Eclampsia : are we doing enough ?

Objectives - This paper reviews the cases ofeclampsia managed at the Kandang Kerbau Hospital with respect to incidence, management, maternal and perinatal outcome. Method - A retrospective analysis of eclampsia occurring over a 4-year period from January 1990 to December 1993. Results - There were 27 cases of eclampsia among 59,599 deliveries during the study period, giving an overall incidence of 45.3 per 100,000 deliveries. Sixteen patients were nulliparous and the mean age was 29 years. Two-thirds of the cohort were booked patients and more than half of the cohort (55.6%) had their first seizure despite being in hospital. The majority (86.2%) of all seizures recorded occurred in the antepartum and intrapartum period. Eleven of the patients (40.7%) were asymptomatic prior to the first fit while headache was the commonest symptom of impending eclampsia in the remainder. Fifteen patients (55.6%) had significant proteinuria and this was associated with significant neonatal morbidity. The mean gestational age was 35.9 weeks and the mean birth weight was 2,328g. Major areas of substandard management included failure to administer anticonvulsant prophylaxis and antihypertensive agents when indicated, failure to assess for proteinuria, and failure to closely monitor the hypertensive and protein uric patient. Seven patients developed convulsions despite anticonvulsant prophylaxis. Twenty-four patients were delivered by Caesarean section. There were 26 live born infants (singletons) and one abortus. There was no perinatal mortality. Neonatal morbidity was frequent and attributable to prematurity (51.9%) and birth asphyxia (29.6%). The majority of infants were well neurologically on long term follow-up. There was no maternal mortality but significant morbidity was present in 8 patients (29.6%). High uric acid levels were associated with intrauterine death, prematurity and intrauterine growth retardation. Seven patients remained hypertensive on follow-up. Residual neurological deficits persisted in 3 patients. Conclusions - The incidence of eclampsia at Kandang Kerbau Hospital shows an unsteady decline over the past 4 years. It carries significant foetal mortality (3.7%) as well as neonatal (74.1%) and maternal (29.6%) morbidity. The observation that neither the occurrence of antenatal office visits nor hospitalisation prevents eclampsia, and that substandard management was identified in most of the cases (77.8%) shows that there is no room for complacency and that more needs to be done. Improvement in patient assessment, institution of appropriate preventive therapy, a high index of suspicion even in apparently low-risk patients coupled with a disease notification system and regular audit may be the key strategies to reduce the incidence of this dreaded obstetric complication.