Severe Preeclampsia Epidemiological, Diagnostic, Therapeutic and Prognostic Aspects at the Thies Regional Hospital Center about 443 Cases

  

    
Complications Fetal 
    
Death 
    
Total 
    
P value 
    
Ods [95% CI] 
  
  

    
Yes 
    
No 
  
  

    
N 
    
% 
    
N 
    
% 
  
  

    
Apgar    <7 
    
37 
    
18.87 
    
159 
    
81.12 
    
196 
    

    
5.8    [3.1-7.8] 
  
  

    
Prematurity 
    
32 
    
17.29 
    
153 
    
82.70 
    
185 
    

    
3.6    [2.5-5.9] 
  

Table 4: Link between fetal complications and perinatal mortality.

OR = 5.8 [95% CI] = (3.1-7.8), P <0.05

In addition, premature newborns had a 3.6-fold risk of dying according to our analysis (Table 4) OR = 3.6 [95% CI] = (2.5-5.9), P <0.05.

Discussion

Prevalence

The prevalence of severe preeclampsia is variously estimated by the authors. It varies according to the population studied, the definition used, the level of development of the given country and the method used. This explains the disparity in the figures reported. The overall prevalence of PES which is estimated at between 3 and 5% of pregnancies in the world, with an incidence which would be much higher in developing countries [7]. In the United States, the prevalence is between 0.7 and 1.5% according to the authors [8]. In France, the incidence of PES was 1.0% (1.5% in nulliparas and 0.7% in multiparas) [5]. In Africa, this prevalence is poorly assessed; only hospital statistics are available with rates varying from 2.8 to 6.1% of deliveries [9]. Compared to studies carried out in Senegal, our rate of 3.12% of deliveries is lower compared to those found by Saar [10], Mbodji [11], Séne [12], Danmadji [13] and El Hasnaoui [6]. Tchente in Cameroon on the other hand had a rate of 2.3% lower than that found in our series [14]. Higher rates are found by Tchaou in Benin [15] and Lokossou in Cotonou [16] with respectively 14, 7% and 4.2%.

Sociodemographic characteristics

The predominance of young age in our series is consistent with data in the literature which consider them to be risk factors for the disease. This predominance of young age is found in the studies of Saar [10], Séne [12], Danmadji [13] and El Hasnaoui [6] in Senegal. In Tchente [14], on the other hand, the majority of patients were older between -Beye in Dakar [18] and Liu in Taiwan [9] were respectively 26 and 30 years old on average. We had recorded 52.37% of firsttime mothers. In Tchaou’s series [15], on the other hand, nulliparas (40.8%) were the most represented. Primigest were the most affected (50.56%) in our series. These results are lower than those found at the Dakar University Hospital (68%) [19] but almost overlap with those observed in the USA in 2010 (47.3%) [20].

The majority of patients in our series (63.86%) were housewives. For Attolou [21], low-income women are subjected to stress and significant physical exertion favoring the development of the disease. These results are corroborated by the work of Beaufils [22] who points out that the risk of having pregnancy-induced hypertension is higher in women who have significant physical or intellectual activity and / or poor social security.

Clinical and paraclinical aspects

The late-onset forms (36-39 WA) were the most frequent (65.3%) in our series. The same observation is made in the studies of Séne [12], Danmadji [13] and El Hasnaoui [6] in Senegal. In Séne [12], preeclampsia was diagnosed in 96% of cases after 29 WA. This late discovery is favored by the insufficiency or absence of correct prenatal follow-up of our patients. The mean number of ANC was 3.28 ± 1.05 in our series. In Tchaou’s study, the pregnancy was not monitored (no prenatal consultation) or was poorly monitored (less than 4 antenatal consultations) in more than half of the patients (52.4%) [15]. The WHO currently recommends at least 8 contacts for monitoring a normal pregnancy [14]. Even though regular monitoring of the pregnancy does not prevent the onset of preeclampsia, it does allow it to be detected early and prevent progression to severe forms of the disease. The insufficient prenatal follow-up of patients explains the late evacuations at the stage of severe preeclampsia. The arterial hypertension was indeed severe in more than 93.90% of the patients in our series. The majority of our patients (95.48%) had albuminuria ≥ 2 crosses. The same observation is made by Hasnaoui [6] in whom 97% of patients had albuminuria ≥ 2 crosses. Tchaou [15] also reported in his study that 97% of parturients had albuminuria ≥ 2 crosses. The 24-hour proteinuria, which gives a more precise value, was rarely performed in our series due to lack of financial means in the patients. The edematous syndrome was inconsistent and found in 90.29% of the patients in our series; while Tchaou [15] and Mayi-Tsonga [25] had lower rates of 71.8% and 50% respectively. Sixty-six point thirteen percent (66.13%) of our patients had hyperuricemia. This rate is higher than that of Tchaou [15] and Mayi-Tsonga [25] who found 36% and 31% respectively in their series. According to Beaufils, the value of 58.8 mg / l of uricemia represents the threshold beyond which the risk of fetal death increases almost linearly, approaching 100% from 100.8mg/l [22].

Therapeutic aspects

In our series, parenteral Nicardipine was the first-line antihypertensive drug in almost all of our patients (99.32%). Alpha methyl dopa was used in combination with Nicardipine in 31% of patients with oral relay. Diuretics were rarely used (0.90% of patients) in acute lung edema or acute renal failure. This therapeutic attitude is the same in most of the studies carried out in Senegal [8,11-13]. Likewise, in the study by Tchente [14], Nicardipine was the most prescribed antihypertensive drug (69.6%) followed by alpha methyl dopa (12.9%), and clonidine (11.04%), Nifedipine (2.07%). These results differ from those of Neji [24] who had used dihydralazine in more than half of their patients. Likewise, Brouh [17] reported Dihydralazine (50.1%) as the first-line antihypertensive agent followed by Nicardipine (25.3%), Clonidine (8.0%), Nifedipine (6.4 %), and Methyl dopa (4.2%). In our study, 77.5% of the patients had also benefited from an anti-convulsant treatment, mainly based on magnesium sulfate (97.29%). Magnesium sulfate is found to be superior in preventing and treating eclampsia attack, compared to other anticonvulsants. Its vasodilator effect is also interesting in order to lower blood pressure levels, but not without a risk of hypotension due to its potentiating action of nicardine [22]. The combination of antihypertensive treatment with magnesium sulfate was almost systematic in our series and did not cause any noticeable side effects under good monitoring. In contrast, benzodiazepines and barbiturates were the only anticonvulsants used in other studies [26].

Regarding obstetrical treatment, the delivery route depends on the term of pregnancy and the maternal-fetal condition. We had comparable rates of vaginal delivery and Caesarean section with 48.53% versus 49.88%. Brouh [17] and Tchente [14] had obtained higher rates of caesarean section with respectively 58.5% and 57.5% of deliveries by caesarean section and this at a term of more than 37 weeks. On the other hand, Tchaou [15] and Lankouande [27] favored the vaginal route with respectively 51.5% and 54.3% of vaginal delivery.

Evolutionary and prognostic data

The outcome was favorable in 95.93% of the patients in our series with, however, significant morbidity in relation to the frequency of complications such as retroplacental hematoma and acute renal failure. Our results are also better than those found by Brouh and Mayi-Tsonga [17,25] with respectively 76.7% and 79% favorable outcome.

In terms of maternal morbidity and mortality, the most frequent main maternal complication was eclampsia with a frequency of 24.78% of cases, followed by Hellp syndrome (3.61%), retroplacental hematoma (3.61%) and acute lung edema (1.12%). Tchente [14] reports as complications the HELLP syndrome (12.7%), acute renal failure (13.3%), infections (8.2%), retroplacental hematoma (3.8%), disseminated intravenous coagulation (3.1%), acute lung edema (3.8%), post-cesarean hemorrhage (1.9%). These same complications are found in most African series [11,14]. They result from a lack of screening, late diagnosis of the disease and above all from insufficient monitoring of these high-risk pregnancies. These complications are remarkable for their unpredictability and their higher risk of maternal-fetal mortality [13,17,28,29]. Patients with eclampsia were 8.5 times more likely to die (p = 0.05 OR = 8.5 [3.9-18.4]).

Our maternal death rate (4.06%) was lower than the rates recorded by Tchaou [15] (6.8%) and by Mayi-Tsonga in Brazzaville (21%) [25]. Tchente had obtained 4.4% maternal deaths [14]. Brouh in Côte d’Ivoire found maternal mortality 16% higher [17]. In developed countries, the prognosis is better thanks to the means of screening and treatment. In the United States, maternal mortality from severe preeclampsia and eclampsia is 0.06% according to Mackay [30].

Fetal development between day 1 and day 6 of life was 84.42% of children alive against 15.57% of deaths. In Tchaou, the evolution was favorable in the short term (first week of life) in 57% of newborns against 17.6% of early neonatal death [15]. Tchente reported 21.8% perinatal deaths [14]. In the literature, the risk factors for perinatal mortality are most often prematurity, fetal hypotrophy and the existence of maternal complications. Thus, the fetal complications most represented in our work were, in order of frequency, by hypotrophy (51.46%) and prematurity (41.08%). In Tchente, the most common fetal complications were, in order of frequency, prematurity: 44.3%, intrauterine growth retardation: 23.4%, fetal death in utero: 17.7% [14]. These results differ from those obtained by Mboudou with 13.4% prematurity as the most frequent fetal complication [29].

Conclusion

Severe preeclampsia is a frequent pregnancy pathology in our practice. In our context, due to the low coverage of the health needs of mother and child, its prognosis is still severe.

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