|Year : 2015 | Volume
| Issue : 1 | Page : 12-15
Perinatal outcome in eclampsia
Victor Khuman, Ranjit L Singh, Rameswor M Singh, Usharani Akoijam Devi, Thangkhoijam Kom
Department of Obstetrics and Gynaecology, Regional Institute of Medical Sciences, Manipur University First Gate, Canchipur, Imphal, Manipur, India
|Date of Web Publication||17-Jun-2015|
Dr. Victor Khuman
Department of Obstetrics and Gynaecology, Regional Institute of Medical Sciences, Manipur University First Gate, Canchipur, Imphal - 795 003, Manipur
Source of Support: None, Conflict of Interest: None
Introduction: Eclampsia is a major cause for perinatal morbidity and mortality worldwide and perinatal outcome is much worse in developing countries even today. The reasons are multi-fold and may be because eclampsia is poorly managed and not up to the prescribed standards as in industrialized countries. Also prematurity usually iatrogenic one is a major cause for high perinatal morbidity and mortality in eclampsia due to non-availability and of neonatal intensive care unit (NICU) facilities. Materials and Methods: All eclampsia patients admitted to the antenatal ward in JIPMER from October 2009 to May 2011 were followedup. The pregnancy outcome was duly recorded and analyzed. Results: Majority of the patients were unbooked, young and primigravida. Majority (65%) of women required labor induction in one or more forms. In the study 20% of cases required cesarean section for delivery. Sixty percent of the cases were preterm deliveries and 44% required NICU admissions. There were 52 (17.2%) stillbirths. There were a total of 16 neonatal deaths; mostly due to prematurity (62.5%). The perinatal mortality rate is 231 per 1000 births. Hundred babies had birth weights <1.5kg; and 212 babies less than 2.5 kg. Average birth weight was 1.825kg, which is much lesser than the institutional Average birth weight. of 2.88 kg during the same period. Prematurity was the most common cause for NICU admissions as well as neonatal deaths. Conclusions: Majority (65%) of the cases required induction of labor and only 23% went into spontaneous labor. Twenty percent of eclamptic women required cesarean delivery. Major indication for caesarean section as anticipated was fetal distress. Most common cause for neonatal death was prematurity and its attendant complications.
Keywords: Eclampsia, Neonatal deaths, Perinatal morbidity, Prematurity
|How to cite this article:|
Khuman V, Singh RL, Singh RM, Devi UA, Kom T. Perinatal outcome in eclampsia. J Med Soc 2015;29:12-5
| Introduction|| |
Hypertension complicates 10% of all pregnancies, and the incidence of preeclampsia is 2-8%. Eclampsia is observed in about 1/2000 deliveries in rich countries whereas in poor countries, estimates vary from 1/100 to 1/1700.  The first step in management of eclampsia is supportive care to prevent maternal injury. Next step is to prevent recurrent convulsions (the universally accepted drug of choice being MgSO 4 ), following which due attention must be given to control high blood pressure. Eclampsia cause severe maternal and perinatal complications. The definitive treatment for eclampsia is understood to be termination of pregnancy. Even though a certain percentage of these women do come with spontaneous labour, majority require some form of labor induction. Labor must be induced once patient is initiated on MgSO4 therapy. In absence of any obstetric contraindication induction of labor should be done. But cesarean delivery is essential if the subject develops status eclampticus or blood pressure remains uncontrolled. Most women with hypertension develop eclampsia before term. These women therefore are usually not in labor and require induction. Also many a times cervical ripening is essential as cervix is unfavorable for induction. , Eclampsia is by itself not an indication for cesarean. Cesarean becomes necessary during the course of labor for maternal and foetal causes like fetal distress, abruption, failed induction, uncontrolled seizures etc. B. M. Sibai considers it best to perform cesarean routinely for women less than 30 weeks of gestation and bishops score less than 5  It is ideal to cut short second stage during vaginal birth and also incidence of fetal distress being higher, operative vaginal delivery is more frequent. ,
Perinatal outcome is much poorer compared to general population. The common perinatal complications associated with eclampsia include:-intrauterine death, intrapartum death, neonatal death, neonatal seizures, prematurity, IUGR, sepsis etc. Neonatal deaths are most commonly due to prematurity, abruption, IUGR etc.
| Materials and Methods|| |
All consecutive eclampsia patients admitted to the inpatient Department of Obstetrics and Gynecology, Jawaharlal Institute of Post graduate Medical Education and Research (JIPMER), Puducherry from October 2009 to May 2011 were included in the study. During this period a total of 303 pregnant women were admitted with eclampsia.
A thorough history and examination of each patient was performed. essential investigations pertaining to eclampsia were done. Pregnancy was terminated in all antenatal patients. Women with antepartum eclampsia were induced once they were conscious and initiated on MgSO 4 therapy (standard Pritchard's regimen or the low dose Dhaka regimen were used). The mode of induction was decided as per departmental protocol. The methods used for induction included-PGE2, EAE, EAP, ARM, EASI, oxytocin infusion etc. The labor duration and progress of labor were duly monitored and recorded. Women with intrapartum eclampsia were started on MgSO 4 therapy if not already initiated. Labor was monitored and augmented as required. Women requiring cesarean delivery and the indications thereof were duly recorded.
Condition of the baby at birth, birth weight, apgar score at 1 and 5 minutes were also recorded. NICU admissions and the relevant causes for admission were documented. Early neonatal deaths that occurred during the hospital stay were also recorded and the causes documented. Outcome for babies born to women with postpartum eclampsia delivered in other institute or at home were also enquired into and duly recorded.
The main outcome measures were perinatal morbidity and mortality and represented as proportions and percentages.
| Results|| |
Of the total 303 women with eclampsia, 252 (83.16%) cases were antepartum eclampsia; 21 (6.9%) cases were intrapartum eclampsia; and 29 (9.57%) cases were postpartum eclampsia.
Amongst the women with antepartumeclampia, 58 cases had spontaneous onset of labor, of these 4 had cesarean delivery due to fetal distress. Six of these patients delivered vaginally without labor augmentation. Others required ARM or oxytocin for augmentation of labour. Fifty out of 252 cases of APE were delivered by cesarean section. Ten patients were given expectant management as their clinical condition was stable, with normal laboratory findings. These patients were induced after 34 weeks of gestation. One patient went off against medical advice after expelling abortus at 20 weeks. All women with intrapartum eclampsia delivered vaginally [Table 1].
Extra-amniotic ethacridine (EAE) was instilled in 21 patients and extra-amniotic prostadin (EAP) in 4 patients. EASI (extra-amniotic saline infusion) was given in three patients. Mean induction delivery interval was 19.34 hours. The minimum duration of admission to delivery interval was 20 minutes and the maximum was 86 hours. If these exceptionally long durations (more than 48hours) are not included in calculation, the mean duration is 16.6 hours. Cesarean delivery had to be performed for 50 cases of the 252 cases of antepartum eclampsia. All the patients with intrapartum eclampsia delivered vaginally. The indications for these caesarean deliveries are as shown in [Table 2]. As anticipated the most common indication was fetal distress.
Ninety five patients (31.4%) were gestations of more than 37 weeks. Twenty eight (9.2%) women were not sure of their dates. Twenty women (6.6%) were at less than 28 weeks of gestation at presentation.
There were 250 live births (82.78%), 52 (17.2%) stillbirths. There were a total of 16 neonatal deaths; mostly due to prematurity (62.5%). Forty four percent (134) of the babies were admitted in the nursery. Perinatal outcome is shown in [Table 3].
The perinatal mortality rate is 231 per 1000 births.
Hundred babies had birthweights: <1.5 kg; and 212 babies weighing less than 2.5 kg.
Average birthweight was 1.825 kg, which is much lesser than the institutional Average Birthweight. of 2.88 kg over the same duration.
[Table 4] shows the causes for NICU admissions. Prematurity (55%) and respiratory distress syndrome (25%) were the major causes. Causes for neonatal deaths are shown in [Table 5].
| Discussion|| |
Majority of the patients required some form of induction and cesarean section was done in 20%. The rate of cesarean in the study is much higher than 6% as reported by R. N. Janelle  but considerably much lower than 79% as quoted by Lee et al.  and 85% as quoted by Agida et al.  This wide variation might be due to the varied institutional protocols regarding decision for induction, operative vaginal deliveries and caesarean-section. Vaginal delivery was achieved in 60% of the cases, out of which 11% required assistance in form of either ventouse or forceps. Caesarean delivery had to be performed for 50 cases of the 252 cases of antepartum-eclampsia. As anticipated the most common indication was foetal distress. All the patients with intrapartum eclampsia delivered vaginally. In the report by R. N. Janelle in Pakistan spontaneous vaginal delivery was accomplished in 60.5% and 30% required vaginal delivery with assistance. Hence their study reported only 6% cases requiring caesarean. And mentioned earlier, this may simply be reflecting the different protocols adopted for intrapartum management of eclampsia, according to the facilities and skills available. [Table 6] shows the modes of delivery in various studies.
|Table 6: Comparison of modes of delivery in eclampsia patients in various studies|
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Majority were nulliparous (72.6%) and in the age group less than 25 years (83.84%). Fifty four percent of eclampsia cases occurred in women at 36 weeks of gestation or lesser. These findings are in agreement to those of Swain and colleagues  - eclampsia is more common in women below 20 years and at 36 weeks or below.
There were 250 live births (82.78%), 43 (14.2%) stillbirths and 9 (3%) IUDs. There were a total of 16 neonatal deaths; mostly due to prematurity (62.5%). Forty four percent (134) of the babies were admitted in the nursery. The following table demonstrates the perinatal outcome in various studies [Table 7].
The rate of severe perinatal complications requiring NICU admissions was 44.2%, as compared to 56% quoted by Lee et al.  Prematurity (55%) and respiratory distress (25%) were the major causes for NICU admissions. Thus prematurity was commonest cause for severe complications requiring NICU admission. The most common cause for neonatal death was again prematurity and its attendant complications (62.5%). Other studies also concluded prematurity as the most common cause for perinatal mortality and morbidity. ,, The perinatal mortality rate is 231 per 1000 births. Other studies in India and Pakistan reported comparable perinatal mortality rates (331/1000; 386/100;416/1000 ). ,,
Amongst the women with eclampsia, 100 patients delivered babies with birthweights <1.5 kg and 212 with birthweights <2.5 kg. Thus the average birthweight was 1.825 kg which is much lower than the overall average of 2.88 kg over the same duration. The following table compares the birthweights of babies born to eclamptic mothers in two studies. It illustrates that low birth weight is common amongst babies born to eclamptic women [Table 8].
| Conclusion|| |
Majority of the patients were unbooked and young and primigravida.
Majority of the cases (65%) required induction of labor and 23% went into spontaneous labor. 28 patients had to be taken up directly for caesarean without any induction.
Twenty percent of eclamptic women required cesarean delivery.
Major indication for cesarean section as anticipated was fetal distress.
Most common cause for neonatal death was prematurity and its attendant complications.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]