Medico-Social Characteristics of Patients with eclampsia in a metropolitan hospital in North western Nigeria: Is there a changing pattern?

Background: Eclampsia is a recognized cause of maternal and neonatal morbidity and mortality in North western Nigeria. It’s a preventable obstetrics calamity were adequate antenatal care services are provided. Objective: To review medico-social characteristics of patients with eclampsia at a metropolitan Specialist Hospital in North-western Nigeria, Methodology: Eighty consecutive patients that presented with eclampsia at Murtala Mohammed Specialist Hospital were recruited for the study from 1st December, 2016 to 28th February, 2017. Data were collected using structured questionnaire, administered by research assistants. Information obtained included sociodemographic data, duration of fits before presentation and maternal-fetal outcome. Results: A total of 1931 patients delivered within the study period, among them 80 had eclampsia. This gives an incidence of 4.0%. Teenage pregnancy accounted for 35%. Forty-nine patients (61.2%) were primigravidae and up to 95% were booked. Majority of the patients 40(50%) had antepartum eclampsia while only 10(12.5%) had postpartum eclampsia. Most of the patients (73.8%) presented within 12 hours of convulsions and (87%) had vaginal delivery. There were 3 maternal deaths with case fatality rate of 3.8%. Live birth was achieved in 65%. Fresh still birth and Macerated still births were recorded in 20% and 12.5% respectively. Conclusion: The incidence of eclampsia is still high despite introduction of free maternity care services. Socio medical factors and poor quality of Antenatal Care services may be the contributing factors to development of eclampsia. There is need to review and improve the quality of antenatal care services offered at the primary health care centers.


Introduction
Eclampsia is a disease that continues to be of significant concern, and is defined as new onset of grand mal seizure activity and/or unexplained coma during pregnancy or postpartum in a woman with eclampsia.Symptoms of eclampsia have been described since the time of Hippocrates.Varandeous coined the term 7 eclampsia in 1619.The two cardinal features of the disease: hypertension and proteinuria, were noted in mid to late 19th century (hypertension) and the early 8 20th century (proteinuria).Delivery was further identified as the key feature of management in the 20th century.Notwithstanding the extensive literature and progress in our understanding, these facts still remain the basis of our management of 9 preeclampsia and eclampsia.It is a multi-systemic disease and has been found occasionally to occur in the absence of hypertension or proteinuria which are 10 the cardinal features of pre-eclampsia.The staggering figure of maternal mortality reported in 2004 by Society of Gynaecologists and Obstetricians of Nigeria moved the Kano state government to initiate programs that will reduce maternal mortality in the state.Among these programs were expanding the ongoing free maternity services to include free Magnesium Sulphate for eclamptic patients and intensive manpower recruitment posted to man strategic hospitals in the state in order to reduce the delays in reaching the Specialist Hospital.At the time of writing this article, we are not aware of any official assessment to look at the implementation and outcome of such intervensions.We wish to share our u n u s u a l f i n d i n g s o f t h e m e d i c o -s o c i a l characteristics of the patients studied so as to give a guide in controlling this menace.

Methodology:
The is a prospective cross sectional study, in which eighty consecutive eclamptic patients that presented to MMSH were recruited for st the study from 1 December 2016 to 28th February, 2017.Ethical clearance for the study was obtained from the state hospital management board.Data were collected using structured questionnaire, administered by research assistants.Information obtained included sociodemographic variables, duration of fits before presentation and maternalfetal outcome.The results were expressed in frequencies and percentages and summarized using mean and standard deviation.education and 95% were booked.Majority of the cases (55.8%) had antepartum eclampsia, 35.4% had intrapartum eclampsia while only 8.8% had postpartum eclampsia.Most of the patients (73.8%) presented within 12 hours of convulsions, while 13(16.2%)presented after 24 hours.Only 5 (6.25%) had twins.Majority (87%) had vaginal delivery while 13% had Caesarean section.Up to 60% were induced using Misoprostol while 27% had spontaneous vaginal delivery (SVD).There were three maternal deaths with case fatality rate of 3.8%.

A
Live birth was achieved in 65%.Fresh still birth and Macerated still births were recorded in 20% and 12.5% respectively.

Discussion
Eclampsia is one of the most dangerous conditions in which those caring for pregnant woman and her fetus must deal with especially since its onset can be dramatic, abrupt and in many women without any 11 warning.
The incidence of 4% is similar to the finding at the 12 same hospital 6 years earlier.This suggest that there is no significant decrease in the incidence of eclampsia despite the state government efforts towards curtailing maternal mortality program.The incident is lower than that obtain in a rural tertiary 13 hospital of 9% in the same geographical region.
There is no significant change in the pattern of age and parity distribution.The finding of almost 50% of the patients with at least secondary education and 95% of the eclamptic patients have booked for ANC are figures that are much higher than previously 12 reported.However, most of these patients had their antenatal care at primary health centers.It is common knowledge that most of these centers lack basic facilities such as sphygmomanometer for measuring blood pressure making it easy for 14 preeclampsia to go undetected .Antepartum eclampsia was the commonest type of eclampsia identified in this study.Several Nigerian studies 12,15, 16 17 have reported similar findings.Akinola et al however reported intrapartum eclampsia to be the predominant type of eclampsia among their patients.Delay in presentation (more than 24 hours following onset of convulsions) was observed in 16% of the patients in this study.This is higher than  Most of the patients in this study were induced with Misoprostol while awaiting surgery many of whom progressed satisfactorily leading to spontaneous vaginal delivery.Those that were fully dilated at presentation had the third stage of labour shortened using either forceps or vacuum (assisted delivery).These reasons may explain the lower caesarean section rated observed in this study.The case fatality rate of 3.8% found in this study is lower than the 12 fatality rates observed by Yakasai et al, Olatunji et 19 18 al and Tukur et al , among their patients.All the patients with eclampsia recruited for this study were given magnesium sulphate as part of their treatment.This may have contributed to the lower fatality rate demonstrated in this study.In addition, the sample size employed in this study is smaller than in the studies quoted.

Conclusion
The incidence of eclampsia is still high despite introduction of free maternity care services.Poor quality of ANC at primary health care centers may be the contributing factors to development of eclampsia.There is need to review and improve the quality of antenatal care services offered at the primary health care centers.

Figure 1 :Figure 2 :
Figure 1: Booking status of the eclamptic patients

12 the 8 .
2% reported by Yakasai et al , but lower than 18 the 56% observed by Tukur et al.Only 13% of the patients in this study required caesarean section.This figure is much lower than the rates reported in 12,15,17,18 many Nigerian studies.

Figure 3 :
Figure 3: Mode of delivery of the eclamptic patients

Social Characteristics of Patients with eclampsia...
total of 1931 patients delivered within the study period, among them 80 had eclampsia.The incidence of elampsia from this study is 4.0%.The age of the patients ranges from 16-49 years with a mean age of 23 and SD of 7.4 years.

Table 1 :
Age and parity of the eclamptic patients www.ibommedicaljournal.

Table 2 :
Educational attainment of the eclamptic patients