European Journal of Cardiovascular Medicine

The most common significant health concern during pregnancy is hypertension, which remains a vital factor in both maternal and fetal morbidity and mortality. Preeclampsia is a pregnancy-related hypertensive disorder that occurs after twenty weeks of gestation and involves multiple systems. Among healthy nulliparous women, the occurrence of preeclampsia varies from 2% to 7%. Hypertensive conditions during pregnancy are responsible for nearly 18% of all maternal fatalities worldwide. ¹

Preeclampsia is designated as severe when there is significant gestational hypertension along with severe proteinuria (a minimum of 5g in a 24-hour urine collection). It is also classified as severe if there are signs of multi-organ involvement, such as pulmonary edema, reduced urine output, seizures, low platelet count, elevated liver enzymes with pain in the upper right abdomen, or ongoing central nervous system symptoms like headaches, altered mental status, blurred vision, or blindness. Eclampsia, a term meaning "shining froth" in Greek, is a serious and potentially life-threatening hypertensive disorder of pregnancy, usually affecting women diagnosed with pre-eclampsia. This condition is marked by the occurrence of tonic-clonic seizures or coma during the latter half of pregnancy and is not connected to other conditions such as epilepsy or pre-existing brain disorders. ²

Preeclampsia stands as one of the most prevalent hypertensive disorders during pregnancy, leading to more than 50,000 maternal deaths and over 500,000 fetal fatalities worldwide. The rate of preeclampsia is reportedly seven times higher in developing nations like India compared to the global average. In India, hypertensive disorders rank as the third leading cause of maternal mortality. ³

Preeclampsia is characterized as a condition marked by high blood pressure (systolic blood pressure >140 mm Hg or diastolic blood pressure >90 mm Hg or both) and either the presence of protein in the urine or, in the absence of proteinuria, the emergence of new hypertension accompanied by any of the following: low platelet count, kidney dysfunction, liver impairment, pulmonary edema, or unexplained headaches, typically occurring at or after the 20th week of pregnancy.

Preeclampsia is a complicated condition, and its precise cause is not fully understood. It is currently thought that the invasion of trophoblast cells and the remodeling of uterine spiral arteries during the development of the placenta play significant roles in the onset of preeclampsia. ³ Factors that increase the likelihood of developing preeclampsia include being a first-time mother, carrying multiple fetuses, obesity, a family history of preeclampsia or eclampsia, having experienced preeclampsia in a previous pregnancy, being over the age of 40, abnormal results from uterine Doppler studies at 18 and 24 weeks, pre-existing diabetes mellitus, presence of a blood-clotting disorder, hypertension or kidney disease, tobacco use during pregnancy, and certain genetic predispositions.

Preeclampsia is a disorder that affects multiple systems and can result in several complications. Severe cases of preeclampsia carry an elevated risk of maternal mortality (0.2%) and morbidity (5%). Potential complications include eclampsia, pulmonary edema, ARDS (adult respiratory distress syndrome), acute renal or liver failure, liver hemorrhage, DIC (disseminated intravascular coagulopathy), HELLP syndrome, and stroke. These complications are more likely to occur in women who experience preeclampsia before reaching 32 weeks of gestation and in those with preexisting health issues. Fetal complications primarily arise from uteroplacental insufficiency, which can lead to IUGR (intrauterine growth restriction), stillbirth, low birth weight infants, IUFD (intrauterine fetal death), and prematurity.

The definitive treatment for severe preeclampsia and eclampsia is delivery, as the condition can lead to deterioration in both maternal and fetal health. Adequate obstetric care is crucial for effective management; any unnecessary delay in delivering the fetus and placenta can negatively impact outcomes for both mother and baby. Therefore, opting for an abdominal delivery when vaginal birth is not likely can enhance maternal and fetal outcomes. The rise in cesarean deliveries correlates with an increase in labor inductions. ¹ This study primarily focuses on maternal and perinatal outcomes in cases of severe preeclampsia and eclampsia while also documenting the prevalence of this condition along with key risk factors such as obesity, parity, and the severity of preeclampsia.

OBJECTIVES:

1) To study maternal outcome in severe pre- eclampsia & eclampsia.

2) To study perinatal outcome in severe pre- eclampsia & eclampsia.

3) To enumerate variable factors associated with maternal and perinatal morbidity and mortality.

Study Design:  Prospective Observational Study.

Study area: Department of Obstetrics & Gynecology, GGH, GMC, KADAPA.

Study Period: 1 year. (March 2023 – April 2024)

Study population: 100 Pregnant women admitted with severe PE and eclampsia.  

Sample size: Study consisted a total of 100 subjects.

Sampling Technique:  Convenience Sampling technique.

Inclusion Criteria:  

1) Gestational age: >20 weeks to 40 weeks

2) Diastolic BP: >90 mmH

3) Proteinuria: >3+ With any of the following

 Persistent headache

 Blurred vision

 Eclampsia

 Elevated liver enzymes

 Low platelets

 Abruptio placenta

 Oligohydramnios

 IUGR

Exclusion criteria:

1) Gestational age: < 20 weeks and > 40 weeks

2) Pre-existing chronic renal and hepatic disease

3) Idiopathic hemolytic anemia

4) Idiopathic thrombocytopenic purpura.

5) Epilepsy

6) Psychiatric disorder

7) Other medical disorders

Ethical consideration:  Ethical clearance was obtained from Government Medical College Kadapa, with the project number 29/2022.

Study tools and Data collection procedure:

After obtaining ethical clearance from institutional ethics committee, data was collected from the pregnant women admitted in the Antenatal ward with > twenty weeks of pregnancy with systolic BP >140 mmHg & diastolic >90mmHg in two separate readings taken 6 hrs apart. Pregnant women fulfilling the inclusion criteria to be explained about the purpose and procedure of study and after taking her written informed consent patients were assessed by taking demographic, medical, obstetric and family history from the pregnant women or her attendant who was appropriate. General physical examination, systemic, abdominal and pelvic examination were carried out. Investigations like Complete blood count with absolute platelet count, Liver function test, Renal function test, coagulation profile and fundoscopy and complete urine examination were performed for the patients. After stabilization of patient ultrasound was done at the time of admission.

The outcome of each pregnancy was obtained by examination of the patient in the labour ward and NICU. Obstetric management was carried out as per department protocol. Corticosteroids were administered if GA was < 34 weeks. The decision regarding time and delivery mode were individualized. Eclamptic patients were given MgSo4 by Pritchard’s regimen, anti-hypertensives drugs were, methyldopa, nifedipine& labetalol were given singly or in combination. Obstetric management was done as per the unit protocol and patients were delivered either by vaginal route or by LSCS. Neonatal care was given by paediatrician after the delivery. Patients with uncontrolled HTN were managed in cooperation with physician and anaesthetist. All mothers were followed for any change in BP and to look for any other complications of eclampsia for up to 6 weeks. All babies were followed during early neonatal period for any complications. Maternal & perinatal complications were noted.

Data analysis:

       All the data collected was entered and analysed in MS EXCEL 2019 and epinifo version 7.2.6.0 software. Data collected was subjected to descriptive analysis with frequencies and percentages. Association between risk factors and maternal & perinatal outcome was analysed by chi square test

Out of 100 cases studied, 9 % belonged to the age group of less than 20 years and 83 % belonged to the age group of 20 – 28 years,8% belonged to the age between 29 - 38 years. In our study 47 members were primi gravida and 53 members were multi gravida. Out of 100 cases, 65 members were with the gestational age of <37 weeks and 35 members were with the gestational age of >37 weeks.

Majority (90%) of cases were booked and only 10 % of cases were un booked. In this study 78% of cases had a BMI of less than 25 and 22 % of cases had a BMI of more than 25. In our study 70% of cases had mild hypertension and 30 % of cases had Severe hypertension. In our study 67% cases were given labetolol, 8% cases were given nifedipine, 19 % cases were given both labetolol and nifedipine and 6% of cases were not given any anti HTN drugs.

In this study 22% of cases had no proteinuria, 25 % of cases had trace amounts of protein in urine, 40% of cases had 1+ protein in urine, 11% had 2+ protein in urine, 2% had 3+ protein in urine. Out of 100 cases, 17% and 30 % of cases had increased renal function tests and liver function tests respectively. 70% and 83% of cases had normal LFT and renal function tests respectively.

Table 1: Distribution of cases according to occurrence of eclampsia

In this study out of 100 cases, 8%, 3%, 4% of cases were antepartum, intrapartum, postpartum eclampsia respectively.

Table 2: Distribution of cases according to maternal complications

Out of 100 cases studied, 15% of cases had abruption, 15% had HELLP syndrome, 10% had cortical vein thrombosis.

In our study 9% of cases developed renal failure, 11% developed pulmonary edema, 2 patients died who had severe pre-eclampsia.  In our study, 52% delivered vaginally, 48% of the cases delivered by LSCS. Out of 48% who had LSCS, 33% of the cases were maternal indication and 15% were fetal indication.

APGAR score of new born at 1 minute, 7% had a score between 0 to 3, 35% had a score between 3 to 5 and 58% of the newborn had an APGAR score of more than 6. In this study 33% of the newborn were less than 2.5 kgs and 67% were more than 2.5 kgs.  

Table 3: Distribution of newborn according to perinatal outcome

In our study 48% of newborn had admitted in NICU, 20% of newborn developed Intra Uterine Growth Retardation, 4% were died in utero and 8% died in neonatal period.

Table 4: Association between age vs eclampsia

Df=2, X2 = 3.56, p=0.16

Out of 100 cases studied, 9% belonged to the age group of less than 20 years, among them 3% developed eclampsia and 83 % belonged to the age group of 20 – 28 years, among them 10% developed eclampsia,8% belonged to the age between 29 - 38 years, among them 2% developed eclampsia and there was no association between age and occurrence of eclampsia.

Table 5: Association between booking status vs abruption

Df=1, X2 =7.614, p=0.005

Majority (91%) of the cases were booked and only 9 % of the cases were un booked. Chi square test revealed significant association between booking status and abruption.

Table 6: Association between BMI vs abruption

Df=1, X2 =5.711, p=0.01

In this study 72% of the cases who had a BMI of less than 25, 6% of cases developed abruption, 28% of the cases who had a BMI of more than 25, 8% developed abruption and there was statistically significant association between BMI and abruption i.e; as the BMI increases chances of abruption.

Table 7: Association between urine analysis vs abruption \

Df=4, X2 =14.94, p=0.004

In this study 22% of cases had no proteinuria, 25 % of the cases had trace amounts of protein in urine, among them only 1% developed abruption. Among 77% of the cases with proteinuria, 13% developed abruption and there was significant association between proteinuria and abruption i.e as severity of proteinuria increases chances of abruption.

In our study 47 members belonged to primi gravida, among them 5% of the cases developed abruption and 53 members belonged to multi gravida, among them 9% developed abruption and there was no association between parity and abruption.

Among 47 primi gravida cases 3% developed HELLP and 12% of cases developed HELLP among 53 multiparous women and there was a significant association between parity and HELLP i.e; as the parity increases chances of occurrence of HELLP increases.

Table 8: Association between urine analysis vs HELLP

Df=4, X2 =28.15, p=0.00001

In this study 22% of cases had no proteinuria, 25 % of the cases had trace amounts of protein in urine, among them only 2% developed HELLP. Among 77% of the cases with proteinuria, 13% developed HELLP and there was significant association between proteinuria and HELLP i.e as severity of proteinuria increases chances of HELLP increases.

Table 9: Association between HTN vs eclampsia

Df=1, X2 =7.563, p=0.005

In this study 30 % of the cases had severe HTN among them 9% developed eclampsia and 70% of the cases had mild HTN among them 6% developed eclampsia and there was a significant association between HTN and eclampsia i.e; as the severity of HTN increases chances of eclampsia increases.

In the present study, out of 100 patients, maximum (82%) cases were in the age of 20 to 28 years, Similar findings were observed in Saxena N et al ⁴ (2016) conducted a prospective study from 1 st January 2014 to 31st December 2014 in a tertiary centre on one fifty pregnant women of severe PE & eclampsia with > twenty weeks of gestation found that majority (79%) were between 20- 30 years of age and 47% were primigravida. 75 patients with convulsions on admission and 75 with severe pre-eclampsia of whom 11 had convulsions. Headache was most common complaint. Common mode of delivery was caesarean section in 72 (48%) women, majority in view of failed induction or non-progress. Maternal complications were noted in 59% attributed to renal dysfunction, postpartum hemorrhage, DIC, placental abruption, HELLP, pulmonary edema, pulmonary embolism and renal failure. 4 maternal deaths were recorded.  

A Cross-sectional study conducted by Amritha Aurora Meduri et al.⁵ (2023) among 105 selected cases from the census of PIH (gestational hypertension, PE & eclampsia) and found that 48% were primigravida and 52% were multi gravida. Preeclampsia (PE) cases were 39, severe preeclampsia (SPE) was 1 and Eclampsia cases were 21. Labetalol alone was used in 62 cases, and 44 babies were born without any complications. As an anticonvulsant magnesium sulphate (MgSO4, 7H2O) was used in all cases of imminent eclampsia and eclampsia (MgSO4 PRITCHARD Regime) in a total number of 38 cases. Preterm/prematurity was the most common cause of perinatal death. The total number of NICU admissions was 42 (40 %).  

Akash J Patel et al.⁶ (2021) conducted a retrospective study from May 2019 to May 2020 in a tertiary care center in Western India. A total 52 (43.33%) of cases were in 21-25 years, 64 (53%) were primi and they were mostly referred from peripheral hospitals. Liver function tests were deranged in 26.68% of the patients and 32.5% had abnormal renal function. Labetalol was the most commonly used antihypertensive and magnesium sulphate was the anticonvulsant used in all the cases. Lower segment caesarean section was the mode of delivery in 62 (51.67%) of the cases. Commonest maternal complication was atonic PPH (12.5%). There was one maternal mortality due to aspiration pneumonia. 85 (70.83%) of the babies needed NICU admission. There were 5 (4.16%) perinatal deaths.

In our study, 65 members were with the GA of <37 weeks & 35 members were with the GA of >37 weeks. Similar findings were observed in A retrospective study conducted by Charu sharma et al.⁷ (2017) in a tertiary center of Northern India from July 2011 to June 2014 found that 62% were with the GA of <37 weeks and 35% were with the GA of >37 weeks. Out of 2,989 deliveries during the defined period, the incidence of women presenting with HDP was 6.92% (n=207). Of these 50.2% (104/207) were pre-eclampsia, 35.7% (74/207) eclampsia, 12.5% (26/207) were gestational hypertension and rest were chronic hypertension. The mean age of women presenting with HDP was 25.42 ±4.64 years. Co-morbid conditions like Gestational diabetes mellitus (GDM) were seen in 1.4% (3/207), twin pregnancy was seen in 5.79% (12/207) and obesity was seen in 7.24% (15/207) cases of HDP. There were 2 maternal deaths and 7 neonatal deaths. Maternal complications like acute renal failure (ARF), congestive heart failure (CHF), acute respiratory distress syndrome (ARDS) & disseminated intravascular coagulation (DIC) were seen more commonly in severe pre-eclampsia group. 62.8% babies (130/207) were premature. Poor neonatal outcome was higher in eclampsia group followed by severe pre-eclampsia group.

A retrospective study conducted by Ch. Madhuri et al.⁸ (2019) for a period of 6 months in the Department of OBG, tertiary health care centre at King George Hospital, Visakhapatnam among 550 pregnant women found that 69% were with the GA of >37 weeks. 62.30 % of cases were in the age group of 20-25 yrs, nearly 67.69% were primigravidae and the majority were referred from peripheral hospitals. Liver function tests were deranged in 12.11% of the patients and 6.5% had abnormal renal function tests. 30.96%of the cases had a preterm delivery and 7.1% of the babies needed NICU admission. There were 28 neonatal deaths.  

Most (90%) of cases were booked and only 10 % of cases were un booked. These findings were different from an observational descriptive study conducted by Jayshree Chimrani et al.¹ (2023) in the Department of OBG in SRVS Medical College, Shivpuri analyzed 112 patients with severe PE found that 39% were booked and 61% were unbooked. Out of the 112 patients in the present study, maximum (44.64%) cases were in the age group of 26 to 30 years, most (57.14%) of them were Primigravida, and most of the cases were between 32-36 weeks of pregnancy. The incidence of preeclampsia was higher in unregistered (60.71%) cases. The majority of the patients had headache 44.64% as a chief complaint, followed by pedal edema (32.14%), vomiting (18.75%), Convulsion (9,82%), Oliguria (9.82%), Epigastric pain (7.14%), Generalized edema (3.57%), and blurred vision (4.46%) respectively. In this study, the most common mode of delivery (57.14%) was caesarean delivery. (42.85%) of patients delivered vaginally. Out of all normal deliveries, (16.96%) of patients delivered Spontaneously, around (20.32%) of all deliveries are preceded by labor induction, and (3.57 %) of patients needed Instrumental assistance (Vacuum extraction) during the second stage of labor. The most common maternal complication in the present study was PPH (16.07%), followed by eclampsia (9.82%) and abruption placenta (9.82%), HELLP (3.57%), DIC (1.78%), Pulmonary edema (0.89%), Renal dysfunction (1.78%), and neurological dysfunction in (1%) of cases. In this study, antepartum eclampsia was the most common one. Neonatal outcomes as preterm babies (73.21%), low birth weight (25%), and IUGR (17.85%). NICU admission is required in (43.75%) of babies with reported Perinatal mortality as (16.07%).

In present study 78% of cases had a BMI < 25 and 22 % of cases had BMI > 25. Similar findings were observed in A study conducted by Ahmed .M et al.⁹ (2014) a prospective study carried out over a period of 1 year from 1st Jan 2009 till 31st Dec 2009 at Grant medical college and Sir J. J. Group of hospitals found that 81% of cases had a BMI of < 25 and 19 % of cases had a BMI of > 25.28.

In this study 70% of cases had mild hypertension and 30 % of cases had Severe hypertension. similar results were observed in A prospective study conducted by Mayur R. Gandhi et al.¹⁰ (2015) from February 2014 to January 2015 in the Department of OBG of GMERS medical college and hospital, Dharpur-Patan found that 61% of cases had mild hypertension and 23 % of cases had Severe hypertension. In the present study, the overall incidence of PIH was 12.8%, which includes preeclampsia in 11.4% and eclampsia in 1.4%. Out of total 95 cases, 69 (72.6%) were emergency cases. 72 (75.7%) cases were from rural area. The most common symptoms were labour pains (48.4%) followed by eclampsia (11.5%). 51 (53.7%) women delivered normally. Eclampsia was the commonest maternal complication affecting 11.6% of cases. Out of total 95 births, perinatal deaths were occurred in 22 (23.15%) cases. Out of 22 perinatal deaths, 13 (61.2%) were still births and 9 (42.8%) were neonatal deaths.

A retrospective study conducted by Pillai SS et al.¹¹ (2017) conducted on 110 women with severe PE & eclampsia in tertiary care centre for a period of 15 months found that 17% had abnormal RFT and LFT were abnormal in 19% of the patients. 42% of the cases were in the age group of 26-30 years, nearly 61% were primigravidae and the majority (64) were referred from peripheral hospitals. Nifedipine was the most commonly used antihypertensive and magnesium sulphate was the anticonvulsant used in all the cases. Lower segment caesarean section was the mode of delivery in 64.5% of the cases. Commonest maternal complication was atonic PPH. There was no maternal mortality but there were 3 maternal near-miss cases due to DIC. 65% of the cases had a preterm delivery and 39% of the babies needed NICU admission. There were 10 neonatal deaths.  

In the current study 15 patients developed eclampsia among them 8 patients developed antepartum eclampsia &3 patients developed intrapartum& 4 patients developed Postpartum eclampsia and it was significantly associated with severity of hypertension. Similar findings were observed in An observational descriptive study conducted by Jayshree Chimrani et al.¹ (2023) in Department of OBG in SRVS Medical College, Shivpuri analysed 112 patients with severe PE found that 11 patients developed eclampsia among them 5 patients developed antepartum eclampsia & 2 patients developed intrapartum& 4 patients developed Postpartum eclampsia.

Out of 100 cases, 14% developed abruption, 15% developed eclampsia, 15% developed HELLP syndrome, 10% developed cortical vein thrombosis, 9% developed DIC, 9% of cases developed renal failure, 11% developed pulmonary edema, 2% of cases died and they had severe pre-eclampsia. In another study done by GawaliS et al.¹² (2021), Maternal complications observed were eclampsia (9.72 %), postpartum hemorrhage (8.80 %), abruptio placentae (7.87 %), partial HELLP (6.94 %), HELLP (1.39 %), renal dysfunction (2.78 %), DIC (2.32 %) and pulmonary edema (0.93%).

A retrospective study conducted by Chaitra S¹³ (2017) at a tertiary care center, included 286 hypertensive cases over a period of 1 year from January 2016 to December 2016. Data were gathered from medical record files. Out of 3250 women delivered in the hospital 286 had hypertension and the prevalence was 8.8%. Out of 286 hypertensive pregnant women 80.06% were diagnosed as gestational hypertension, 14.68% as preeclampsia, 2.09% as eclampsia and 2.79 % as chronic hypertension. Maximum number of women was nulliparous (46.85%) and 21-25 years was the dominant age group (46.15%). It is more prevalent at term (49.65%). Eighty-two (27.97%) mothers had a vaginal delivery, and 204 (71.32%) had a caesarean delivery. Preterm delivery was the most prevalent morbid outcomes (28.67%). Seventy-six (26.57%) of the babies were categorized as low birth weight and 14.68% were diagnosed as intrauterine growth restriction.

A prospective randomized study conducted by Vidyadhar B. Bangal ¹⁴ (2010) from February 2009 to January 2010 in the Department of Obstetrics and Gynecology of Pravara Rural Hospital, Loni, India. A total of 100 pregnant women with PIH were enrolled. In this study, the overall incidence of PIH was 8.96%, which includes preeclampsia in 7.26% and eclampsia in 1.70%. Preterm labour was the commonest maternal obstetrical complication observed in 18% of mild PIH and 48% of severe PIH cases. Prematurity was the commonest foetal complication seen in 17.99%, 47.62% and 52.63% of mild PIH, severe PIH and Eclampsia cases respectively.

Severe preeclampsia leads to higher risks of life-threatening complications, preterm delivery, and IUGR, with maternal mortality observed in multigravida cases. Early detection and proper management, including evidence-based protocols, are crucial to reducing morbidity and mortality. Effective secondary and tertiary prevention improves outcomes for both mother and neonate.

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