Trend in admissions, clinical features and outcome of preeclampsia and eclampsia as seen from the intensive care unit of the Douala General Hospital, Cameroon

Introduction Hypertensive disorders in pregnancy (HDP) are a major cause of maternal morbidity and mortality. We aimed at determining the trends in admission, profiles and outcomes of women admitted for preeclampsia and eclampsia to an intensive care unit (ICU) in Cameroon. Methods A retrospective study involving 74 women admitted to the ICU of the Douala General Hospital for severe preeclampsia and eclampsia from January 2007 to December 2014. Clinical profiles and outcome data were obtained from patient records. Statistical analysis was performed using SPSS version 20. Results Of the 74 women admitted to ICU (72.5% for eclampsia), mean age was 30.2years and the majority (90.5%) were aged 20-39 years. While overall trend in admission for HDP increased over the years, mortality remained stable. Mean gestational age (GA) on admission was 34.0 weeks (33.5 for preeclampsia vs 35.4 for eclampsia). Most patients presented with complications of which acute kidney injury was most frequent (66.7%). Visual problems were more common in patients with eclampsia compared to preeclampsia (p = 0.01). HELLP syndrome and acute pulmonary oedema (APO) were predominant in patients with preeclampsia, while cerebrovascular accidents (CVA) occurred more in patients with eclampsia. Overall mortality was 24.3%. Presence of APO was associated with mortality in multivariable analysis (O.R.= 0.03, p = 0,01). Conclusion Trends in admission for HDP were increasing with high but stable mortality rate. Patients presented late most of whom with complications. Interventions improving antenatal care services and multidisciplinary management approach may improve maternal outcome in patients with HDP.


Introduction
Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity and mortality [1]. These generally involve hypertension related conditions occurring primarily during pregnancy or may be pre-existing and persist during and or after pregnancy [2]. Generally, HDP are said to complicate 5-10% of pregnancies and account for 10-15% of maternal deaths globally [3,4]. Recent data suggests that the increasing incidence of HDP is partly due to an increasing trend in obesity worldwide [5,6].
Furthermore, the resultant worrisome maternal morbidity and mortality from HDP shows some disproportionate affection geographically, as majority of these maternal deaths are found to occur in low and middle income countries (LMICs) [7]. Preeclampsia is a HDP in which there is hypertension (systolic blood pressure (SBP) ≥140mmHg and or diastolic blood pressure (DBP) ≥90mmHg) and proteinuria occurring after 20 weeks gestation, measured on two different occasions at least 4 to 6hours apart in women previously known to be normotensive [8,9]. In severe preeclampsia, SBP (DBP) is ≥160 (110) mmHg in the presence of proteinuria.
When convulsion occurs in the presence of these features, the condition is known as eclampsia [3]. Amongst others, preeclampsia is known to be a disorder of nulliparity, but multi parous pregnant women with new partners have been shown to have a similar elevated risk for development of preeclampsia like nulliparous women [10]. A study in northern Cameroon found teenage status, illiteracy, nulliparity and family or personal history of hypertension as risk factors for HDP [11]. It should be noted that the adverse effects of preeclampsia and eclampsia are not only limited to the mother but also to the foetus with several complications ranging from intra-uterine growth restriction to intra-uterine foetal death [12]. Several theories exist on the pathogenesis of preeclampsia, but at present, it is suggested that the placenta is the primary agent in the development of preeclampsia, hence, removal of the placenta (by termination of the pregnancy is the sole method of treating the condition [13]. Studies continue to suggest the increasing burden of HDP around the world making it a growing public health problem [1,14]. Currently, data on risk profiles and outcome of preeclampsia and eclampsia are limited in Cameroon. We thus set out to describe the trends in admission, clinical profiles and outcomes of women admitted to ICU for preeclampsia and eclampsia in Douala General Hospital, Cameroon.

Study Procedure, variables and data collection
Medical records of women hospitalized to ICU for HDP within study period were sorted and checked for completeness. Using a structured case report form, socio-demographic characteristics like; maternal age, marital status and mode of admission were obtained, obstetric characteristics obtained were; gravidity, parity, gestational age on admission and history or presence of multiple pregnancy.
Other clinical characteristics collected were; SBP, DBP, oedema (facial and or pedal), visual problems, neurologic deficit, glasgow coma score (GCS), mode of delivery and type of ventilation (spontaneous or assisted). Biology parameters obtained were; liver and kidney function tests, serum electrolytes (sodium, potassium, chloride), full blood count, prothrombin time. Pregnancy complications and outcomes were; mode of delivery, presence of HELLP syndrome, placenta abruptio, acute pulmonary oedema, cerebrovascular accident, acute kidney injury and death.

Data analysis
Data was transferred from the case report form to Microsoft excel spread sheet and statistics software; statistical package for social sciences (SPSS) version 20 for cleaning and subsequent analysis.
Categorical variables were summarized as frequencies and proportions while continuous variables were summarized as means, Page number not for citation purposes 3 standard deviations and median where applicable. Group comparisons were done using chi square and fisher exact tests and students t-test for categorical and continuous variables respectively.
Logistic regressions were used to investigate factors associated with mortality. Statistical significance was considered at p < 0.05.

Ethical Considerations
Ethical and administrative approval was obtained from the Ethics committee of the Douala General Hospital. Being a retrospective study, written informed consent was not required but confidentiality of patient records was also maintained.

General Characteristics of Study population
In all, 74 women were admitted to the ICU during the study period (72.5% eclampsia and 27.5% preeclampsia). The overall mean age and mean gestational age of study participants was 30.2 years and 34.0 weeks respectively. Most women were aged 20-39 (90.5%) ( Figure 1). Median (range) gravidity and parity was 3 (1-9) and 2 (0-7) respectively. ( Table 1) depicts the general characteristics of the study population.

Trends in Admission and death
Overall, there was an increase in general admissions and admissions for HDP in the ICU between 2007 to 2014. There was an increasing trend in overall mortality in ICU but deaths due to HDP remained stable (Figure 2).

Factors associated with Mortality
On bivariate analysis, receiving transfusion [O.  [19]. Other studies Page number not for citation purposes 4 suggest low rates of patients with AKI [1] with current estimates in developed countries as low as 1-2.8% [20]. In developing countries, the incidence of renal failure in HDP is higher with values as high as 36% [21]. In our study, AKI was present in up to 66.7% of cases, further re-iterating the possible late presentation to hospital.
Contrary to Seyom and colleagues who reported low rate of cases with renal failure, but rather more frequent was retroplacental haematoma [1]. Acute Pulmonary Oedema was the only predictor of mortality in our study. This was contrary to other reports, where, no antenatal care, high DBP, grand multiparity, high creatinine levels were predictors of maternal death [2,3,22].
Overall mortality rate from our study was high (24.3%). This was similar to reports from Ghana [23] and Nigeria [24], though much higher than reported in Ethiopia, where eclampsia related maternal deaths were 11.6% [2]. However, our findings are much lower than reported in a population based study in South Africa which had rates as high as 57% [25] and from India with 67% [26]. We suggest that the high rate of complications resulted in high mortality in our study. Even though this mortality was stable across years, this was probably due to the increase in personnel which probably resulted in better management. The extent of complications overemphasizes on the need of a multidisciplinary team for management, including nephrologist and ophthalmologist. Indeed AKI was found to be more frequent in patients with preeclampsia than eclampsia, which further suggests, that the nephrologist should be brought in at a very early stage so as to limit the proportion of AKI which has been shown elsewhere as a strong predictor of outcome. The retrospective design of the study however limits the study with a number of missing variables which could not obtained from patient records together with the small sample size which didn't permit further exploration of predictors of mortality. However, findings from our study deserve attention, as being the first study conducted in a key referral hospital in central Africa where there is absent data on this worrisome and leading cause of maternal mortality in the region. We recommend larger and even multi-centre national studies to further confirm our findings and investigate predictors of mortality for HDP so as to reduce the resultant maternal mortality.

Conclusion
Our findings suggest an increasing trend in ICU admissions for HDP with high but stable mortality rate. Most patients present to health facility in advanced disease states with target organ damage.
Interventions to strengthen and improve antenatal care services as well as multidisciplinary management approach may play a crucial role in reducing the burden of HDP in Cameroon.

Competing interests
The authors declare no competinf interest.