1%) by spontaneous vertex delivery.

Table 1

Sociodemographic characteristics

Characteristics	n (%)
Age (years)
<19	11 (14.1)
20-25	24 (30.8)
26-30	30 (38.5)
31-35	11 (14.1)
36-40	2 (2.6)
Total	78 (100)
Occupation
Farming	28 (35.9)
Trading business	17 (21.8)
Civil servants	15 (19.2)
Vocational skills	11 (14.1)
House wives	7 (9)
Total	78 (100)
Booking
Booked	47 (60.3)
Un booked	31 (39.7)
Total	78 (100)
Parity
Primigravida	56 (71.8)
Para 1-4	21 (26.9)
Para 5 and above	1 (1.3)
Total	78 (100)
Gestational age (weeks)
28-33	12 (15.4)
34-37	19 (24.3)
38-40	42 (53.8)
41-42	3 (3.8)
>42	2 (2.6)
Total	78 (100)

Table 2

Antenatal complications

Complication	n (%)
Placenta praevia (Type 3)	1 (5.9)
Previous cesarean section	3 (17.7)
Abruption placenta	1 (5.9)
Intrauterine growth restriction	2 (11.8)
Intrauterine fetal death	4 (23.6)
Obstructed labor	2 (11.8)
Cephalopelvic disproportion	2 (11.8)
Domestic violence	2 (11.8)
Total	17 (100)

Of the 86 babies delivered by the eclamptic women, 71 (82.6%) were delivered alive while 15 or 17.4% were dead giving a perinatal mortality rate of 174 per 1000 of the babies that were delivered. Six of the babies that died were from mothers that booked giving 12.8% of the 47 booked mothers, and the other 6 were from unbooked mothers. This means that 19.4% of the perinatal mortality was from the unbooked 31 mothers, majority of the babies born 52 (73.2%) as can be seen from Table 3 had good Apgar score of 8–10, 17 (24%) 5–7, and only 2 (2.8%) had an Apgar score of 4 or less in the 5th min.

Table 3

Fetal characteristics

Characteristics	n (%)
Fetal weight (kg)
<1.51	9 (10.6)
1.6-2	6 (7)
2-2.5	29 (34.1)
2.6-3	24 (27.9)
3-3.5	15 (17.6)
3.5-4	2 (2.4)
>4	1 (1.2)
Total	86 (100)
Sex
Male	54 (62.8)
Female	32 (37.2)
Total	86 (100)
Apgar score in 1 min
<4	16 (22.5)
5-7	32 (45.1)
8-10	23 (32.4)
Total	71 (100)
Apgar score in 5 min
4 or less	2 (2.8)
5-7	17 (24)
8-10	52 (73.2)
Total	71 (100)

The majority of the babies 54 (62.8%) were male while 31 (37.2%) were female.

After delivery, 3 (3.8%) of the women had post part hemorrhage. Two out of the 78 eclamptic mothers died giving a maternal mortality ratio of 2564 per 100,000 deliveries or a percentage maternal death of 2.6%.

DISCUSSION

The prevalence of eclampsia in our center from this study is 1.12% or one case of eclampsia for every 89 women that delivered in our hospital. This prevalence is high. It is higher than the prevalence in developed countries like the United States with a prevalence rate of eclampsia of 0.08%.[12] These differences resulted from differences in obstetric services and early presentation of cases.

The incidence of 1.12% in our center is similar to the 1.02% (1 in 97 deliveries) found by Tukur and Muhammad in Kano,[22] 0.91% by Ade-Ojo and Loto in Ile-Ife,[30] 1.08% observed by Sumta Mor et al. in their study, and 1.2%[26] by Ade-Ojo et al. and Berhan and Endeshaw in their study in Ethiopia.[27] This similarity may be due to similarity in the management of preeclampsia in these centers.

Our prevalence of 1.2%, however, is <1.7% got by Olatunji and Sule-Odu[28] 1.66% by Fabamwo et al.[29] in Lagos, 2.7% by Okeudo et al. in Orlu Imo state,[31] 2.1% by Adekanle and Akinbile et al. in Osogbo[32] and 9.42% by Tukur et al. in Birni Kudu, and Jigawa state of Northern Nigeria.[21] Our lower prevalence could be due to a lot of differences in the cultural, religious and social beliefs, and practices in these areas. For example, early marriages which are acceptable in some of these cultures could predispose their patients to a lot of teenage pregnancies, which is known to be a risk factor for eclampsia.

In addition, the high prevalence of twins by the Yorubas could increase the prevalence in Lagos and Osogbo. All these are known to be risk factors for eclampsia.

Our incidence of eclampsia of 1.12%, however, is more than the, 0.65% by Nwora et al. in Nnewi.[333435] This lower prevalence of eclampsia in their center could be due to their operating environments being different from ours.

The majority of our eclamptic patients 54% or 69.3% were aged between 20 and 30 years. However, 11% or 14.1% of them were aged 19 years or below. Although this number 11% or 14.1% looks low in absolute terms, it is significant in the sense that considering how small the number of women that deliver in this age group is, this percentage of them having eclampsia is quite huge. This shows that eclampsia is common in this teenage age group. The 14.1% of teenage mothers that had eclampsia in our study is much <58.5% that Tukur et al.[21] got in their study in Northern Nigeria. This difference could be accounted for by religious and cultural differences in the areas in which the studies were conducted. While our study was conducted in Southeastern Nigerians who are predominantly Christians and where their females mainly because of western education marry later in life after their education, in their study environment, Islam is the predominant religion and child marriages are culturally and religiously acceptable.

Our findings of eclampsia in 14.1% of teenage mothers however agrees with the 12% got by Nwora et al.[33] in Oshogbo. The similarity in both works may be because they were done in Southern parts of Nigeria who are predominantly Christians and where western education for females holds sway hence making teenage pregnancy uncommon.

Although a majority of our patients (60.3%) were booked in our center, it is common practice for booked patients to attend all or part of their antenatal care in the hospital and deliver elsewhere at times in traditional birth attendants’ homes, spiritual homes, pentecostal churches, etc., They then come to hospital when complications arise. When they come this way, they will still be regarded as booked.

It is also a common practice for our booked patients to default in keeping their antenatal appointments only for them to come when they have problems. Some of these booked defaulters that were brought in with eclampsia may have also contributed to booked patients being in the majority in our study. Our findings here is in contrast to Ade-Ojo and Loto[30] in Lagos and Tukur and Muhammad in Birni Kudu Northern Nigeria[22] who had higher incidence of eclampsia in their centers in unbooked cases. This could be due to the afore-mentioned high default rate in our booked patients. In addition, because their centers are in more cosmopolitan centers, their patients could be more enlightened making those that booked to attend antenatal clinics more regularly.

The majority of our patients, 56 (71.8%) were primigraridae. Our findings here are in keeping with similar studies that found eclampsia to occur more in the primigravidae.[29]

Seventeen of the 78 women or 21.8% had various complications in the antenatal period. This high number of women with various antenatal complications goes to show that indeed, eclampsia is a high-risk condition that is fraught with complications. Our rate of antenatal complications, however, is <38% Sunita Mor et al.[26] got in their study. This may be due to the fact that majority of our patients were booked. Although they had eclampsia, some of the complications that could have arisen were prevented because of their booked status. Moreover, the environment in which we did our work was different from theirs.

Of the complications that occurred antenataly in our study, majority (23.6%) were intrauterine fetal deaths followed by 3 women 17.7% who had previous cesarean sections, 2 each 11.8% who had intrauterine growth restrictions, obstructed labor, and domestic violence. One, (5.9%) each had placenta previa (type 3), Abruptio placenta, and cephalo-pelvic disproportion. In fact, one of the women who had domestic violence was beaten up in a bid to wake her up from the coma, because they thought she was acting up the scene. The percentage of intrauterine fetal deaths found in our series is high and shows that eclampsia is a serious cause of intrauterine fetal death. Our intrauterine fetal death rate of 23.6% however is <60% got by Onyearugha and Ugboma[34] in Aba, Abia State as intrauterine fetal deaths due to eclampsia. This difference could be due to the difference in our operating environments. It could also be due to the fact that as a teaching hospital which is bigger than our center which is a mission hospital, bureaucratic bottlenecks could lead to delays that impact negatively on emergency deliveries, thereby leading to more incidence of intrauterine fetal deaths.

Thirty-one or 39.7% of our patients presented preterm (from 28 to 37 weeks). This percentage of prematurity is very high and entailed that these babies may suffer from all the problems associated with prematurity including early neonatal deaths. This makes eclampsia one of the serious threats to optimal pregnancy outcome and child survival. Our preterm pregnancy rate of 39.7% is similar to the 36% got by Adekanle and Akinbile in Osogbo Southwest Nigeria.[32] This similarity could be due to both works being done in the same Southern Nigeria. Our prematurity rate however is <48% got by Sunita Mor et al.[26] in their work. This difference could be due to the work being done in different environment.

Majority of the women, 43 (55.1%) delivered per vaginam while 35 or 44.9% of the women who had eclampsia in our center were delivered by emergency cesarean section. This cesarean section rate is high and shows that eclampsia is a major contributor to the unacceptable increasing cesarean section rates. Our cesarean section of 44.9% is less than the 52% got by Sunita Mor et al.[26] 54.2% by Adekanle and Akinbile in Oshogbo[32] Nigeria, and 86.7% by Okeudo et al. in Orlu Imo state Nigeria.[31] This higher rate of the cesarean section could be due to differences in the mode of presentation of patients and the doctors in the different centers having different thresh holds for cesarean section in their eclamptic patients.

Eight or 10.3% of the pregnancies were twin pregnancies. Twin pregnancy is one of the known risk factors for eclampsia. Fifteen of the 85 babies delivered died given a perinatal mortality rate of 174 per 1000. This perinatal mortality rate is very high, making eclampsia a very big cause of perinatal mortality. Our perinatal mortality is more than 69 per 1000 got at Nnewi Southeast Nigeria[33] but <312 per one thousand that Tukur and Muhammad got in Kano.[22] This difference could be because of the differences in our area of practice and also in the neonatal facilities available.

The maternal mortality ratio from eclampsia in this study of 2564 per 100,000 deliveries or 2.6% is high, our maternal mortality ratio is much higher than the Nigerian national average of 530 per 100,000 births as shown in the 2013 Nigerian National Demographic and Health Survey[35] and 1981 per 100,000 deliveries by Adekanle and Akinbile in Osogbo.[32] This could be because the Nigerian national maternal mortality ratio was calculated with broader denominators that comprised diseases whose effect on maternal mortality may not be as devastating as eclampsia.

Our maternal mortality ratio or percentage mortality however is <3.3% got by Okeudo et al. in Orlu in the same Southeastern Nigeria,[31] 4% by Sunita,[29] 8 percent by Ade-Ojo and Loto in Ile-Ife,[30] 10.6% by Tukur et al. and Umar in Birni Kudu, and Jigawa State of Northern Nigeria.[21] These differences could probably be due to, late presentation of cases, and differences in study settings.

CONCLUSION

The prevalence of eclampsia is high in this study. It occurs more frequently in teenage primigravidae and causes very high and unacceptable perinatal and maternal mortalities. This unmitigating calamity is preventable, and all efforts must be made toward its prevention including public education, retraining of health workers, and enlightenment of the populace. There is every need for obstetricians to be the arrow head in this regard-initiating, propagating, and coordinating efforts in this fight.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.