Maternal-Fetal Prognosis of Eclampsia at the Second Reference Hospital in the Urban Commune of Segou in Mali

Aim: To describe the epidemiological, therapeutic and prognostic aspects of eclampsia at the second reference hospital in the urban commune of Ségou in Mali. Patient and Methods: This was a descriptive, cross-sectional, analytical, retrospective and prospective study based on a comprehensive de-engineering. It covered a 3-year period from January 1, 2010 to December 31, 2012 and involved 176 cases. Results: The incidence of eclampsia during the study period was 2.9%. Classically, it occurred in 74.4% in young primigeste, in 73.9% in the 3 rd trimester of pregnancy and 26.1% of cases during postpartum. We recorded maternal complications such as retro-placental hematoma, acute kidney failure and delivery hemorrhage. The case fatality rate was 2.3% or 4 cases of maternal death. At the fetal level, there was 29.5% prematurity, 31.8% neonatal suffering, 11.4% hypotrophy, 11.9% in utero fetal death and 7.4% early neonatal death. Conclusion: The maternal-fetal prognosis remains reserved despite the progress made in the management of eclampsia in our ser-vices.

situation responsible for significant maternal and perinatal mortality and morbidity (6% -10%) according to FAYE A. [1] in his study of eclampsia at the University Hospital of Libreville published in the French journal of obstetric gynecology. They are more common in developing countries than in developed countries.
They contribute to worsening maternal mortality and morbidity in developing countries. As a result, the rate of eclampsia is an indicator of the level of socio-health organization of a country, a region.
What are the epidemiological, therapeutic and prognostic specificities of eclampsia in a context lack of qualified personnel, difficult geographical accessibility and the reference and counter-reference system with failures at the second reference hospital in Ségou, Mali?

Objectives
Objective: To describe the epidemiological, therapeutic and prognostic aspects of eclampsia at the second reference hospital in the urban commune of Ségou in Mali.

Patients and Methods
This was a cross-sectional, analytical descriptive study with retrospective data collection (January 2010 to December 2012) or a 3-year study period in the obstetric gynecology department of the second-reference hospital in Ségou, Mali.
Human resources available: For the obstetric gynecology department, we have two (2) Specialists in Obstetric Gynecology; two (2) General Practitioners; eight (08) Midwives; Five (5) Obstetrician nurses. For the resuscitation anesthesia department, we have a resuscitator anaesthetist, four nurses. For the paediatric ward, we have three (03) doctors, five (05) nurses. The study population consisted of pregnant women, parturients and birth attendants admitted to the ward.
The sampling was exhaustive. The criteria for inclusion were: patients who have a tonic-clonic attack associated with systolic hypertension (HTA) of 140 mmHg or/or higher diastolic blood pressure or equal to 90 mmHg (HTA-140/90 mmHg) associated with a positive two-cross urinary strip (significant proteinuria-0.30 g/24H). Patients whose records were not available, as well as those who had seizures during pregnancy not associated with high blood pressure, were excluded: convulsive seizures related to pernicious bouts of malaria confirmed by thick gout, epileptic seizures with the notion of history-based seizures, and ongoing anti-epileptic treatment. The data was collected using a previously tested fact sheet. The sources of data collection were: medical records, admission, delivery, and operational reporting records. The reference sheets/evacuations were used to collect the general information of the evacuated patients. The variables studied were: epidemiological characteristics (age, parity, number of antenatal consultations, risk factors, patient origin), therapeutic aspects (delivery pathway, resuscitation, blood transfusion) and prognostic (the morbi maternal-fetal mortality). The limits: the lack of financial resources and the inadequacy of the tech-

Results
After counting, 176 files met the inclusion criteria that served as work materials.
It was these 176 files that were used as materials Epidemiological characteristics: During the study period we recorded 176 cases of eclampsia out of the 5976 patients admitted during the gravido-postpartum period, representing a frequency of 2.9%. The average age of the patients was 20.65 years with extremes of 14 and 44 years. The 14 -19 age group was the most affected with a frequency of 60.2%. In our series 81.8% of patients were out of school and 13.6% had a primary level. These are patients who were most often unaware of the importance of antenatal consultations whose pregnancies were not followed or poorly followed. 61.9% of patients had not performed any antenatal consultations. These were patients evacuated in 66.4% of cases and they came from health facilities located within a 150 km radius.
Direct admissions accounted for 33.6% of cases. Table 2 shows the distribution of eclamps according to the method of admission.
Clinical aspects: The eclampsia attack occurred in anate, per or post partum with varying tension figures having more or an impact on the condition of the fetus as shown in Table 3.

Therapeutic and Prognostic Aspects
In our study 54.5% of patients had given birth by caesarean section. The delay between the crisis and childbirth was more than 5 hours in 63.1%. Medical treatment has been instituted in all of our patients. This treatment associated: antihypertensives whose most used was Nicardipine 10 ml in 88.6% of cases, anti-convulsives whose most used was magnesium sulphate (MgSO 4 ) in 90.9% of cases, oxygen therapy in 18.2% of cases.
As our service does not have a resuscitation unit, 43.7% of our patients were transferred to resuscitation and had an average stay of 2.71 days. The average length of hospitalization was 4.52 days ( Table 4).

Prognosis
Maternal complications accounted for 8.5% of cases. These maternal and fetal complications are listed in Table 5.
Infectious complications (endometritis and parietal suppuration) were the most common maternal complications with 53.4% of cases. The other complications were represented acute kidney failure with 20% of cases, retro-placental  Eclampsia is often associated with morbid fetal complications. These are dominated by prematurity (29.5%) hypotrophy (11.4%).
Fetal death in utero was noted in 13.7% of living infants were resuscitated and referred to the paediatric ward for neonatal suffering. The stillbirth rate was 11.9%. Table 6, Table 7 and Table 8 show us the search for a statistical relationship between certain study variables.

The Frequency
The lack of financial resources and the inadequacy of the technical platform to carry out certain biological examinations, the incompleteness of certain files of the retrospective period were limiting factor in the follow-up and management of patients. Despite these limitations, this study has allowed us to obtain results comparable to other studies.
The frequency of eclampsia during the posted gravity period was 2.9%. This frequency varies according to the authors this is how ours was superior to those reported by AHMADOU H. with 0.78% of cases [2], CISSE CT. and Al with 0.8% of cases [3], PAMBOU O. and Al with 0.32% of cases [4], DEMBELE N F. with 1.13% of cases [5].
Our frequency could be explained by the free caesarean section in Mali but also by the fact that our hospital has a resuscitation service thus receiving references from all health facilities in the region and some neighbouring regions.
Eclampsia is rare in Europe, with an incidence of 1.5 to 3 per 10,000 pregnan- The dysfunction of the health system, the poor organization of health care that results in the absence or irregularity in prenatal follow-up, the delay in management could explain this difference in frequency between developing and developed countries.

Socio-Demographic Characteristics
The average age was 20.65 years with a predominance of the 14 to 19 age group.
The same trend has been reported by Keïta M and Col. with average age 20 -4 ± years and predominance of the 15 -19 age group [8].
Most authors agree that adolescence is a factor in eclampsia due to their physiological immaturity and inexperience for proper prenatal follow-up.
According to some studies eclampsia is a condition of a young priparous woman under 25 years of age or of the multipare over 35 years of age [8]. We noted a predominance of primigeste (74.4%). This predominance of young primipares is reported by M. D. Beye et al. [9] (64.2%), Cissé CT et al. [10] (74.4%).
We have 77.3% housewives versus 22.7% singles. Our singles rate is lower than that of AHMADOU H. [2] and superior to that of HAMDA S. [10] with reported 24.74% and 20.60% of cases respectively. Single women in our country are most often without financial support inciting them to risky unwanted pregnancy behaviours that the perpetrator is not always identified Financial management of single pregnancies is a problem most often. Sometimes the perpetrator of the pregnancy is not known. However, even if the latter is known, there is a refusal to recognize this paternity of the pregnancy. We think like MERGER R. [8] that young primigestes are most often exposed to this had a primary level. These were patients who were most often unaware of the importance of antenatal consultations whose pregnancies were not followed or poorly followed. Our result is superimposed on those of KONATE S. [11] and DIARRA I. In our series, illiterates were the most affected with 81.8%. Our frequency is higher than that of DIARRA I. [6] and lower than FOFANA B. [12] who reported an illiteracy rate of 74% and 85% respectively. This shows us a low rate of school enrolment within the country. In the organization of our societies, women most often have modest or unfavourable socio-economic conditions and are unaware of the importance of antenatal consultations.

Clinical Aspects
High blood pressure is the first warning sign in this context of eclampsia. It appears to be the predictor of a poor maternal-fetal prognosis. In our study, systolic HTA was found in 94.3% with extremes of 140 and 240 mmHg. It was severe in 52.8%. As for the diastolic HTA that was most often associated with this systolic HTA was found in 96.6% with extremes of 90 and 140 mmHg and it was severe in 35.8%. Our result is higher than that of DIAKITE M. [13] which re- death. Fetal death was diagnosed at admission in 13.9%. When these fetuses were alive, they had fetal suffering with abnormal fetal heart noises in 14.6% (5.4% fetal bradycardia and 9.2% fetal tachycardia). Our result is lower than that of DIARRA I. [6] which yielded 26% at admission and 60% pathological (18% fetal bradycardia and 42% fetal tachycardia).
The alteration of the state of consciousness was frequently noted in our patients ranging from simple obnubilation to deep coma. This alteration of the state of consciousness was related to the number of seizures.
More than half of our patients had their long-term pregnancy as in DIARRA I. [6] (54%). This trend is also observed in CISSE CT. [3]

Statistical Analyses between Variables
The Glasgow score calculated to assess a patient's level of consciousness may be related to the Apgar of the newborn, however our study did not find a statistical link (Table 6) [Khi2-9.0382; ddl-6 and p-0.1714].
The appearance of the first convulsive seizures that contribute to triggering labour, the poor fetal-maternal exchanges caused by pre-eclampsia with its consequences of intrauterine growth retardation and stillbirth explained tell us more about a significant statistical link between fetal prognosis and the period of occurrence of seizures as shown in Table 7 [Khi2-17,3217; ddl-6 and P-0.0082].
The coma that takes place after several seizures makes vaginal delivery difficult. So many authors opt for caesarean section. This close relationship between the birthing route and the Glasgow score was reported by our series with a Khi2-25.60, ddl-2 and p-0.0000 (Table 8).

Support
Indeed, the crisis often triggers labour in this context of remoteness from our health facilities with the consequences of deliveries before arrival at the centre.
In our study 54.5% of our patients were caesarean. This result is lower than that of DIAKITE M. [13] who had a caesarean section rate of 85.1%. In the Open Journal of Obstetrics and Gynecology the rate of caesarean section found in cases of eclampsia is 87% of cases, which is higher than our result. These are most often patients admitted in latency with unstable tension figures most often associated with acute fetal suffering.
The prognosis reflects the quality of prevention and care at all levels of care.
For this management, we have instituted medical treatment in all our patients.
This treatment has combined several molecules. These were anti-hypertensives whose most used was nicardipine 10 ml in 88.6%; anti-convulsants, the most commonly used of which was Magnesium Sulfate (MgSO 4 ) in 90.9%; oxygen therapy in 18.2% in crisis intervals and vascular filling of all our patients. As our service does not have a resuscitation unit, 43.7% of our patients were transferred to resuscitation and all returned to the ward after an average stay of 2.71 days.
The average length of hospitalization was 4.52 days.

Prognosis
Eclampsia is a pathology responsible for maternal and fetal complications that are sometimes serious. In our study, we recorded 8.5% of maternal complica- we can say that the frequency of eclampsia was higher in our study and the maternal prognosis is less severe. This could be explained by the current improvement in case management with free caesarean section and the use of magnesium sulphate. The difference in the quality of care between developed and developing countries remains relevant and explains this death rate reported by the French series [18] which is 2.2% lower than ours.
Eclampsia due to repeated seizures, tension figures, and utero-placental ischemia is responsible for fetal death in utero. 13.7% of live infants were resuscitated and referred to the paediatric ward for neonatal suffering. We see a marked decrease in the stillbirth rate of 11.9% for our series of 24% and 17% for studies conducted a few years earlier [5] [6] in the same department. This improvement in fetal prognosis may be due to the significant changes that have

Conclusion
The maternal-fetal prognosis remains reserved despite the progress made in the management of eclampsia in our services.

Authors' Contributions
All the authors participated in the writing of the manuscript. They all approve the final version of the manuscript.

Ethics Authorisation
The ethics committee's authorization was found prior to the start of the study.