Eclampsia-scenario in a Hospital-a Ten Years Study

This cross sectional record based institutional study was conducted in the Department of Obstetrics & Gynaecology, Burdwan Medical College, Burdwan over ten years (1999-2008) aiming analysis of eclamptic mothers for evaluation of maternal and perinatal outcome with different anticonvulsant medications. Total 5991 pregnant mothers with eclampsia admitted in the inpatient department of the tertiary care teaching hospital were recruited for the study, irrespective of their previous antenatal check up history. Subjects with known seizure disorders were excluded from the study. The subjects were managed according to standard regimens (Menon, Ph-sodium, diazepam & magnesium sulphate) and results were documented in standardised format. Case fatality rate, mean induction delivery time & birth-weight, perinatal mortality rates were recorded. Study reveals that the incidence of eclampsia <20 years was 6.97% and majority (5.41%) came from rural areas. Eclampsia was noted primarily in primigravida (7.43%) and unbooked (6.41%) mothers. Ante partum eclampsia predominated (64%) and incidence of caesarean section was 22.25%.The overall case fatality rate was 6.05% and eclampsia contributed 27.85% of all maternal deaths during the last two years of the study period. The overall incidence of low birth weight baby was 26.96% and perinatal mortality was 30.33% (1411/4651).The incidence of perinatal mortality and low birth weight babies are lower in the last 4 years when compared to earlier studies. Proper socio-demographic assessment of pregnancy with eclampsia, planned delivery, shorter induction delivery interval, good control of convulsion by magnesium sulphate, intensive intranatal monitoring causes less maternal and perinatal morbidity and mortality.


Introduction
Eclampsia is a multi-system disorder with complex pathogenesis.Majority of the death occurs in the developing countries and most of them are preventable.Eclampsia causes 12% of all global maternal deaths 1 .The eclamptic convulsion is a major source of perinatal morbidity or mortality unless expertly managed 2 .In India maternal mortality rate in eclampsia is very high.The figure ranges from 8-14% [3][4][5] and perinatal mortality varies from 24-34% 6,7 .The role of injection magnesium sulphate as an anticonvulsant is better over diazepam and phenytoin sodium 8 .
The study was carried out to analyze the incidence of eclampsia, types of eclampsia, sociodemographic characteristics of the subjects, mode of delivery, maternal and perinatal outcomes over the study period.The study also evaluated the utility of different management protocols followed in the hospital to treat pregnancy with eclampsia.

Materials and Methods
A retrospective analysis of case records of eclamptic mothers was reviewed from January, 1999 to December, 2008 in the Department of Obstetrics and Gynaecology, Burdwan Medical College, Burdwan.Burdwan is a district town located approximately 100 Km from Kolkata, capital of West Bengal, India.This is a tertiary care teaching hospital with 1105 beds with more than 17500 deliveries conducted every year.There was 1,40,701 deliveries during the study period and 5991 eclamptic mothers were studied.All mothers with eclampsia, irrespective of booking status were admitted in the hospital without refuse and they were kept in a separate room.The pregnant women with known seizure disorders were excluded from our study.All of these cases were analyzed with reference to age, gravidity, and socio-economic status, type of eclampsia, mode of delivery, maternal mortality and fate of fetus.In the study period of the year1999-2000, out of 1280 eclamptic mothers the lytic cocktail (menon's regime) was used in 640 (50%) cases and diazepam regime was used in 640 (50%) cases respectively.During the year of 2001-2002, phenytoin sodium was solely used as an anticonvulsant for the treatment of 1315 eclamptic mothers.In the year 2003-2004, out of 1044 cases, injection magnesium sulphate was used in 940 cases (90%) and Inj.phenytoin sodium was used in 104 (10%) cases.Two thousand and three hundred fifty two mothers with eclampsia were treated exclusively with inj.magnesium sulphate (MgSO 4 ) regime in the year 2005-2008.After stabilization of patients with different anticonvulsant drugs at different phases of the study period, obstetric management was undertaken and detailed analysis was recorded in a predesigned proforma.
The statistical analysis was done in Microsoft excel by ANOVA-two ways without replication and chi square test.p-value <0.05 is considered significant.
Table IV shows the different mode of delivery.The lower segment caesarean section (LSCS) rate was higher in MgSO 4 (27.55%) and phenytoin sodium group (22.63%) when compared to menon and diazepam groups.

Discussion
The overall incidence of eclamptic mother in our study was 4.23% (5991/140701).This is mainly because our hospital serves predominantly on rural population.The incidence of eclampsia has been reported between 0.179% to 2.9% 3,7,10 in different studies.In our study of 10 years, the incidence of eclampsia is shown in figure 1 and the lowest incidence (2.96%) was noted in the year 2008.In the present series 6.97% of eclamptic mothers were below the second decade, 2.37% were below 25 years.The younger age group is an important risk factor of eclampsia and this was supported by different reports 10,11 .Primigravida appeared to be the worst victim (7.43%) for eclampsia (Table I).Primigravida comprises the bulk of the series in different studies 3,5,10 .Eclampsia developed in 1.97% of booked cases in our study.The incidence of eclamptic convulsions was higher (6.41%) in unbooked cases as they were unidentified for prompt treatment of pregnancy induced hypertension (PIH), which increases the incidence of eclampsia.The majority of cases (64%) were antepartum eclampsia in our series.Antepartum eclampsia is also very common in different studies and the incidence were 29.13% 3 , 51.2% 5 and 60.2% 6 , but a few studies reported the predominance of intrapartum eclampsia over the antepartum eclampsia 10 , and postpartum eclampsia has an upward trend 7 .Previously there was no standard protocol for obstetric management in eclampsia and vaginal delivery was more preferable with more relaxation of inductiondelivery (I-D) interval for fear of caesarean section complications, but now caesarean delivery is the method of choice if vaginal delivery is not anticipated within 12 hours from the onset of convulsion and even after induction.Early caesarean section was also performed in repeated recurrence of convulsion.Anticonvulsant likeinj MgSO 4 used for stabilization of eclamptic mother had less recurrence of convulsion (5.71%) [Table II].Normal vaginal delivery occurred in 58.32% (2682/4598) of cases.Second stage of labour was made cut short by forceps in 882 cases.Caesarean section was performed in 22.25% (1023/4598) of cases in our series.Agarwal et al 9 reported similar incidence (22%) of caesarean section.Many centres liberalised caesarean section for better maternal and fetal outcome.The reported incidence varies between 49-70% 7,8,12 .
The perinatal outcome in our study was low birth weight (26.96%, 1254/4651), still birth (22.7%; 1054/4651) and neonatal death (7.67%; 357/4651).Our observation was similar with the findings of Agarwal et al 9 .Reports from different hospitals showed a high still birth rate 5,9,10,12 .The perinatal mortality was 31% in ph.sodium, 41%in MgSO 4 and 58.1% in menon's regime 13 .Prematurity, low birth weight, placental insufficiency, late arrival were the contributing factors of perinatal loss in our study.Magnesium sulphate regime can reduce the perinatal mortality to a reasonable standard of 22.4% (Table V) in our report and it was comparable with the findings of Desai et al 6 .The maternal mortality was 10.72% which comprised 14.08% of all maternal deaths 5 .Maternal mortality was 6.05% in our series.It is a low figure than other Indian studies [2][3][4]10 . Hapazard combinations of sedative and anticonvulsants and improper management of labour in different centres are important factors for high maternal mortality in eclampsia.In the present series death of eclamptic mothers formed the main bulk (45.14%) of maternal death (Table VII).Regarding the choice of anticonvulsant, it was noted that the introduction of inj.magnesium sulphate dropped the maternal death in eclampsia in the last four years [mean 23.5 (range 17-31)] (Table VII).The contribution of eclamptic maternal death is also reduced in the last two years (27.85%)[Fig- 3] but still is higher on comparison to world standard.This is mainly due to late referral, poor antenatal check up, and transfer of moribund patient just before death to the tertiary hospital Conclusion: Eclampsia still remains the major problem in developing countries.Incidence of perinatal mortality and maternal mortality is disappointing in eclampsia.Poor socio-economic status, lack of essential obstetric care is the fundamental determinants of maternal deaths not only for eclampsia but as a whole.Unless the social, educational status are uplifted and antenatal coverage is brought to the grass root level no miracle can be expected.A moderate reduction of death of both mother and fetus in our institution is possible due to wider use of magnesium sulphate; timed delivery and proper implementation of emergency obstetrics care (EmOC) facilities to mothers with eclampsia.

Fig. 1 -
Fig.1-Incidence of eclampsia R 2 value shows that about 61% of the variation in incidence is explained by time factor (years) through the linear model

Table I :
Socio-demographic profile of eclamptic mothers

Table II :
Number of patients having recurrence of convulsion *ANOVA-Two factors without replication, the rows (different types of eclampsia) have a significant effect as F-value is larger than the critical value n (%); APE, Ante partum eclampsia, IPE, Intrapartum Eclampsia, PPE, Postpartum eclampsia.

Table IV :
Mode of Delivery VD: vaginal delivery; LSCS: Lower segment caesarean section, Death of undelivered mother-37; All PPE cases(1356) excluded; n(%), ANOVA-two factors without replication: The rows (different methods of delivery have a significant effect as F-value (9.55140) is larger than the critical value (3.86254) and p value=0.003701.

Table V :
Fate of Fetus

Table VI :
Low Birth Weight babies in eclampsia

Table VII :
Case fatality rate and contribution of eclamptic maternal death Year P e rc e n ta g e