Neonatal Outcomes Of Eclamptic Mothers In A Tertiary Government Teaching Hospital With A Rural Background
Name of the Institution of study: Burdwan Medical College and Hospital, Burdwan, West Bengal, India.
Corresponding Author: Dr. Rajib Das, Department of Pediatrics, Burdwan Medical College, Burdwan-713101, West Bengal, India. E-mail id: firstname.lastname@example.org
Received: 12, Apr 2019; Reviewed: 21 May 2019; Accepted: 23, June, 2019.
Citation of article: Santanu Bandyopadhyay, Asok Kumar Datta, Medhatithi Burman, Rajib Das, Neonatal Outcomes Of Eclamptic Mothers In A Tertiary Government Teaching Hospital With A Rural Background New Indian Journal of Pediatrics, 2019;8.3.
Abstract: Neonatal outcomes of eclamptic mothers and their significance in a rural tertiary healthcare institution which caters mainly agro-based village population largely representing the typical pattern of socio-economic and demographic characteristics of rural India is important for follow up and early intervention . This prospective, cross-sectional, observational, epidemiological study was conducted in the departments of paediatrics and obstetrics of Burdwan Medical College Hospital, West Bengal from April, 2012 to March, 2013. The study comprised of newborn babies born to 100 consecutive mothers admitted with eclampsia or with pre-eclampsia but subsequently developing eclampsia along with those born to 100 consecutive non-eclamptic mothers ( considered as control ) with normal blood pressure. The non-eclamptic mothers were selected after statistically matching the socio-demographic and nutritional profile like religion, caste, age, socio-economic status, parity, body weight and height with those of eclamptic mothers. Mothers less than 28 weeks of gestation or suffering from essential hypertension, chronic illness, epilepsy or taking any drug with teratogenicity and those giving birth to twin babies or babies with gross congenital malformation were excluded from both the groups. Eclampsia among rural population of India still remains a significant risk factor for neonatal morbidities like preterm and low birth weight, intra-uterine growth restriction and birth asphyxia. Increased incidence of late preterm births is also significantly associated with eclampsia.
Keywords: eclampsia, preeclampsia, neonatal outcome, birth asphyxia, late preterm
Introduction: Eclampsia (a Greek word meaning shining forth or more literally a bolt from the blue} is an acute and life threatening hypertensive disorder of pregnancy, characterised by the appearance of tonic-clonic seizures and coma that happen during most often during second half of pregnancy, non-attributable to other causes like epilepsy or pre-existing or organic brain disorders , generally in a woman diagnosed with preeclampsia . Preeclampsia is currently classified as a pregnancy-specific syndrome characterized by the presence of new-onset hypertension (a systolic BP >140 mm Hg or a diastolic BP >90 mm Hg) in a previously normotensive woman after 20 weeks gestation with proteinuria (urinary excretion of ≥ 0.3 grams of protein in a 24-hour specimen) .
Though the etio-pathogenesis is still hypothetical , development of complications like placental insufficiency [4,5], placental abruption[5,6] and foetal bradycardia[7,8] in pre-eclampsia/eclampsia syndrome may affect perinatal morbidity and mortality adversely.
During a ten year period from 1999 to 2008 the incidence of eclampsia in age group below 20 years was 6.97% in Burdwan Medical College, West Bengal while the national incidence of eclampsia in India, according to the reports published from 1976 to 2015, ranged from 0.179 to 5% , the average being 1.5%. The incidence of eclampsia showed a receding tendency over the decades while the perinatal mortality in eclampsia was remaining still high as in 1984 it was 45% and the corresponding figure in 2010 was 24.5-48% .
The present study was planned to find out different neonatal outcomes of eclamptic mothers and their significance in a rural tertiary healthcare institution which caters mainly agro-based village population largely representing the typical pattern of socio-economic and demographic characteristics of rural India.
Material And Methods: This prospective, cross-sectional, observational, epidemiological study was conducted in the departments of paediatrics and obstetrics of Burdwan Medical College Hospital, West Bengal from April, 2012 to March, 2013.
The study comprised of newborn babies born to 100 consecutive mothers admitted with eclampsia or with pre-eclampsia but subsequently developing eclampsia along with those born to 100 consecutive non-eclamptic mothers ( considered as control ) with normal blood pressure. The non-eclamptic mothers were selected after statistically matching the socio-demographic and nutritional profile like religion, caste, age, socio-economic status, parity, body weight and height with those of eclamptic mothers. Mothers less than 28 weeks of gestation or suffering from essential hypertension, chronic illness, epilepsy or taking any drug with teratogenicity and those giving birth to twin babies or babies with gross congenital malformation were excluded from both the groups.
All the mothers included in the study were first evaluated clinically by first history including age, parity, LMP, socio-economic status according to modified Kuppaswamy scale, 2007 , detailed data from antenatal records and then by examination including weight, height, blood pressure etc. Data from history and clinical examination for the demographic variables of the eclamptic mothers were then collected. They were then computed with those of the non-eclamptic mothers for matching and selection as control group.
All eclamptic mothers were treated routinely as per institutional protocol with Magnesium sulphate at a loading dose of 2.5 gm deep IM in each buttock along with 3 gm IV bolus over 15 minutes followed by a maintenance dose of 2.5 gm Magnesium Sulphate deep IM every 4 hourly. Mothers with BP > 160/110 mmHg were treated with Labetelol 10 mg IV stat followed by repeat doses of 20-40 mg IV, if needed and a maintenance dose at the rate of 10 mg IV 8 hourly or 100 mg PO 8 hourly.
All the neonates in labor room or OT were evaluated at birth for birth asphyxia and managed accordingly. Routine Apgar scoring at 1 minute and 5 minutes, CBG and serum Ca estimation were also done for all at birth. All the neonates were re-examined at 24 hours after birth including gestational age according to New Ballard Scores , estimation of body weight percentile according to intrapartum growth chart  and anthropometry and were routinely followed till completed 7th postnatal day or through their course of illness. Sick neonates of eclamptic and non-eclamptic mothers were further evaluated by sepsis screen as per the institutional protocol, blood culture, CBG, chest xray, USG etc. according to the relevant clinical conditions and managed accordingly.
In categorising the various neonatal outcomes standard definitions of preterm as delivery before 37 completed weeks of gestation, LBW as birth weight < 2.5kg, IUGR as birth weight less than 10th percentile according to gestational age, EOS as onset of sepsis within 3 days of potnatal period, END as neonatal death within 7 days of postnatal period and SB as delivery of dead fetus after 28 weeks of gestation were followed.
All the data were compiled and analysed in the SPSS (version 25.0) software for appropriate statistical tests. Student t tests for continuous maternal variables to compare means and Chi square tests for categorical variables were done to find no significant difference (p>0.05) between the two groups of eclamptic and control mothers. Chi square tests were done to find out significance (p<0.05) of association between neonatal outcomes and eclampsia.
Results: Results are shown in the four tables (1 to 4) and a bar diagram (picture-1). 90% of both eclamptic mothers took full course of Fe-Folate supplementation while 52% received at least 3 antenatal visits at local Government sub-centres. 70% had 10 gm% or more haemoglobin concentration as evidenced from their antenatal records.
Majority of eclamptic mothers were primigravida (86%), < 19 years of age (66%), non-tribals (78%), having body weight of 40-44 kgs (52%), height of 145-150 cm (54%) and socio-economic status of class – IV (92%) graded according to modified Kuppaswamy scale(2007)(Table-1).
There was no significant difference observed in respect of age, weight, height, religion, caste, parity and socioeconomic status between eclamptic and control mothers (Table-2 and 3) and thus the two groups were statistically matched.
Neonates of eclamptic mothers of this study were found to have mean body weight of 2.32 kg ± SD = 0.416, mean head circumference of 31.40 cm ± SD = 0.264, mean crown heel length of 46.56 cm ± SD = 2.903 and mean pondoral index of 2.28 ± SD = 0.23.
In this study adverse outcomes of newborns of eclamptic mothers were significant (p <0.001) since 72 babies (72%) of eclamptic mothers (OR = 3.143, 95% CI = 1.746-5.659) were born with one or more defined adverse outcomes as against 45 (45%) such of control mothers. The Bar diagram (Picture – 1) shows the comparison between different outcomes of neonates of eclamptic and control mothers.
In this study four significant neonatal outcomes of eclamptic mothers (Table – 4) were observed as preterm (OR=3.037,95%CI=1.588-5.808, p value = 0.001), LBW (OR=3.188, 95%CI=1.784-5.694, p value < 0.001), IUGR (OR=4.409, 95%CI=1.204-16.141,p value = 0.032 ) and birth asphyxia ( OR=2.459, 95%CI=1.231-4.913,p value = 0.016) while other outcomes as HIE (OR=4.530,95%CI=0.936-21.936, p value = 0.087), EOS (OR=2.524, 95%CI=0.749-8.507, p value =0.211 ), END (OR=2.733, 95%CI=0.517-14.454, p value = 0.399), still birth (OR=2.374, 95%CI=0.706-7.978, p value = 0.251) were not significant. Only live born babies were considered for the statistical study of birth asphyxia, HIE, EOS and END.
Majority( n=34, 85% ) of preterm newborns of eclamptic mothers were observed as late preterm babies (34-36 weeks of gestation) against only 44.4%(n=8) among the control group and as such they constituted a significant proportion of preterm births of eclamptic mothers ( OR = 7.083, 95% CI = 1.986-25.270, p value = 0.004).
Discussion: In this study 72% of babies of eclamptic mothers (p value <0.001) were born with adverse outcomes, which is comparable to the similar studies in India [14, 15, 16] and abroad [17, 18, 19, 20, 21, 22, 23].
In this study Preterm babies born to eclamptic mothers were significant ( 40% p value =0.001).This is comparable to 74.5% , 62.5% (p value = 0.000006) , 59% , 50%  of preterm births as reported by similar studies, though few studies also observed lesser percentages as 26.23% , 17%  and 31.1% . This study also observed increased incidence of late preterm births (34 -36 weeks of gestation) with eclampsia being a significant risk factor (p value = 0.004). This is comparable to several studies [24, 25] which suggest eclampsia is one of the most common co- morbidities or variables associated with increased risk of late preterm birth.
In this study LBW babies figured as a significant outcome of eclampsia (60%, p value <0.001) as compared to the results documented as 70% , 68.6%  and 34.4%  of similar studies.
IUGR came out as a significant outcome(12%,p value=0.032) in our study , which is comparable to a study at Ayub Medical college, Pakistan, while another study at Khon kaen Hospital at Thailand showed a lower incidence with no statistical significance.
This study also showed birth asphyxia as a significant outcome (33%, p value =0.016), which is in consonance with the similar studies that recorded 26% , 25.49% and 42.46% of neonatal outcomes as birth asphyxia in eclampsia.
Several studies pertaining to outcomes of eclampsia had shown no statistical significance regarding HIE , EOS [17, 19, 15], still birth [17, 18, 16] and END [17, 18, 19, 16, 21]. Our study too was comparable to their findings.
Conclusion: This study has limitations. This study had no scope to consider the influence, if any, of the therapeutic intervention of eclampsia upon the neonatal outcomes and as such to exclude the treatment modalities of maternal eclampsia as a confounding variable in the study, since all patients were compulsorily treated with the institutional protocol of MgSO4 regime.
In conclusion, therefore, elampsia among rural population of India still remains a significant risk factor for neonatal morbidities like preterm and low birth weight, intra-uterine growth restriction and birth asphyxia. Increased incidence of late preterm births is also significantly associated with eclampsia. There is a definite need for further studies to unfold the role of therapeutic management of eclampsia per se on the development of different neonatal outcomes.
Contribution of Authors: SB: Collection of data, writing manuscript, statistical analysis, AKD: Concept of study, revising manuscript, MB: Collection of data, revising manuscript, RD: Collection of data, revising manuscript
Conflict of Interest: None
Ethical Approval: The study approved by the Institutional Ethics Committee
Acknowledgements: We deeply express our gratitude to late Professor Dr. Nabendu Choudhury for his esteemed guidance
What this study adds: Antenatal management of eclampsia and preeclampsia is important to prevent and decrease serious complications in neonates. Preterm and low birth weight, intra-uterine growth restriction, birth asphyxia and increased incidence of late preterm births are common complications in babies born to eclamptic mothers.
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