Maternal and fetal outcome in eclampsia: caesarean vs vaginal delivery.
INTRODUCTION: Motherhood is long cherished desire of every woman, but enormous precious maternal lives are lost in the process. Improving maternal health is one of the eight Millennium Development goals adopted by the international community at the United Nations millennium summit in year 2000 and the target is to reduce MMR by 75% from 1990 to 2015. The MMR in developing countries is 450 maternal deaths per 1,00,000 live births vs 9 per 1,00,000 in developed countries (1).The word "ECLAMPSIA" is derived from the Greek term "ECLAMPION" used by Hippocrates. He described it as "fever of sudden onset". The word "Eclampsia" means "Flash or shining forth" and emphasizes the dramatic and frightening onset of convulsions in a pregnant or puerperal woman. It is an unpredictable, multisystem, life threatening emergency disorder and is unique to human pregnancy. (2,3) It is defined as the occurrence of generalised convulsions and or coma associated with preeclampsia during pregnancy, labour or within seven days of delivery and not caused by epilepsy or other convulsive disorders.
The incidence of eclampsia has often been viewed as an index of civilization in a country. The hospital incidence in India ranges from 1 in 500 to 1 in 30. In the US the incidence of eclampsia is about 1 in 3250 pregnancies (4) while in Europe eclampsia complicates approximately 1 in 2000 deliveries (5). The incidence of eclampsia is declining in the developed world due to adequate antenatal care and proper management of preeclampsia. However in the developing countries, the scourge of eclampsia continues and its incidence varies from 1 in 100 to 1 in 1700 in pregnancies (6,7) (8) Nulliparity, family history of preeclampsia, prior preeclampsia and eclampsia, poor outcome of previous pregnancies, pre-existing medical conditions like obesity, hypertension, renal diseases, gestational diabetes, SLE, teen pregnancies, patients older than 35 years, multifetal gestations, lower socioeconomic status (9). Increased incidence in molar pregnancies and hydrops fetalis is due to associated hyperplacentosis. It is more in cold weather due to vasoconstriction. Obesity is a definite risk for developing pregnancy induced hypertension including eclampsia (10).
Delivery of the fetus with elimination of placental and residual tissue is the only known definitive treatment. However there is controversy regarding the mode of delivery, whether vaginal or caesarean section. Some contend that, in eclampsia delivery should occur within 12 hours of onset of convulsions (11). Pritchard et al (12) has advocated delivery of the patient as soon as convulsions are controlled and the patient is conscious and definitely within 48 hours of the initial convulsion.
According to RCOG's guidelines on "Management of severe preeclampsia/eclampsia" Magnesium sulphate should be given to women with severe preeclampsia once a delivery decision is made and in immediate postpartum period. (13). As far as the baby is concerned perinatal mortality and morbidity is related to placental insufficiency and premature delivery.
Majority of maternal deaths occur in developing countries and most of these are preventable. Eclampsia is responsible for about 12% of all maternal global death and about 16-31 % of perinatal deaths (12,14,15,16) In India, maternal morbidity and mortality from eclampsia is very high, it ranges from 8-14 %. The perinatal mortality ranges from 14.6 to 47.4% because eclampsia still kills.
Eclampsia is an obstetric enigma. Though it has almost been eradicated from the developed world, it continues to be a major cause of maternal and fetal mortality and morbidity in the developing countries. The incidence of eclampsia can be decreased with better antenatal care, early recognition and treatment of severe preeclampsia. But there are minority of patients in whom eclampsia may not be preventable as it comes like a "Bolt from the blue". For these unfortunate patients and also ignorant patients, we can offer service by reducing both maternal and perinatal mortality due to eclampsia rather than prevention of eclampsia. The real challenge of eclampsia has not been met. In spite of considerable progress made in the field of obstetrics, the incidence of eclampsia and its consequent complications have not been significantly decreased in our country. However the management of eclampsia still poses a fascinating challenge to the obstetrician, requiring the greatest skill, judgment and patience. (17)
Faced with this reality, a plan of management has to be evolved. Though the exact pathophysiology leading to the occurrence of fits is still not understood, one thing has been proved beyond doubt that the termination of pregnancy removes the basic cause of the disease.
Keeping this view, an attempt had been made in the present study to ascertain if caesarean section has any distinct advantage over vaginal delivery in lowering maternal and perinatal deaths. (18) There is enormous scope for preventing death from eclampsia world wide--a suitable challenge for our generation.
AIMS AND OBJECTIVE:
i) To evaluate the maternal and foetal outcome in eclampsia; depending on its mode of termination whether caesarean or vaginal.
ii) To analyze the criteria used to decide the time and mode of termination of pregnancy.
iii) To evaluate which cases are clear cut indication of caesarean without giving induction of labour a trial.
PATIENTS AND METHODS: The study entitled "Maternal And Fetal Outcome in Eclampsia:
Caesarean Vs Vaginal Delivery" was done in M.K.C.G. Medical College & Hospital, Berhampur. The study period extended from October 2010 to August 2012.
The 210 patients were studied by dividing them into two groups for comparative analysis. The first group consisted of patients in whom conservative obstetric management and delivery per vaginum was carried out and was called the "V.D. group" and the second group consisted of patients in whom lower segment caesarean section was carried out due to eclampsia and varied associated complications of eclampsia, unfavourable cervix, failed induction and was called the "C.S. group".
OBSERVATIONS: The incidence of Eclampsia in MKCG medical college in the study period. Out of 10125 deliveries, there were 210 cases of Eclampsia giving an incidence of 2.07%. (Table-I)
Out of 210 cases of eclampsia 115 (54.76%) had vaginal delivery and 95 (45.24%) underwent caesarean section. Outlet forceps were applied in 10 (8.69%) patients and in 25 (21.73 %) patients ventouse application was done. 15 (15.79%) cases in the C.S. group were operated for antepartum eclampsia per se with uncontrolled convulsion, 68 (71.58%) patients underwent caesarean section due to unfavourable cervix at the time of admission, 2 (2.10%) cases were operated due to HELLP syndrome and 10 (10.53%) cases underwent C.S. due to failed induction (Table-II).
83 (87.36%) cases in the C.S. group were operated within 2 hours of admission, whereas the remaining 12 (12.64%) cases were operated beyond 2 hours of admission. 46 (40%) patients in the VD group delivered within 6 hrs of induction, 69 (60%) patients delivered after 6 hrs (Table-III).
Out of 115 women in the VD. group 79 had complications giving a maternal morbidity of 68.70%, out of 95 cases in the C.S. group, 16 had complications, giving a maternal morbidity of 16.84 %(Table-IV). Chi-square without Yates correction--Chi squared equals 56.465 with 1 degrees of freedom.
The two-tailed P value is less than 0.0001.
The association is considered to be extremely statistically significant
Complications like PPH, Abruption, Hepatic Failure, Pulmonary oedema etc occur more frequently in VD group than in CS group (Table-V).
Out of 115 women in the V.D. group, 24 died, giving a Maternal Mortality Rate of 20.86%. Out of 95 women in the C.S. group, 7 women died, giving a Maternal Mortality Rate of 7.37% (Table-VI). Common causes of maternal mortality are pulmonary oedema, hepatic failure, cerebro vascular accident, renal failure, cardiac arrest, sepsis, HELLP syndrome.
Chi-square without Yates correction
Chi squared equals 7.536 with 1 degrees of freedom.
The two-tailed P value equals 0.0060
The association between rows (groups) and columns (outcomes) is considered to be very statistically significant.
PERINATAL OUTCOME: 72 (62.06%) babies out of total deliveries in the VD group were born alive and 74 (76.28%) babies in the C.S. group were live borns. Stillbirths were 30 (25.86%) in the VD group and 8 (8.24%) in the C.S. group. Early neonatal deaths were seen in 10 (8.62%) babies out of total deliveries in the VD group and in 4 (4.12%) babies in the C.S. group. Corrected PMR in the VD group was 36.11% and 10.30% in the C.S. group (Table-VII).
[Chi square] = 15.785 DF = 2. The two-tailed P value equals 0.0004
By conventional criteria, this difference is considered to be extremely statistically significant 60 (83.33%) babies out of total live births in the VD group had Apgar score <7 at 1', whereas it was seen in 37 (50%) babies in the C.S. group. 52 (72.22%) babies out of total live births in the VD group required NICU admission, whereas 26 (35.13%) babies in the C.S. group were admitted to NICU (Table-VIII).
For Apgar score <7 at 1', Chi-square without Yates correction
Chi squared equals 18.185 with 1 degrees of freedom.
The two-tailed P value is less than 0.0001
The association between rows (groups) and columns (outcomes) is considered to be extremely statistically significant.
For NICU admission,
Chi-square without Yates correction .Chi squared equals 20.172 with 1 degrees of freedom.
The two-tailed P value is less than 0.0001
The association between rows (groups) and columns (outcomes) is considered to be extremely statistically significant
When caesarean was performed within 2 hours of admission in 83 cases, there were 2 (16.67%) perinatal deaths, but when it was done beyond 2 hrs in 12 cases there were 10 (83.33%) perinatal deaths (Table-IX).
Chi-square without Yates correction
Chi squared equals 62.212 with 1 degrees of freedom.
The two-tailed P value is less than 0.0001
The association is considered to be extremely statistically significant
When caesarean was performed within 2 hrs in 83 cases there were 18 (21.68%) NICU admissions, but it was done after 2 hrs in 12 cases there were 8 (66.66%) NICU admissions. (Table-X)
Chi-square without Yates correction
Chi squared equals 10.671 with 1 degrees of freedom.
The two-tailed P value equals 0.0011
The association between rows (groups) and columns (outcomes) is considered to be very statistically significant.
DISCUSSION: Eclampsia, a dreaded complication in pregnancy is still associated with a great deal of maternal and fetal loss. A couple of decades ago, the conventional treatment of eclampsia entailed a conservative approach with the use of sedative, tranquilizers, anticonvulsants and antihypertensives to be followed by induction or stimulation of labour after the fits are controlled. Caesarean section was considered to be an extremely risky procedure and reserved for highly selected cases (16).
But, now in the 21st century, with advancements in the field of anesthesiology and availability of blood, caesarean section in eclampsia is no more risky and promises reassuring maternal and perinatal outcome raising the vital question, whether a deviation from the conservative approach is worthwhile. Both early control and follow up of lab parameters and immediate delivery by LSCS if necessary may lead to reduction of maternal morbidity and mortality and to improvement of perinatal result (19). The main stay of management are integrated antenatal care, access to monitoring services, stabilization of maternal condition and delivery of baby in way to benefit both mother and Child. Antenatal care must provide easy access to monitoring services. The perinatal mortality rate for eclampsia in the series was relatively good for developing country, this may be due to early reason to LSCS.
CONCLUSION: "In antepartum eclampsia in women with unfavourable cervix on admission with expected fetal weight >1.5 kgs, an early decision for caesarean section either within 6 hours of admission or 12 hours of first fit whichever is earlier improves the fetomaternal outcome".
With advanced expert surgical and anaesthetic techniques in modern obstetrics, caesarean section is not unsafe as seen in previous years. Both maternal and perinatal outcome can be improved by taking an early decision for caesarean section when on admission cervix is unfavourable or delivery is not anticipated within 6 hours. In the severe antepartum eclamptic with a closed uneffaced cervix and unengaged presenting part, it might give better results if conservative treatment is supplemented by timely caesarean section instead of withholding it. As this study comprised mostly of young primigravidae, it was seen that most had unfavourable cervix and induction failure and moreover the duration of labour was more in comparison with multigravida patients. Therefore, from this study, caesarean section if done promptly leads to more favourable outcome than conservative obstetric management with vaginal delivery in eclampsia in primigravidae with unfavourable cervix on admission.
REFERENCES:
(1.) Maternal mortality in 2005 estimates developed by WHO, UNISEF, UNFPA and the World Bank. Geneva: World Health Organisation. 2007.
(2.) Salha O, Walker JJ Modern Management of eclampsia. Postgrad Medj 1999: 75-8.
(3.) Lu JF, Nightingle CH: Magnesium Sulphate in eclampsia and preeclampsia Clin pharma cokuiet 2000 Apr; 38 (4) 1: 305-14.
(4.) Ventura SJ, Martin JA, Curten SC et al. Births: Final date for 1998. National Vital Statistics Reports, Vol. 48, No 3, Hyattsville, Md, National Center for Health Statistics, 2000.
(5.) Douglas KA, Redman CWG. Eclampsia in the United Kingdom BMJ 1994; 309: 1395-1400.
(6.) World Health Organisation International Collaborative study of Hypertensive Disorder of pregnancy. Am J Obstet Gynecol 1958: 158:80-83.
(7.) Growther CA. Eclampsia at Harace Maternity Hospital An epidemiological study. Safr Med J, 1985; 68:927-929.
(8.) Bergstorm S. Poney G, Songane F, Ching C. Seasonal incidence of eclampsia and its relationship to meteorological data in Mozabrque: J Perinat Med, 1992; 20: 153-158.
(9.) Dr. Dema Abi-Satd, Am. j. Epidemiol. 1995, 142 (4): 437-441.
(10.) Martin JN, JR May WL, Rinchart BK, Martin RW, Magaan EF, Increasing maternal weight; a risk factor for preeclamsia but apparently set for HELLP syndrome. Southern Medical Journal 2000 93(7): 689-91
(11.) Mathi M, Sanghvi H, Guidotti Rj; major contributors. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. Geneva: Department of reproductive Health and Research, World Health Organisation; 2000: 543.
(12.) Pritchard JA, Cunningham FG, Pritchard SA, The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 case Am J obstet gynecol 1984: 148: 951- 63.
(13.) RCOG Guideline No. 10 (A). The Management of severe preeclampsia/Eclampsia. 2006.
(14.) Say L, Inove M, Mills S, Suzuki E. Maternal Mortality in 2005 estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organisation; 2007.
(15.) Which anbeoavulsant for woman with eclampsia? Evidence from the collaborative eclampsia treat (Erratum ch: Lancet 1995; 346: 258) Lancet 1995; 345: 1455- 63.
(16.) Igberase, GD, E Beigbe PN. Eclampsia: Ten year's experience in a rural tertiary hospital in the Niger delta, Nigeria. J obstet Gynecol 2006; 26:414-7.
(17.) Dutta DC. "Textbook of Obstetrics", 4th Ed., Calcutta, New Central Book Agency Pvt. Ltd.; 1998: 234-254 pp.
(18.) Williams Obstetrics, 22nd Ed., McGraw Hill Co. Inc., 2005: 761-808 pp.
(19.) Rath W Loos W, Kuuhrs W, Graef W. The important of early laboratory screening methods for maternal & fetal outcome in cases of HELLP syndrome. Eur-J Obstet- Gynaecol-Reprod Biol; July-Aug 1990.
Sudhanshu Sekhara Nanda [1], Bharati Mishra [2], Aishwarya Nupur [3], Subhalaxmi Dash [4]
AUTHORS:
[1.] Sudhanshu Sekhara Nanda
[2.] Bharati Mishra
[3.] Aishwarya Nupur
[4.] Subhalaxmi Dash
PARTICULARS OF CONTRIBUTORS:
[1.] Senior Resident, Department of Obstetrics & Gynaecology, M.K.C.G. Medical College, Berhampur, Ganjam, Odisha, India.
[2.] Professor and HOD, Department of Obstetrics & Gynaecology, M.K.C.G. Medical College, Berhampur, Ganjam, Odisha, India.
[3.] Post Graduate, Department of Obstetrics & Gynaecology, M.K.C.G. Medical College, Berhampur, Ganjam, Odisha, India.
[4.] Senior Resident, Department of Obstetrics & Gynaecology, M.K.C.G. Medical College, Berhampur, Ganjam, Odisha, India.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Sudhanshu Sekhara Nanda, Senior Resident (Dept. of Obst. & Gyn.), M.K.C.G. Medical College, Berhampur, Ganjam, Odisha, India--760004. Email-sudhansu81@gmail.com
Date of Submission: 28/08/2013.
Date of Peer Review: 29/08/2013.
Date of Acceptance: 04/09/2013.
Date of Publishing: 10/09/2013.
Table 1: Incidence of Eclampsia
No of deliveries in No of cases of Percentage
study period eclampsia
10125 210 2.07%
Table 2: Distribution of Eclampsia according to mode
of Delivery and Indications of Caesarean Section
Route of No. of cases Percentage
delivery
Vaginal NVD 80
Forceps application 10 115 54.76
Ventouse application 25
Caesarean Failed induction 10
section Unfavourable cervix 68 95 45.23
Uncontrolled convulsion 15
HELLP syndrome 02
Table 3: Incidence of Caesarean Section according to the time when
LSCS was performed after admission and Induction Delivery Interval
Time when LSCS was CS VD
performed (hours)/
Induction delivery
interval(hours)
No. of Percentage No. of Percentage
Cases Cases
0-2 83 87.36 00 00
2-6 12 12.63 46 40
6-12 00 00 51 44.35
12-18 00 00 14 12.17
18-24 00 00 03 2.60
>24 00 00 01 0.87
Table 4: Maternal Morbidity
Mode of Total No. of No. of Maternal Percentage of
Delivery Cases Morbidity Maternal Morbidity
VD 115 79 68.70
CS 95 16 16.84
'P' Value <0.0001
Table 5: Maternal Complications
Complications VD (n=79) CS (n=16)
No. of Percentage No. of Percentage
Cases Cases
PPH 8 10.12 1 6.25
Abruptio placentae 8 10.12 1 6.25
DIC 1 1.27 0 0.00
Hepatic failure 6 7.60 1 6.25
Renal failure 4 5.06 1 6.25
Pulmonary oedema 16 20.25 5 31.25
Transient 7 8.86 1 6.25
blindness
Electrolyte 10 12.65 1 6.25
imbalance
Retained placenta 6 7.60 0 0.00
Psychosis 4 5.06 1 6.25
Cerebral 2 2.53 1 6.25
hemorrhage
Cerebral 1 1.26 0 0.00
infarction
Cerebral oedema 6 7.60 1 6.25
HELLP Syndrome 0 0.00 2 12.50
Table 6: Maternal Mortality
Mode of Total No. No. of Maternal Maternal Mortality
Delivery of Cases Death Rate
VD 115 24 20.86
CS 95 07 7.37
'P' Value 0.0060
Table 7: Perinatal Mortality
VD CS
Perinatal No. of Percentage No. of Percentage
Mortality Cases (n=116) Cases (n=97)
Live births 72 62.06 74 76.28
Still 30 25.86 8 8.24
births
Early 10 8.62 4 4.12
neonatal
deaths
IUDS on 14 12.06 2 2.06
admission
Corrected 26/72*100 36.11 10/97*100 10.30
PMR
'P' Value 0.0004
Table 8: Perinatal Morbidity
Perinatal VD CS
Outcome
No. of Percentage No. of Percentage P Value
Cases Cases
(n=72) (n=74)
Apgar score 60 83.33 37 50.00 <0.0001
<7 at 1'
Need for 52 72.22 26 35.13 <0.0001
NICU
admission
Table 9: Relation of PNM to CS Done in
Early & Late period after admission
Time period after PNM Percentage
admission (hours)
Early 0-2 2 16.67
Late >2 10 83.33
'P' Value <0.0001
Table 10: Incidence of NICU admission in relation to
CS done in early & late period after admission
Time period after admission Total No. NICU Percentage
(Hrs.) of Cases Admission
Early 0-2 83 18 21.68
>2 12 8 66.66
'P' Value 0.0011
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| Title Annotation: | ORIGINAL ARTICLE |
|---|---|
| Author: | Nanda, Sudhanshu Sekhara; Mishra, Bharati; Nupur, Aishwarya; Dash, Subhalaxmi |
| Publication: | Journal of Evolution of Medical and Dental Sciences |
| Article Type: | Report |
| Date: | Sep 16, 2013 |
| Words: | 3241 |
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