Incidence and determinants of adverse outcomes among women who were managed for eclampsia in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background: The incidence of eclampsia and its adverse maternal outcomes are very high in developing countries, particularly in Subsaharan African Countries. Identifying predictors for adverse maternal outcomes of eclampsia has paramount importance for helping health care providers to optimize their management outcomes. Therefore, this study aimed to assess the incidence of adverse maternal outcomes of eclampsia and its determinant factors. Methods: A retrospective follow-up study design was applied. The data were extracted from patient charts using a structured, pre-tested, questionnaire. Descriptive analyses (frequencies, means, and standard deviation) were calculated, and bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. After the data were coded and entered into Epi-Info Version 7.2 Software, the data were analyzed using STATA Version 14 Statistical Software. Results: The magnitude of eclampsia was 5.36 per 1000 pregnancies (95% CI: 4.72, 6.10). The incidence of adverse maternal outcomes in eclamptic mothers was 53.7% (95% CI: 47.02, 60.24%). After adjusting for covariates maternal age 30–34, AOR 5.4 [95% CI = 1.02, 28.6]; age above 34, AOR 10.5 [95% CI = 1.3, 88.6]; gravidity 2–4, AOR 0.3 [95% CI = 0.1, 0.9]; 10 or more convulsions, AOR 4.6 [95% CI = 1.4, 14.9]; mild pyrexia, AOR 20.4 [95% CI = 3.7, 112.7]; moderate pyrexia, AOR 14.6 [95% CI = 1.7125.1]; platelet count below 50,000 cells/mm3, AOR 34.9 [95% CI = 3.6, 336.2]; platelet count between 50,000 and 99,000 cells/mm3, AOR 24.5 [95%CI = 5.4111.6]; and stillbirth of the current pregnancy, AOR 23.2 [95%CI = 2.1257.5] were strong predictors of adverse maternal outcomes in eclamptic mothers. Conclusions: The incidence of adverse maternal outcomes of eclampsia was found to be high compared to similar studies discussed in this study. This study recommends early identification of patients with the risk factors (having many convulsions, high body temperature, low platelet count, patient age above 30 years, and 2–4 pregnancies), strengthening the referral system, and advocation of research on the area of adverse maternal outcomes and thereby encourage evidence-based medicine. We employed a retrospective follow-up study design to assess the incidence of adverse maternal outcomes of eclampsia and its determinants at the University of Gondar Compressive Specialized Hospital (UOGCSH), Gondar, Northwest Ethiopia. UOGCSH is one of the pioneer hospitals in the country and serving the population for more than 60 years. This teaching hospital provides more than 18 undergraduate and postgraduate programs in medicine and related sciences. Besides, it serves as a referral center for more than 7 million populations with varying climatic and geographical characteristics from related provinces, regions, and countries. Department of Obstetrics and Gynecology started a specialty program in 2010. There are now 50 residents and three subspecialty programs in three fields that have just opened. Every year, roughly 200,000 individuals visit the hospital, according to the Hospital Plan and Program Information Center. The total number of deliveries each year averages 8000. In this study, the data were collected from September 01, 2013, to August 31, 2020. All patients who were diagnosed with eclampsia during pregnancy or postpartum period and were admitted and managed as eclampsia at UOGCSH in the data collection period were included in the study. Patients with a previous history of epilepsy and patients with other causes for convulsions (like infection, electrolyte imbalance, toxic or metabolic encephalitis, brain tumors, and trauma) were excluded from the study. The sample size was determined using the single population proportion formula by assuming a 95% level of confidence, 16% incidence [13], 5% margin of error, and adding 10% to account for incomplete/lost charts, resulting in a required sample size of 227. To get to this size, all eclamptic patients in the specified period were taken. Therefore, the final sample size included in this study was 231 patients. The diagnosis and medical record number were searched from the morning presentation registry and all medical records/charts with eclampsia diagnosis were considered for data collection. A pretested and structured questionnaire was used for data collection. The data collection questionnaire was adapted from different literature [29, 30] and modified by investigators to satisfy the objectives of this study (Supplementary file 1). The clients’ demography, detailed clinical characteristics, complications, and management characteristics were extracted through chart reviewing of eclamptic patients. Data collection was done by three General Practitioners (Physicians). The medical record number of eclamptic patients in the morning registry was used to access patients’ main charts. In the beginning, after the identification of eclamptic patient charts, all baseline data were collected. Then, all patient charts were followed to observe the status of the outcome. During the follow-up, all the necessary data were recorded (clinical profile, maternal measurements, medications or procedures prescribed, clinical features, maternal complications, and diagnostic/laboratory findings, for example). At the end of the follow-up, all outcome status, clinical management information, and maternal complications were also recorded meticulously. The adverse maternal outcomes of eclampsia were an outcome variable. It refers to maternal mortality or one or more serious complications of major organ morbidity. Eden’s criteria and WHO maternal near-miss criteria were employed for describing the severity of eclampsia. Adverse maternal outcomes are abruption placentae, DIC, maternal shock, HELLP, AKI, respiratory distress, neurologic complications, PPH, blood transfusion requirement, ICU admission, and maternal deaths. The explanatory variables are socio-demographic, clinical, laboratory, and management. These are maternal age, residency, parity, gestational age, number of gestation, the presence of antenatal care visit, place of antenatal care, eminent symptoms, the number of convulsions, duration of convulsions, referral system to our hospital, past obstetric history, history of self-chronic illness, history of family chronic illness, vital signs at admission, blood pressure at referral, labor initiation, duration of labor, place of delivery, mode of delivery, indication for cesarean section, antihypertensive requirement, anticonvulsant requirement, and laboratory/imaging findings. Definitions: Adverse maternal outcomes included maternal mortality or one or more serious complications of major organ morbidity. Hypertensive disease of pregnancy: Diastolic blood pressure (DBP) > 90 or systolic blood pressure (SBP) > 140 with two occasions at least 4 h apart and 1 week, after 20 weeks of pregnancy and 12 weeks of the postpartum period with ± proteinuria. Maternal death or maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Maternal near-miss: The International Statistical Classification of Diseases and Related Health Problems 10th version defined a maternal near-miss case as a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Uncontrolled seizure: It is when there is a requirement of another anticonvulsant or reloading of Magnesium Sulfate after 15 min of an initial loading dose of Magnesium Sulfate to control recurrent seizures. After data extraction was completed, the data were checked for completeness and accuracy. Then, the data were coded and entered into Epi-Info Version 7.2 Software. Finally, the data were exported into STATA Version 14 Statistical Software for analysis. Univariate analyses were performed and presented as frequencies and percentages for categorical variables. Mean and Standard Deviation (SD) were reported for normally distributed data. The median and interquartile ranges were considered for non-normally distributed data. Bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. Bivariate analyses were made between independent variables and the outcome variable (adverse maternal outcomes of eclampsia) and the variables with a P-value < 0.2 were selected for multivariable analysis. A P-value < 0.05 (95% confidence interval) was taken as a cut-off point for a statistically significant variable in multivariable logistic regression analysis. The goodness of fit was assessed by using the Hosmer and Lemeshow test. A standardized data collection tool was employed, which is adopted and modified contextually. The data collection instrument was pretested for clarity and appropriateness before the actual data collection. To ensure the quality of data, the collected data were checked daily for completeness, accuracy, and clarity by the investigators. Data clean-up and crosschecking were done before analyses. The training was given to the data collectors for 3 days to equip them with the necessary skills. The investigators continuously supervised during the data collection process and the collected data were entered on the same day to address inconsistencies regarding wrong entries. Ethical clearance/approval was obtained from the ethics committee of the School of Medicine, University of Gondar. With this clearance, formal approval was sought and the permission for conducting the study (official letter) was secured from the administration of UOGCSH and the Department of Gynecology and Obstetrics before commencing the study. “Informed Consent waiver was obtained from the ethics committee of School of Medicine, University of Gondar” (Dr. Abebe Muche, Chair of Ethical Review Board, reference number: 2169/08/2020) and hospital directors (Signed and approved on reference number, 2169/08/2020). The confidentially of the data gathered was kept and handled during all phases of research activities. We confirm that all methods were performed following the relevant guidelines and regulations (institutional, national, and international).