Feto-maternal Outcomes in Cesarean Section Compared to Vaginal Delivery in Eclamptic Patients in a Tertiary Level Hospital

Background: Over half-a-million women die each year from pregnancy-related causes, and 99 percent of these occur in developing countries. In Bangladesh though maternal mortality rate (MMR) declined significantly around 40% in the past decade, still eclampsia accounts for 20% of maternal deaths. Eclampsia is uniquely a disease of pregnancy, and the only cure is delivery regardless of gestational age. A rational therapy for general management of hypertension and convulsion has been established in Bangladesh by the Eclampsia Working Group. But controversy still exists regarding obstetric management. Objective: To evaluate the feto-maternal outcome in cesarean section compared to vaginal delivery in eclamptic patients. Materials and Methods: This prospective cohort study was conducted in the department of Obstretics & Gynecology, Dhaka Medical College & Hospital (DMCH), from January to December 2011. A total 100 eclamptic women with term pregnancy and live foetus were purposively included in the study (Group I, 50 patients with vaginal delivery and Group II, 50 with cesarean section). Results: Out of these 100 patients 56% were aged <20 years, 71% were primigravida and 77% were from low socioeconomic status. Sixteen percent patients from vaginal delivery group and 18% from cesarean section group had no antenatal care. The mean gestational age was about 38 weeks in two groups. No significant difference was found between the two groups regarding blood pressure, proteinuria, consciousness level and convulsion. Recurrence of convulsion occurred in 30% patients of vaginal delivery group compared to 6% in cesarean section group. Maternal complications such as postpartum hemorrhage, cerebrovascular accident, renal failure, obstetric shock and abruptio placenta were higher among vaginal delivery group patients (46%) than cesarean section patients (16%). Maternal mortality was 6% in the vaginal delivery group and none in the cesarean section group. Regarding fetal outcome, stillbirth was 20% after vaginal delivery and 6% after cesarean section, the result was statistically significant. Birth asphyxia was less in the cesarean section group (23.4%) than in vaginal delivery group (60%) and this was statistically significant. Conclusions: The result of the present study shows a better fetomaternal outcome in the cesarean section group than in the vaginal delivery group.


Feto-maternal Outcomes in Cesarean Section Compared to Vaginal
Delivery in Eclamptic Patients in a Tertiary Level Hospital occur up to 6 weeks postpartum. 1,3er half-a-million women die each year from pregnancy related causes and 99% of these occur in the developing countries.In Bangladesh though maternal mortality rate (MMR) declined significantly around 40% in the past decade, still eclampsia accounts for 20% of maternal death. 4 Bangladesh, the incidence of eclampsia is high (7.9%)according to the results of a house to house survey. 5In the baseline survey of Emergency Obstetric Care (EOC) in Bangladesh, 5% of total obstetric admissions in health facilities were due to pre-eclampsia and eclampsia. 6Eclampsia contributes to 20% of maternal mortality on a national basis.Though rare in developed countries, it is a common problem in developing countries because illiteracy, lack of health awareness and education, poverty, superstition and prevent women from seeking medical advice during pregnancy.Still eclampsia is one of the leading causes of maternal death in Bangladesh. 4 Eclampsia is a multisystem disorder, and the pathophysiology is thought to involve cerebral vasospasm leading to ischemia and cerebral edema. 1 Until recently, the treatment of eclampsia varied throughout the world.The basic principles of management are: (a) control of convulsion, (b) control of hypertension, (c) initiation of steps to effective delivery, and (d) general nursing care.The first goal of management of eclampsia is control of convulsions and stabilization of the patient's basic cardiovascular status.Administration of magnesium sulphate by an established protocol is considered to be the most rapid, efficient and safe pharmacologic approach for accomplishing this goal. 7gh blood pressure is controlled by injection of hydralazine intravenously followed by oral nifedipine or methyldopa or atenolol.Eclampsia is uniquely a disease of pregnancy, and the only cure is delivery regardless of gestational age.A national therapy for general management, management of hypertension and convulsion has been established in our setup by 'The Eclampsia Working Group of Bangladesh', but controversy exists regarding the obstetric management. 7 we do not have adequate facilities for intrapartum management, cesarean section is preferred in many cases, particularly when the fetus is alive, considering the fact that patients and the fetuses may not tolerate the stress of labor. 8 Bangladesh, many researchers have worked on eclampsia, but most of the works are related to efficacy, dose and frequency of use of magnesium sulphate.There are only a few works on obstetric management of eclampsia.So, we conducted this study in Eclampsia Unit of Dhaka Medical College Hospital, trying to find out a relatively better mode of delivery for eclampsia patients.

Results
Table I shows comparison of baseline demographic and clinical characteristics between the two study groups.There was no significant difference in any of the variables.
Maximum number of women in Groups I and II belonged to age group < 30 years (96% and 98%); mean ± SD of age was 22 ± 4.23 and 21.94 ± 3.12 years, respectively.Gestational age was 38.02 ± 1.19 and 38.24 ± 1.36 weeks in Groups I and II, respectively.
Table II shows that there was no significant difference in blood pressure between Group I and Group II.Table III shows comparison of mean ± SD values of different aspects of convulsion parameters between Group I and Group II.There was no significant difference between the groups.Recurrence of convulsion was significantly high (P<0.05) in Group I (30%) compared to Group II (6%) (Table IV).Both groups received loading and maintenance doses of MgSO 4 .

Discussion
Eclampsia is a well-recognized major cause of maternal and perinatal morbidity and mortality.
Though the incidence has fallen considerably in the developed countries, its incidence, morbidity and mortality are still very high in Bangladesh. 5 In Bangladesh, among the causes of death in women of reproductive age, maternal death contributes 14% and eclampsia accounts for 20% of maternal death. 4ontrol of convulsion and management of hypertension are two important parts of the management of eclampsia.There is now conclusive evidence that magnesium sulphate (MgSO 4 ) is the best available drug for management of convulsion 7 and is widely used in different centers of Bangladesh.Once the convulsions are under control, there is universal agreement to deliver the patient regardless of gestational age.The mode is determined by gestational age, condition of the cervix and fetal condition. 1e chances of successful induction of labor are low in primigravide with an unfavorable cervix at <34 weeks gestation.Even if induction is successful in this group, emergency cesarean section becomes necessary in up to 45% of cases because of fetal intolerance of labor.A high proportion of such cases are, therefore, delivered by cesarean section without attempt to induction, particularly when delivery needs to be expedited quickly because of concerns about maternal condition. 1 our study, both vaginal delivery group and cesarean group patients were compared on important characteristics such as recurrent convulsion, maternal and perinatal morbidity and mortality etc.
In this study, average age was 22 ± 4.23 years in vaginal delivery group and 21.94 ± 3.12 years in cesarean section group, and most of the patients (56%) belonged to <20 years age group.In the comprehensive study of Khanam et al 9 82.7% of patients were in the age group between 15--25 years.El-Nafaty et al 10 also found teenage preponderance (66.9%) in the occurrence of eclampsia.Chuni and Khanna 11 found 36.89% patients below the age of 20 years.Rouf et al 12 found age preponderance between 15--25 years in 76% of eclamptic patients.In our study, most of the patients at term had a mean gestational age of 38 weeks.This corresponds with the other studies. 10,12n our study 80% patients of vaginal delivery group and 74% patients of cesarean section group were from low socioeconomic status.Study done by Chowdhury 13 has shown that 95% patients belonged to low socioeconomic group and 73.5% of patients in the study of El-Nafaty et al. 10 On an average 17% of patients in our study did not receive any antenatal care which was 35.57% in the Khanam et al 9 study and 69.2% in the El-Nafaty series. 10e two groups of patients were also matched with regard to blood pressure and proteinuria and consciousness level.Most of the patients of both groups presented with anteparturn eclampsia in unconscious or semiconscious state, which is similar to the another study. 9currence of convulsion was 30% in vaginal delivery group and 6% in the cesarean section group.This rate is similar to the study of Onuh and Aisien 14 showing a recurrence rate of 4.8% in the cesarean section group.Number of convulsions before admission was 4.40 ± 1.51 (in vaginal delivery group) versus 4.84 ± 2.20 (in cesarean section group).This is similar to the findings of Ikechebelu and Okoli. 15Convulsions occurred in 55.8% patients after the 37th week in the study of Khanam et al. 9 In this series, maternal complications were more in vaginal delivery group.CVA and pulmonary edema developed in 8% cases.In cesarean section group, it was about 2% and 6% respectively.In the study of Begum et al 5 both pulmonary edema and CVA were found to be more in the vaginal delivery group (22% and 12% of patients respectively).This corresponds with some other studies. 5,16In the study of Khanam et al 9 the major complications like pulmonary edema, HELLP syndrome, DIC, renal failure and obstetric shock were similar to the findings in our study.
Renal failure occurred in 21.7% of vaginal delivery patients in our study and it was two percent in the study of Begum et al. 4 Six percent of the vaginal delivery group patients died from CVA.No patient died in the cesarean section group in our study.The maternal mortality was 5% in both groups in the study by Chowdhury 13 and 4% in the study by Begum. 8Pulmonary edema and CVA were two common causes of the death.
Regarding fetal outcomes, a higher number (20%) of babies were born stillbirth in vaginal delivery group as against six percent in the cesarean section group.Most of the babies had low birth weight.Mean birth weight was 2.42 kg in vaginal and 2.47 kg in cesarean section groups.APGAR score in 1st minute was 5.42 ± 2.29 in cesarean section group which was better than in vaginal delivery group.Jahan A 17 has shown almost similar findings.Birth asphyxia was higher in vaginal delivery group in our study (60 percent as against 23.4 percent in the cesarean section group).A higher number of babies were treated in neonatal care unit (NCU) from vaginal delivery group.Perinatal mortality has been found to be higher in vaginal delivery group in many studies in this country. 8,13echebelu and Okoli 15 have reported in their series a high cesarean section rate of 85.7 percent among eclamptic patients.Other studies carried out by Ogunniyi et al 18 and Chama et al 19 also revealed high cesarean section rates ranging between 50 percent to 76.5 percent.Arora et al 20 have advocated early cesarean section in eclamptic patients, at least in the referral centers.This is because they found in their series a maternal mortality of 4.3 percent in the cesarean section group, which is almost half the mortality rate of 7.1 percent in the vaginal delivery group.Moreover, El-Nafaty 10 in his series found a perinatal mortality rate of 25.6 percent in the cesarean section group, which is also about half the perinatal mortality of 47.7 percent in the vaginal delivery group.Jahan A 17 has shown almost similar findings.
It is observed in this study that the patients undergoing cesarean section showed a better maternal outcome with fewer incidences of recurrent convulsions and other maternal complications than vaginal delivery group.Regarding fetal outcome, the number of stillbirths and asphyxiated baby was less in the cesarean section group than that in the vaginal delivery group; the result being statistically significant.So the result of the study shows a better feto-maternal outcome in the cesarean section group than in the vaginal delivery group.

Table I
a P value reached from unpaired t-test b P value reached from chi-square test

Table II :
Comparison of blood pressure of the study subjects (n=100)