Perinatal Mortality Risk Factors of Infants Born from Eclamptic Mothers
at Tokoin Teaching Hospital of Lomé
Amah Biova Adama-Hondegla,
Eclampsia during pregnancy is often associated with a higher rate of perinatal
mortality, especially in Africa. Implementation of preventive and curative strategies
to reduce perinatal mortality in eclampsia needs regular assessment of risk
factors. This study is held to determine the impact of several risk factors
in eclampsia on perinatal mortality at Tokoin Teaching Hospital of Lomé,
Togo (West Africa). It is a retrospective and comparative study concerning recorded
files of 178 newborns from eclamptic women. Maternal and newborns risk factors
have been compared in two groups of babies (dead ones versus still living ones:
at 7th day of life). The data were processed by using SPSS 12.0 software. Chi-square
Exact Test of Fisher and calculation of Odds Ratio have been used to establish
significance (p<0.05) and correlation between variables. The total dead fetuses
and newborns during the perinatal period was 17.4%. Vaginal rate of delivery
increased significantly perinatal death, compared to cesarean section (OR =
5; p<0.001). Prematurity (gestational age less than 37 weeks) versus newborn
at term was at risk of perinatal death (OR = 4.61; p<0.001). Perinatal mortality
was increased in babies with lower Apgar score (<7) at first minute compared
to those with Apgar score upper than 7 (OR = 2.9; p<0.001). Caesarean section
in eclamptic women still prevents a lot from fetal and newborn death. Better
handling of premature babies and improvement of newborn resuscitation in the
center, will help to decrease perinatal mortality due to eclampsia.
to cite this article:
Amah Biova Adama-Hondegla, Koko Lawson-Evi, Akila Bassowa, Selomey Modji, Kokou-Fia Egbla and Koffi Akpadza, 2013. Perinatal Mortality Risk Factors of Infants Born from Eclamptic Mothers
at Tokoin Teaching Hospital of Lomé. Journal of Medical Sciences, 13: 391-395.
Received: February 02, 2013;
Accepted: March 27, 2013;
Published: June 14, 2013
Eclampsia is a severe complication of pregnancy characterized by tonic and
clonic seizures in association with hypertension, proteinuria (>300 mg/24
h after 20 weeks of gestation) and edema (Kamyabi and Mahani,
2004). It is a frequent disorder with incidence of 2-8% among pregnancies
that continues to be a major problem worldwide, particularly in developing countries,
causing maternal and perinatal mortality (Sahin, 2003;
Urassa et al., 2006; Okafor
et al., 2009). Perinatal outcome and stillbirth rates often give
an image of the quality of the obstetrical and neonatal services offered in
a health care system. Complications that can occur during pregnancy and labor
will have, therefore, a direct impact on fetal prognosis, leading to perinatal
death (Makinde, 2012). Fetal death is one of the major
complications during eclampsia and according to many authors; premature delivered
babies are at risk to die within the first seven days of life (Sibai
et al., 1983; Fardiazar et al., 2013).
Studies have also revealed the evidence of low birth weight and advanced maternal
age on perinatal mortality (Ahinko and Tuimala, 1994;
Olusanya and Solanke, 2011; Yaliwal
et al., 2011).
West Africa sub-region has one of the highest perinatal mortality rates in
the world (75-76/1000 births) (Ansari et al., 1995).
In Togo (West Africa), a recent study conducted in the Clinic of Gynecology
and Obstetrics (Tokoin Teaching Hospital Center of Lomé) estimated maternal
mortality of eclamptic woman at 8.8% (Adama-hondegla et
al., 2011) but there was little information about the perinatal outcome
The objective of this study is to determine the impact of maternal and newborn
risk factors on perinatal mortality in eclampsia at Tokoin Teaching Hospital
of Lomé (Togo). The results of this work would help in implementation
of preventive and curative strategies to reduce perinatal mortality due to eclampsia.
MATERIALS AND METHODS
This is a retrospective and comparative study of 178 infants born in eclamptic
mothers over three years from January 2007 to December 2009. The study was conducted
at the maternity clinic of Gynecology and Obstetrics of Tokoin Teaching Hospital
Center of Lomé in Togo (West Africa). Perinatal outcome of the newborns
(dead or alive) in relation with several maternal risk factors and newborns
parameters have been assessed.
The data have been collected by files review of delivery history of newborns
from eclamptic mothers. Were included in this study all record files of newborn
over 28 weeks of gestation from mothers who were at diagnosis of eclampsia before
delivering. Diagnosis of eclampsia has been considered on those criteriae: tonic
and clonic seizures occurring over 20 weeks gestation, significant proteinuria
(over 30 mg dL-1), hypertension (systolic blood pressure over 140
mm of mercury and/or diastolic blood pressure over 90 mm of mercury) and edema
of the lower limbs or weight gain during pregnancy over than 15 kg.
The newborns files were divided in two groups: a first group of 147 still living
babies till the 7th day of life and a second group of 31 dead babies (stillbirths
and dead newborns within first seven days). We compared in the two groups: maternal
risk factors as maternal age, blood pressure, proteinuria, Glasgow liege score,
number of eclamptic seizures, use of Magnesium sulfate and route of delivery.
Were also assessed in the two groups; newborns parameters as gestational age,
weight, sex and Apgar score at first minute.
The data were processed using the SPSS 12.0 software. For comparison of variables
chi-square test of Fisher Yates has been used and the relation has been considered
significant for p<0.05. Logistic regression was used to estimate the Odds
Ratio (OR); for establishing the degree of correlation between variables.
It has been recorded a total of 178 births from the 170 eclamptic patients
(There were 8 twins). The total of dead fetuses and newborns in the perinatal
period was 17.4% (31/178).
In Table 1 are mentioned the newborns outcome according to
the maternal parameters.
Maternal age over 35 years, very high blood pressure from 16/11 millimeters
of mercury (mmHg), proteinuria over 3 g per day , Glasgow Liege score under
12, more than 3 eclamptic seizures before delivery and the use of magnesium
sulfate did not influence perinatal death. Vaginal delivery route (74.2%), increased
significantly (OR = 5; p<0.001) the number of perinatal death compared to
cesarean section (25.8%).
As reported in Table 2, about 37.64% (67/178) of newborns
were <37 weeks gestational age. The logistic regression show that infants
born from eclamptic mothers with gestational age <37 weeks gestation lead
to 67.7% of death (OR = 4.61; p<0.001). Neither newborn weight, nor newborn
gender influenced the perinatal death (p>0.05). Apgar score at first minute
<7 presented a high risk of perinatal death.
Birth weights ranged from 720 to 3740 g with average weight as 2850 g. Newborn
weight in relation to gestational age shown that:
||Among premature newborns (<37 weeks gestational age), 15
(8.4%) were more than 2500 g and 52 (29.2%) less than 2500 g
||Among newborns from 37 weeks gestational age and more, 78 (43.8%) were
subjects to hypotrophy (less than 2500 g) and 33 (18.6%) were more than
2500 g. The hypotrophic babies (called small for gestational age) represented
70.3% of low birth weight infants and 43.82% of all newborns. Impact on
perinatal mortality doesnt
show any significant difference (p>0.05 and OR = 0.68)
|| Maternal risk factors and impact on perinatal mortality
|*Magnesium sulfate was used by intravenous route; by putting
10 g in 500 mL of ringer lactate with a rate of 20 drops/minute, **Cesarean
sections were performed under general anesthesia, Value in brackets are
|| Newborn parameters and impact on perinatal mortality
|Value in brackets are numbers
For many authors, eclampsia is the most common medical complication in pregnancy
which can be classified as a true obstetrical emergency (Moller
and Lindmark, 1980; Ahinko and Tuimala, 1994; Yaliwal
et al., 2011).
The perinatal mortality rate in this series was 17.4%. This rate was similar
to the one (17%) reported in Gabon (Mayi-Tsonga et al.,
2006) but lower than that of Noutsougan (28.6%) in Lomé (Noutsougan,
1999) and that of Adam (35.5%) in Suden (Adam et
al., 2009). By comparing our result with those of Noutsougan (done in
the same center), it appears that perinatal outcome was in improvement in those
last 10 years in the department.
Maternal age over 35 years, high blood pressure (more than 160/110 millimeters
of Hg, proteinuria (≥3 g/24 h), Glasgow Liege score (≥12), more than three
eclamptic seizures before delivery and the use of magnesium sulfate did not
affect significantly the newborns status (p>0.05). In the present study,
gestational age less than 37 weeks leads to 67.7% of death (OR = 4.61; p<0.001).
Indeed, fetal complications in eclampsia are directly related to gestational
age and the severity of maternal disease including increased rates of preterm
delivery and perinatal death (Sibai et al., 1983).
Then, the major complications for the newborn are related to prematurity, although
data on morbidity and outcome for preterm infants of women who have eclampsia
are conflicting. Otherwise, perinatal mortality was found to be closely linked
to birth weight and gestational age. Samueloff et al.
(1989) reported that, perinatal mortality rate was over 20-fold higher for
infants with a birth weight below 2500 g or born before 37 weeks of gestation;
but in the present study, birth weight below 2500 g had no influence in the
perinatal mortality (OR = 1.9; p>0.05).
Another aspect of the newborn risk factor on perinatal mortality was the newborn
gender bias eclampsia. According to Hall, two issues have been considered: the
association of a particular gender with the development of eclampsia or the
role that gender plays in the perinatal outcomes (Hall,
2002). The increased male/female ratio in infants born in pre-eclampsia,
suggests the probable role of androgens and testosterone in the pathophysiology
of pre-eclampsia (Steier et al., 2002). It has
been noticed in this study that newborn gender (male or female) did not influence
the perinatal mortality (OR = 1.57; p>0.05) though, 54% (96/178) of the newborns
were female versus 46% (82/178) of male.
Fetal growth restriction risk in eclampsia was estimated by comparing infant
birth weight to term delivery (gestational age). It has been noticed a high
prevalence of low birth weight (weight <2500 g) with gestational age ≥37
among newborns. The hypotrophies represented 70.3% of low birth weight infants
and 43.82% of all newborns versus 18.53% normal birth weight infants (of all
newborns). They had so presented a fetal growth restriction which was not correlated
(OR = 0.68; p>0.05) with perinatal mortality in eclampsia. According to De
Souza Rugolo et al. (2011) among patients who had chronic hypertension,
eclampsia development did not affect the risk for intra uterine growth restriction,
suggesting different pathways of fetal growth impairment.
The most predominant route of delivery in pregnant eclamptic women was cesarean
section due to the emergency of the pathology (Moller and
Lindmark, 1980; Fardiazar et al., 2013).
In this series, vaginal birth increased significantly (OR = 5; p<0.001) the
perinatal death (74.2%) compared to cesarean section (25.8%). It can be explained
by the fact that vaginally route of delivery represents a supplementary proof
for the fetus which was already bearing effects of the pathology and its treatment.
Apgar score at first minute <7 presented a high risk (OR = 2.9; p<0.001)
of perinatal death. This shows that a fetus in eclampsia mother must been going
under chronic distress. The pathogenesis for the observed association between
low Apgar scores and eclampsia is not clear but may be related to the hypothesis
of reduced uteroplacental blood flow from morphologic changes in the placenta
accompanied by vasospasm and decreased intravascular volume (Olusanya
and Solanke, 2011).
The severity of neonatal outcome of this study may be related to the insufficient
Antenatal Care (ANC) for pregnant women, predisposing them to pre-eclampsia
and its complications. The same observation was made in the literature (Mayi-Tsonga
et al., 2006) where only preventive measures awareness, public education;
screening and early treatment of hypertension during pregnancy could reduce
This study shows that several maternal risk factors in eclampsia as advanced
maternal age, high blood pressure, proteinuria, Glasgow-Liege score, number
of eclamptic seizures and use of magnesium sulfate did not influence significantly
perinatal mortality. Vaginal delivery has increased significantly perinatal
death in newborns of eclamptic mothers. Within newborn parameters, premature
delivery and Apgar score less than 7 at first minute were at significant higher
risk of perinatal mortality. Cesarean section as route of delivery is still
the best choice in eclampsia occurring on a viable fetus but chances of resuscitation
and handling premature and low birth weight babies of the center must influence
the decision. The more the pregnancy is close to term greater will be the chances
of newborn survival. Collaboration between pediatrics and obstetricians should
also be encouraged.
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