Eclampsia in the United Kingdom. The 'BEST' way forward

Preeclampsia and eclampsia-specific maternal mortality in Bangladesh: Levels, trends, timing, and care-seeking practices

Background

Despite improvements in many health indicators, maternal mortality has plateaued in Bangladesh. Achieving the global target of reductions in maternal mortality and the associated Sustainable Development Goals will not be possible without actions to prevent deaths due to preeclampsia/eclampsia. Here we examined the levels, trends, specific causes, timing, place, and care-seeking behaviours of women who died due to these two causes.

Methods

We used nationally representative Bangladesh Maternal Mortality and Health Care Surveys (BMMSs) conducted in 2001, 2010, and 2016 to examine levels and trends of deaths due to preeclampsia/eclampsia. We based the analysis of specific causes, timing, and place of preeclampsia/eclampsia deaths, and care seeking before the deaths on 41 such deaths captured in the 2016 survey. We also used BMMS 2016 survey verbal autopsy (VA) questionnaire to highlight stories that put faces to the numbers.

Results

The preeclampsia/eclampsia-specific mortality ratio decreased from 77 per 100 000 live births in the 2001 BMMS to 40 per 100 000 live births in the 2010 BMMS, yet halted in the 2016 BMMS at 46 per 100 000 live births. Although preeclampsia/eclampsia accounted for around one-fifth of all maternal deaths in the 2010 BMMS, in the 2016 BMMS, the percentage contribution reached the 2001 BMMS level of 24%. An analysis of the VA questionnaire's open section showed that almost all such death cases left their homes to seek care; however, most had to visit more than one facility before they died, indicating an unprepared health system.

Conclusions

A cluster of preeclampsia/eclampsia-specific mortality observed during the first trimester, during delivery, and within 48 hours of birth indicates a need for preconception health check-ups and strengthened facility readiness. Awareness of maternal complications, proper care seeking, and healthy reproductive practices, like family planning to space and limit pregnancy through client-supportive counselling, may be beneficial. Improving regular and emergency maternal services readiness is also essential.

Eclampsia in India Through the Decades

BACKGROUND

Eclampsia is still prevalent in India with high maternal and perinatal mortality. In India, there is no community-based survey of eclampsia. Sporadic reports of study on eclampsia are being published in medical journals.

OBJECTIVES

The objective of this study was to find out the incidence of eclampsia and maternal and perinatal mortality in India.

METHODS

Data on incidence, maternal mortality and perinatal mortality of eclampsia were collected from articles published in journals and from book of Abstract published during AICOG conferences from 1980 onwards, along with our own data from 1976 to 2014. Data were analyzed yearwise.

RESULTS

Reports published from 1976 to 2015 (January-February) reveal that incidence of eclampsia in India ranges from 0.179 to 5 %, the average being 1.5 %. In the period between 1980 and 1989, the average incidence was 0.92 % and the corresponding figure between 2002 and 2010 was 2.15 %, indicating that there is no reduction in incidence of eclampsia in India over the decades. Maternal mortality in 1982 was 14.12 %, and in 2010 it was 2.2-9 %. Maternal mortality has shown a receding tendency, while perinatal mortality is remaining still high as in 1984 it was 45 % and the corresponding figure in 2010 was 24.5-48 %.

CONCLUSION

Incidence of eclampsia in India is about 1.5 %. Detail analysis of data from 1980 to 2015 (January-February) shows that there is no reduction in incidence of eclampsia and perinatal mortality rate over the last few decades. Maternal mortality has shown a slight receding trend.

Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003

OBJECTIVE

To establish the risk of serious complications from severe pre-eclampsia and eclampsia in a region using a common guideline for the management of these conditions.

DESIGN

A five-year prospective study.

SETTING

Sixteen maternity units in Yorkshire.

POPULATION

All women managed with severe pre-eclampsia and eclampsia.

METHODS

A common guideline was developed for the management of women with these conditions. A network of midwives prospectively collected outcome data.

MAIN OUTCOME MEASURE

Incidence of the conditions and serious complication rates.

RESULTS

A total of 210,631 women delivered in the 16 units between 1 January 1999 and 31 December 2003. One thousand eighty-seven women were diagnosed with severe pre-eclampsia or eclampsia (5.2/1000). One hundred and fifty-one women had serious complications including 82 women (39/10,000) having eclamptic seizures and 49 women (23/10,000) requiring ICU admission. There were no maternal deaths but 54 out of 1145 babies died before discharge, giving a mortality rate of 47.2/1000. Of the 82 cases of eclampsia, 45 occurred antenatally (55%), 18 before admission to the maternity unit. Eleven cases occurred in labour (13%), including 1 during a caesarean section, and 26 cases occurred following delivery (32%). Twenty-five women developed pulmonary oedema (2.3% of cases) and six women required renal dialysis (0.55% of cases). One hundred and sixty-five (15%) required no antihypertensive therapy and 489 (53%) of the remainder required only oral therapy. Two hundred and one (18.5%) required more than one drug.

CONCLUSION

A regional guideline for severe pre-eclampsia and eclampsia can be developed and implemented. Its use may contribute to a low rate of serious complications.

The effects of tibolone

Tibolone is a non-bleeding form of hormone replacement therapy (HRT). When ingested, it is broken down into metabolites, of which the progestogenic metabolite predominates at the level of the endometrium, so that an atrophic endometrium is produced. For the postmenopausal woman, the availability of non-bleeding HRT has great appeal, and compliance is substantially improved. Other clinical situations in which tibolone is particularly useful include: women who have had hormone-dependent tumors in the past, women who have had endometriosis and women taking gonadotropin-releasing hormone agonists.

Eclampsia: is there a seasonal variation in incidence?

OBJECTIVE

To clarify whether seasonal variation of temperature and humidity has any effect on the incidence of eclampsia. Eclampsia is the second major cause of maternal mortality in Pakistan.

METHODS

Data was collected monthwise for the year 1996 from 4 large Govt. teaching hospitals of 4 provincial metropolis of Pakistan. Each province has diverse climate with considerable variation of air temperature and humidity.

RESULTS

There were 395 cases of eclampsia amongst 18,483 deliveries in 1996, giving an incidence of 2.14%. In Karachi (Sindh Province) with mild hot and humid climate and mild winter months, there was increase in eclampsia cases from April-July and in September. Otherwise the incidence remained stable. In Rawalpindi (Punjab Province) with moderately hot summer and cold winter, it was highest in hot season from May to September but was stable in winter. In Peshawar (N.W.F.P) and Quetta (Baluchistan Province) with more severe cold and dry winter the incidence peaked in winter and summer months both.

CONCLUSIONS

The pattern of eclampsia cases showed variations in extremes of temperature but it was stable in mild weather. However, the statistical analysis revealed non-significant relationship of incidence of eclampsia with temperature when analysed by linear regression analysis.

Eclampsia in Kuwait 1981-1993

The aim of this study is to investigate the maternal and fetal outcome and the risk factors for developing eclampsia in Kuwait. The study includes all patients with eclampsia observed at the Maternity Hospital, Kuwait during the period from 1981 to 1993. It revealed that the risk factors predisposing to eclampsia were primiparity, a maternal age below 30 years, multiple pregnancy and the presence of preeclampsia. The pregnancy outcome in terms of the stillbirth rate, neonatal death rate and low birth-weight babies was significantly higher in mothers with eclampsia than in noneclamptic mothers. The operative delivery and maternal mortality rates were also significantly higher in these patients.

Eclampsia in the United Kingdom

OBJECTIVES

To measure the incidence of eclampsia, establish how often it is preceded by signs of pre-eclampsia, document the morbidity associated with eclampsia, and determine the maternal case fatality rates.

DESIGN

A prospective, descriptive study of every case of eclampsia in the United Kingdom in 1992. Information was collected from reviews of hospital case notes and questionnaires to general practitioners.

SETTING

All 279 hospitals in the United Kingdom with a consultant obstetric unit.

RESULTS

Obstetricians and midwives notified 582 possible cases, and 383 were confirmed as eclampsia. The national incidence of eclampsia was 4.9/10,000 maternities (95% confidence interval 4.5 to 5.4). Most convulsions occurred despite antenatal care (70%) and within one week of the woman's last visit to a doctor or midwife (85%). Three quarters of first seizures occurred in hospital, of which 38% developed before both proteinuria and hypertension had been documented. Forty four per cent of cases occurred postpartum, more than a third (38%) antepartum, and the remainder (18%) intrapartum. Nearly one in 50 women (1.8%) died, and 35% of all women had at least one major complication. The rate of stillbirths and neonatal deaths was 22.2/1000 and 34.1/1000, respectively. Preterm eclampsia occurred more commonly antepartum and was associated with more maternal complications and fetuses that were small for gestational age, as well as with higher rates of stillbirth and neonatal mortality. Antepartum eclampsia, which was more likely to occur preterm, was associated with a higher rate of maternal complications and a higher neonatal mortality. Both factors (gestational prematurity and antepartum occurrence) contributed independently to the severity of the outcome.

CONCLUSION

Eclampsia occurs in nearly one in 2000 maternities in the United Kingdom and is associated with high maternal morbidity and fatality in cases. It may present unheralded by warning signs. Preterm and antenatal eclampsia seem to be particularly severe.

Management of severe pre-eclampsia and eclampsia by UK consultants

OBJECTIVE

To determine the current management of severe pre-eclampsia and eclampsia in the United Kingdom.

DESIGN

One-page postal survey to all (1007) UK consultant obstetricians with questions about use of antihypertensive and anticonvulsant drugs in severe pre-eclampsia and eclampsia, other management strategies, definition of factors determining severity, protocol development and regional review.

RESULTS

688 replies (69.6% response rate). The antihypertensive drugs used were mainly oral labetalol (35%), oral methyl dopa (23%) and parenteral hydralazine (29%); diuretics were not used. Diazepam was the preferred drug in eclampsia. Very few consultants used magnesium sulphate (2%). Anticonvulsants were also prescribed by 85% of consultants to prevent fits; the drugs then preferred were diazepam (41%), phenytoin (30%) and chlormethiazole (24%). Two-thirds of consultants felt there was a need for trials to study the effectiveness of antihypertensive and anticonvulsant drugs. In a woman with proteinuric hypertension, 15% of consultants did not regard the development of headache as indicating severe pre-eclampsia. Consistent management practices were not associated with agreement about protocols. Regional review does not appear to have occurred.

CONCLUSION

Antihypertensive and anticonvulsant therapies are widely used but trials are considered necessary. Improvements in the management of women with severe pre-eclampsia or eclampsia might occur if UK obstetricians sought more collective opinion and undertook regional audit of protocols.