The Burden of Eclampsia: Results from a Multicenter Study on Surveillance of Severe Maternal Morbidity in Brazil

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Abstract

Objective

Maternal mortality (MM) is a core indicator of disparities in women’s rights. The study of Near Miss cases is strategic to identifying the breakdowns in obstetrical care. In absolute numbers, both MM and occurrence of eclampsia are rare events. We aim to assess the obstetric care indicators and main predictors for severe maternal outcome from eclampsia (SMO: maternal death plus maternal near miss).

Methods

Secondary analysis of a multicenter, cross-sectional study, including 27 centers from all geographic regions of Brazil, from 2009 to 2010. 426 cases of eclampsia were identified and classified according to the outcomes: SMO and non-SMO. We classified facilities as coming from low- and high-income regions and calculated the WHO’s obstetric health indicators. SPSS and Stata softwares were used to calculate the prevalence ratios (PR) and respective 95% confidence interval (CI) to assess maternal characteristics, clinical and obstetrical history, and access to health services as predictors for SMO, subsequently correlating them with the corresponding perinatal outcomes, also applying multiple regression analysis (adjusted for cluster effect).

Results

Prevalence of and mortality indexes for eclampsia in higher and lower income regions were 0.2%/0.8% and 8.1%/22%, respectively. Difficulties in access to health care showed that ICU admission ( _adjPR 3.61; 95% CI 1.77–7.35) and inadequate monitoring ( _adjPR 2.31; 95% CI 1.48–3.59) were associated with SMO.

Conclusions

Morbidity and mortality associated with eclampsia were high in Brazil, especially in lower income regions. Promoting quality maternal health care and improving the availability of obstetric emergency care are essential actions to relieve the burden of eclampsia.

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Most cited references 15

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Maternal near miss--towards a standard tool for monitoring quality of maternal health care.

Lale Say, João Souza, Robert C Pattinson … (2009)

Maternal mortality is still among the worst performing health indicators in resource-poor settings. For deaths occurring in health facilities, it is crucial to understand the processes of obstetric care in order to address any identified weakness or failure within the system and take corrective action. However, although a significant public health problem, maternal deaths are rare in absolute numbers especially within an individual facility. Studying cases of women who nearly died but survived a complication during pregnancy, childbirth or postpartum (maternal near miss or severe acute maternal morbidity) are increasingly recognized as useful means to examine quality of obstetric care. Nevertheless, routine implementation and wider application of this concept in reviewing clinical care has been limited due to the lack of a standard definition and uniform case-identification criteria. WHO has initiated a process in agreeing on a definition and developing a uniform set of identification criteria for maternal near miss cases aiming to facilitate the reviews of these cases for monitoring and improving quality of obstetric care. A list of identification criteria was proposed together with one single definition. This article presents the proposed definition and the identification criteria of maternal near miss cases. It also suggests procedures to make maternal near miss audits operational in monitoring/evaluating quality of obstetric care. The practical implementation of maternal near miss concept should provide an important contribution to improving quality of obstetric care to reduce maternal deaths and improve maternal health.

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Incidence and predictors of severe obstetric morbidity: case-control study.

Kevin C. Wolfe, S Bewley, M Waterstone (2001)

To estimate the incidence and predictors of severe obstetric morbidity. Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population with four randomly selected pregnant women as controls for every case. All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the region between 1 March 1997 and 28 February 1998. 48 865 women who delivered during the time frame. There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to 13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were 6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe pre-eclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture. Age over 34 years, non-white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or anti-depressants at antenatal booking were all independently associated with morbidity after adjustment. Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. Most events are related to obstetric haemorrhage and severe pre-eclampsia. Caesarean section quadruples the risk of morbidity. Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of haemorrhage and pre-eclampsia.

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Eclampsia in the United Kingdom 2005.

, Gwenan Knight (2007)

To estimate the national incidence of eclampsia in the UK and to describe the management and associated outcomes since the introduction of magnesium sulphate. A population-based descriptive study using the newly established UK Obstetric Surveillance System (UKOSS). All 229 hospitals with consultant-led maternity units in the UK. All women in the UK delivering between February 2005 and February 2006. Prospective case identification through the monthly mailing of UKOSS. Incidence and mortality rates with 95% confidence intervals. Data collection was complete for 94% of women. The incidence of eclampsia was 2.7 cases per 10,000 births (95% CI 2.4-3.1). Thirty-eight percent of women had established hypertension and proteinuria in the week before their first fit. Ninety-nine percent of women were treated with magnesium sulphate. No women in the study died. Fifty-four women (26%) had recurrent fits. One hundred and nineteen women (56%) were admitted to intensive care or obstetric high dependency units for a median of 2 days (range 1-9). Twenty-two women (10%) were reported to have other severe morbidity after the eclamptic episode. Outcomes were known for 222 infants (204 singletons and 18 twins). Eight infants were stillborn and five died in the neonatal period (perinatal mortality 59/1000 births [95% CI 32-98]). The incidence of eclampsia and its complications have decreased significantly in the UK since 1992, following the introduction of management guidelines for eclampsia and pre-eclampsia. These results are consistent with the findings of the randomised controlled trials of magnesium sulphate. This study has shown the practical benefits of the incorporation of research evidence into practice.

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Author and article information

Contributors

C. Mary Schooling: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2014

Publication date (Electronic): 13 May 2014

Volume: 9

Issue: 5

Electronic Location Identifier: e97401

Affiliations

[1 ]Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil

[2 ]Center for Studies on Reproductive Health of Campinas (CEMICAMP), Campinas, São Paulo, Brazil

CUNY, United States of America

Author notes

* E-mail: parpinelli@ 123456caism.unicamp.br

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: JCG MAP JGC SMH. Performed the experiments: JGC MAP SMH MLC FGS JLPS. Analyzed the data: JGC MAP MHS. Contributed reagents/materials/analysis tools: MAP JCG SMH MHS. Wrote the paper: JCG MAP MLC.

Article

Publisher ID: PONE-D-13-54346

DOI: 10.1371/journal.pone.0097401

PMC ID: 4019598

PubMed ID: 24825164

SO-VID: eb460905-81cc-4f12-ace2-4b7cd8661425

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 30 December 2013

Date accepted : 19 April 2014

Page count

Pages: 10

Funding

The study was financially supported by CNPq/DECIT (The National Research Council and the Department of Science and Technology of the Brazilian Ministry of Health), grant number 402702/2008-5. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The Burden of Eclampsia: Results from a Multicenter Study on Surveillance of Severe Maternal Morbidity in Brazil

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Abstract

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PLOS Global Public Health

Most cited references 15

Maternal near miss--towards a standard tool for monitoring quality of maternal health care.

Incidence and predictors of severe obstetric morbidity: case-control study.

Eclampsia in the United Kingdom 2005.

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