ABSTRACT
Main Objective: This study was therefore to access the incidence of Preeclampsia in
women admitted to FMC Yola in their pre and postnatal wards during their last
trimester.
Study Design: The study was carried out among pregnant women who are admitted
in antenatal and postnatal wards after 20 weeks of gestation and was carried out at
FMC Yola Adamawa State from February to April 2015.
Method: Structured Questionnaires from patients in antenatal and postnatal wards at
FMC Yola.
vii
Results: The number of women who were diagnosed with either Preeclampsia or
Eclampsia was thirty in number. About 90% of the participants who were presented
to the hospital during their last trimester were unbook and have high level of blood
pressure of 140/90 mmHg and above. They women with the normal blood pressure
of 120/80 mmHg are 3 (10%), 160/110 are 17(56.7%), BP 140/80 mmHg are 4
(13.3%), BP 150/110mmHg are 6 (20%) and they also have high level of proteinuria
in their urinary analysis with, Proteinuria of +3 (61.3%) and Proteinuria of +2
(32.3%) and (3.3%) were negative for the latter biomarker in their urine respectively.
A greater number of the women don’t show up for antenatal visits with (56.7%),
those that show up once during their pregnancies were (13.3%), those that show up
twice were (10.0%), three times (6.7%), four times (3.3%), five times (6.7%) and six
times (3.3%) respectively.
Conclusion: The fact that most of the causes of Preeclampsia and Eclampsia is due
to high level of blood pressure and proteinuria, measures should focus on how to
reduce this problem and patients should come on time to the hospitals. The exact
etiology of Eclampsia remains speculative for now and most are presenting to health
facility for the first time and the study showed the importance of antenatal care.
Key Words: Preeclampsia, Eclampsia, Hypertension, Proteinuria, Gestational
Hypertension, Pregnancy induce hypertension, antenatal care, chronic Hypertension,
pregnant women, FMC Yola
viii
TABLE OF CONTENTS
Title page …………………………………………………………………………………………………… i
Certification page ………………………………………………………………………………………. ii
Reader’s Approval Page …………………………………………………………………………….. iii
Dedication Page ……………………………………………………………………………………….. iv
Acknowledgements ……………………………………………………………………………………. .v
Abstract ………………………………………………………………………………………………….. vi
Table of Contents ……………………………………………………………………………………. viii
Definition of Terminologies and Meaning of Acronyms ………………………………… xi
1.0 Introduction ………………………………………………………………………………………….. 1
1.1 Limitations …………………………………………………………………………………………… 2
1.2 Comparison of Eclampsia in Nigeria with other parts of the world …………….. 3
1.3 Maternal health……………………………………………………………………………………… 4
1.4 Complications of maternal health ……………………………………………………………. 4
1.5 Antenatal care……………………………………………………………………………………….. 7
1.6 Aim and objectives of antenatal care ……………………………………………………… 7
1.7 Life style concerns ………………………………………………………………………………. 8
1.8 Screenings done during antenatal for maternal complications …………………. 11
1.9 Hypertension ………………………………………………………………………………………. 12
2.0 Classification of hypertensive disorders ………………………………………………… 14
2.1 Pre-existing (Chronic) Hypertension ……………………………………………………. 14
2.2 The definition and diagnosis of hypertensive Disorders …………………………… 15
ix
2.3 Etiology and pathophysiology of Preeclampsia and Eclampsia …………………. 17
2.4 Types of Eclampsia …………………………………………………………………………… 18
2.5 Complications of Eclampsia ………………………………………………………………. 19
2.6 Diagnosis of Preeclampsia and Eclampsia …………………………………………….. 20
2.7 Epidemiology and risk factors ……………………………………………………………… 20
2.8 Treatment, solutions and management ……………………………………………………. 21
2.9 NGOs and health organizations …………………………………………………………….. 22
3.0 Methods ……………………………………………………………………………………………… 25
3.1 Study Area ………………………………………………………………………………………….. 27
3.2 Subjects ……………………………………………………………………………………………… 27
3.3 Sample Collection ……………………………………………………………………………….. 27
3.4 Age of the subjects ………………………………………………………………………………. 28
3.5 Known History of Preeclampsia ……………………………………………………………. 28
3.6 Number of children ……………………………………………………………………………. 28
3.7 Ethical consideration ………………………………………………………………………….. 28
3.8 Data Management ……………………………………………………………………………….. 28
4.0 Results ……………………………………………………………………………………………….. 29
4.1 Graphical Representation of the Background of the Participant …………………. 29
4.2 Background information of Preeclampsia ……………………………………………… 30
5.0 Discussion and Conclusion …………………………………………………………………. 43
5.1 Discussion ………………………………………………………………………………………….. 43
5.2 Conclusion …………………………………………………………………………………………. 46
x
DEFINITION OF STUDY TERMINOLOGIES AND MEANING OF
ACRONYMS
Antenatal: The care given to pregnant women during pregnancy
PIH: Pregnancy Induce Hypertension
GH: Gestational Hypertension
PCH: Pre-existing (Chronic) Hypertension
MDGs: Millennium Development Goals
WBR: World Bank Record
WHO: World Health Organization
FMC: Federal Medical Centre
MgSO4:
Magnesium Sulphate
GLT: Glucose Load Test
MMR: Maternal Mortality Ratio
MHC: Maternal Health Complication
UNICEF: The United Nation Children Fund
HNI: Hypoxia Neurology Injury
1
1.0 INTRODUCTION
Preeclampsia is one of the hypertensive disorders that affect pregnant women
worldwide; it is characterized by the presence of proteinuria in the pregnant woman’s
urinary analysis and increase in blood pressure above 140/90 mmHg, edema or both.
Preeclampsia is the second largest cause of deaths of both mothers and babies in the
United Kingdom with the death of at least 6 to 9 mothers annually and 175 babies
(Norwitz at el, 2013). Preeclampsia includes a condition known as preeclamptic
toxemia (PET) or gestational proteinuric hypertension, which pregnant women
develop after twenty weeks of gestation, due to the placenta disease. Preeclampsia is
characterized by high blood pressure, proteinuria and edema, without proper
management and intervention it will progress to Eclampsia; this is characterized by
malignant hypertension and epileptiform convulsions which will require emergency
caesarian section to the woman (Attahir et al, 2010).
Preeclampsia is an illness that occurs more in pregnant women living in developing
countries with the estimate of 98% and over 63,000 women nationwide also die of
the complications. It is also known that about 10% of Preeclampsia cases occur in
women with first time pregnancies and the severe stage of Preeclampsia will lead to
multisystem complication, such as hepatic and renal dysfunction, cerebral
hemorrhage, and respiratory compromise (Edmonds, 2007). Women with
preeclamptic condition suffer headache, blurred vision, edema in both legs and the
feet and hands, and blood pressure above 140/90 consistently (NCBI, 2014).
2
Aims/ objectives:
1. To access the incidence of Preeclampsia in pregnant women because it is the
major cause of illness and death for both mother and baby and the incidence
of the disease hasn’t decreased over the last 20 years as obesity seems to
increase the risk.
2. To determine the relationship between Preeclampsia and hypertension.
3. To check if there are ways in which pregnant women can protect their selves
from Preeclampsia, by checking if diet can help in preventing Preeclampsia.
4. To interview the pregnant women with the illness about Preeclampsia and
how they manage the disease
5. Lastly to interview the doctors about the clinical aspects of the disease and
how they monitor the disease.
Hypothesis: High blood pressure in pregnant women usually causes Preeclampsia.
1.1 Limitation of the study
• Limitation to data collection in FMC due to low number of patients with
Preeclampsia and Eclampsia cases.
• Limitation due to strike
• Data from antenatal ward is incomplete because the pregnant women have
not given birth yet.
3
1.2 Comparison of Eclampsia in Nigeria with other parts of the world
The major cause of maternal mortality in Sub-Sahara Africa is globally known and
the problems are still not address by the Millennium Development Goals (MDG 5),
which have a target of reducing 75% of maternal mortality ratio from1990 to 2015
(Ronsmans, et al, 2006). The rate of mortality rate in Sub- Sahara Africa have
dropped globally from 500, 000 in 1986 to 358, 000 in 2008 base on the World
Health Organization records but still developing countries account for 99% of the
maternal deaths(WHO, 2014). Base on the World Bank record, the rate of maternal
mortality had dropped 45% between 1990 and 2013 in most region and countries
except in Sub-Sahara Africa where MDG 5 target of reducing maternal deaths by
75% 1990 to 2015 were not made (Worldbank, 2015). Nigeria’s maternal mortality
rates is one of the worst compare to other countries like Rwanda, Somalia, Libya,
Kenya, Ghana at the same time falls behind its contemporaries in the 1960s like the
oil- producing countries like Saudi Arabia, Kuwait, Iran, and Qatar (Rogo, 2013).
The estimated ratio of maternal mortality per 100,000 live births in Nigerian women
who died from pregnancy related causes while pregnant from 2010 to 2013 had
dropped a little from 610 to 560 (Worldbank, 2015)
The socio-economic impact in developing countries is huge, even more so if we
consider that in Columbia, for example, the rate of maternal mortality is ten times
higher than in the United States. Despite the fact that rate of Preeclampsia and the
number of maternal deaths from hypertensive disorders in pregnancy has fallen
consistently over recent years in some developing countries, in places where
maternal mortality is high the majority of these deaths are connected with
4
Preeclampsia and Eclampsia. Preeclampsia / Eclampsia remains one of the most
common causes for maternal death during pregnancy worldwide (Sahin, 2003).
1.3 Maternal Health
Maternal Health is refers to the general health of women during gestation or
pregnancy, childbirth and the postpartum period. While motherhood is often
regarded to as the positive fulfilling experience in a woman life, which a lot of
women experience is associated with suffering, ill-health and even death (WHO,
2015). The major causes of maternal morbidity and mortality are associated with
these complications which includes high blood pressure, unsafe abortion, infection,
haemorrhage and obstructed labour (WHO, 2014)
1.4 Maternal Health Complications
Complications that women encounter during pregnancy involve the baby’s health,
the mother’s wellbeing or even both. Some women have issues with their health that
emerge during pregnancy, while other women have health issues before they get to
be pregnant that could lead to maternal complication problems such as Preeclampsia,
placental abruption (when the placenta separates from the wall of the uterus), and
gestational diabetes (CDC, 2014). It is important for women to get medical services
before and during pregnancy and to always check their health status in order to
reduce risk factors of diabetes, renal impairment and high blood pressure.
In developing countries, pregnancy-related problems such as hypertension disorders,
gestational diabetes and obesity are known as the primary cause effect of death
amongst women of reproductive age. According to the United Nations (2005) in
developing countries more than 80% of women lose their lives each year during
5
pregnancy or childbirth and twenty times that number suffer serious injury or
disability. Some development has been made in reducing maternal deaths in
developing regions, but not in the countries where giving birth is most risky (United
Nations 2005). Locally, Africa has only 12% of the worldwide populace; however, it
represents a large portion of all maternal deaths and half the deaths of children less
than five year of age. Almost 4.7 million moms, new-borns, and children die each
year in sub-Saharan Africa: 265,000 mothers die because of complications of
pregnancy and childbirth or labor (Bryce & Requero 2010; UNICEF 2009).
Maternal Health complication is made up of several diseases that affect the health of
women during pregnancy and childbirth worldwide; some of the problems are related
to the unborn child while others to the mother. These are some of the issues women
undergo during pregnancy, which are maternal diabetes or gestational diabetes,
hypertension, Preeclampsia, renal impairment and cardiac disease (Sibai, 2013).
Gestational diabetes: This is a condition that occurs during pregnancy when the
insulin resistance level in the mother’s blood is increased and the peripheral uptake
of glucose reduced, which makes the flow and supply of glucose to the fetus in a
continuous process. Gestational diabetes has few risk factors to the mother but rather
has high risk factors to the fetus; such risks factors are exposure to high level of
concentration of glucose, which will result in making the fetus to grow large. When
the fetus grows bigger the mother is in the risk of having a cesarean section delivery
or birth injury during normal delivery (El-Mowafi, 2002).
Gestational diabetes screening test is advise during pregnancy because insulin
resistance has a 50% chance of developing maternal diabetes in subsequent
pregnancy and 40-60% of developing diabetes in future (Norwitz at el, 2013). The
6
Glucose Load Test (GLT) machine is used in screening for gestational diabetes for
pregnant women after 24 to 28 weeks of gestation, especially those with a history of
diabetes, obesity, gestational diabetes and sustained glycosuria or fetus macrosomia
(Agboola, 2001).
Renal Impairment: This is a condition that is caused by bacteria that is
asymptomatic, which is likely to progress to pyelonephritis and cause Escherichia
coli. Women suffering from renal disease are advised by doctors to try and conceive
when the degree of their renal impairments is in a controlled stage. That is when the
danger is moderate because if the couple delays it will affect the pregnancy. When
the renal impairment is in its chronic stage, it leads to risk of infertility,
Preeclampsia, spontaneous abortion, fetal growth restriction or death and preterm
delivery. For women that are at the end-stage of renal impairment, it is advised to
have transplant of renal which is their best chance of having a successful pregnancy
(Norwitz at el, 2013).
Gestational Hypertension: This is hypertension that affects pregnant women after 20
weeks of gestation. Women with histories of pre-existing hypertension should be
monitored and their blood pressure should be checked daily and anti-hypertensive
drugs should be given to control the blood pressure (Agboola, 2001).
Preeclampsia: This condition is normally caused by high blood pressure and
proteinuria in the pregnant woman’s urine. Women with low intake of calcium
supplement in their normal diet during pregnancy have the high risk of developing
Preeclampsia and women with histories of Preeclampsia in the previous pregnancies
have 10% risk of recurrence in future pregnancies (Edmonds, 2012). Pregnant
women with or without histories of Preeclampsia are advised to start taking aspirin in
7
the early stage of pregnancy in order to reduce the risk of developing Preeclampsia
(Sibai, 2003).
1.5 ANTENATAL CARE
Antenatal care is the professional care and advice given to pregnant women who visit
the hospital/ health center/ clinic for screening, monitoring, advice, nutrition
supplementation and referrals if necessary. This type of healthcare helps mothers to
know the medical condition of the health of their unborn child and their health; it
also helps in identifying women who require specialist support and it helps to
providing information from several healthcare professionals regarding pregnancy to
first time pregnant women and to inform them on childbirth and parenthood (
Edmonds, 2010). Every pregnant woman should know antenatal care visits are very
important from the early stage of pregnancy, as early as from the first six months on
a monthly basis, and when the pregnancy is in its 7th and 8th months, the visits should
be on a two week basis and in the 9th months it should be on a weekly basis
(Agboola, 2001).
1.6 AIMS AND OBJECTIVES OF ANTENATAL CARE
Antenatal care is a very important part of pregnancy care that every pregnant woman
is advised to take very seriously and be part of if she wants her unborn child to be
healthy and she too will know her health status.
Antenatal visits: Help in early detection and prevention of pregnancy related
complications and disorders such as Preeclampsia, Eclampsia, anaemia, diabetes and
haemorrhage and how it can be treated in its early stages. It also helps in knowing the
8
mal-position and disproportion that may influence the decision in preparation for
labour (El-Mowafi, 2002)
Antenatal Education: This is the most important part of antenatal care because some
husbands in Nigeria take it as the less important part of pregnancy cycle. Some
people don’t allow the wives to visit the hospitals due to their traditional and
psychological beliefs. In these cases it is advised that women and the husbands or
partners should be involved in decision making regarding their antenatal care, and
antenatal classes should be attended by both partners, where they should discuss the
physiological and psychological changes of pregnancy, baby development, labor and
childbirth and the way newborn babies are taken care of (Edmonds, 2012).
1.7 LIFE STYLE CONCERNS
During the early stage in pregnancy, a woman’s life style is completely changed and
her diet too is changed for the benefit of the baby’s health care. Pregnant women that
engage in smoking, exercising, wearing high-heeled shoes, drinking and sexual
activities are advised to stop because it affects the health of their unborn child. Some
of the birth defects are a fetal alcohol spectrum disorder (FASD) and Down
syndrome. The pregnant women are advised to eat balance diets including
vegetables, minerals( Iron and Calcium), Vitamins (Folic acids, ascorbic acids,
vitamin A,B1,B2,D and Nicotinic acid), and meat and fish (El-Mowafi, 2002).
Clothing: It is advised that pregnant women should wear looser and lighter clothes
that are not made from synthetic material because these are more comfortable.
Nigerian women are advised to use wrappers because they are suitable for pregnancy
9
and they should tie them at their waist rather than their abdomen. High heels are
discouraged during pregnancy; instead, flat shoes or slippers are advised.
Bathing: Pregnant women are advised to take their baths using showers rather than
bath tubs or sea bathing because they might get several infections from there and
vaginal douching is not advice.
Medication and Travelling: Pregnant women are advised not to take un-prescribe
medication and long and tiring journeys are not advised because they might cause
miscarriage of pregnancy.
Breasts: Pregnant women are advised to massage their nipples with Vaseline, or a
mixture of alcohol and glycerin at the last six weeks of pregnancy in order to reduce
the incidence of cracked nipples.
The warning signs and symptom: These are very important signs and symptoms.
When they are experienced by a pregnant woman she should immediately contact her
doctor or rush to a hospital or clinic because they are serious signs indicating
something is wrong with her pregnancy or is about to happen to the pregnancy. The
signs and symptoms are the following:
a) Vaginal bleeding
b) Abdominal pain
c) Oedema of lower limbs or face
d) Blurring of vision
e) Gush of fluid per vaginum
f) Persistent headache and vomiting.
10
Immunizations: This is an important part of antenatal care, in which the doctors and
nurses are advised to give immunization vaccines for several diseases, bacteria and
infections that affect women, including pregnant women. Some of the important
vaccines and the infections they protect the pregnant women. (See table 1.1)
Nature of Vaccines Name of Disease
Inactivated virus Vaccines Influenza, Rabies
Inactivated bacterial Vaccines Cholera, Typhoid Fever, Plague,
Meningitis and Meningococcal
Toxoid Tetanus and Diptheria
Live Virus Vaccines Measles, Mumps, Yellow Fever, Rubella
and Poliomyelitis.
Immune globulins Rabies, Tetanus, Varicella, Hepatitis A,
Hepatitis B and Measles
(El-Mowafi, 2002) Table 1.1 Different types of vaccines and associated disease
Sexual Intercourse: Normal sexual intercourse should be done during pregnancy
except if the pregnant woman is having abdominal pain or vaginal bleeding. Doctors
should advise the couple to have their normal sex life because in Nigeria having
sexual intercourse during pregnancy is considered taboo. Having normal sexual
intercourse may reduce labour pain and bring it closer because of the presence of
prostaglandin in seminal fluid.
11
1.8 SCREENINGS DONE DURING ANTENATAL FOR MATERNAL
COMPLICATIONS
Several screenings are done to new mother and the baby’s father in some cases to
avoid maternal problems. Serious infectious disease can be contracted during
pregnancy or puerperium and conception may occur more in women already
subjected to infection. These can cause fetal death as the result of contagious
infection, which may be caused by viruses, bacteria and protozoa because they are
able to cross the placental insufficiency, hyperpyrexia or maternal exhaustion and
toxemia (Sibai, 2013). The fetus can be born with transmitted diseases or contract it
during close contact with the infected mother in the process of delivery or breast
feeding process. In the early and late stage of pregnancy women are more susceptible
to serious infections of genital tract childbirth fever, which has always been one of
the most important causes of maternal death in Nigeria.
Blood Group Screening: This is an important part of antenatal screening done in
order to prevent haemolytic disease, specifically from rhesus alloimmunization
presence in the atypical antibodies. Antibody screening is done when a pregnant
woman made her booking and the same routine is done again when the pregnancy is
in the 28th week of gestation regardless of the rhesus status (Edmonds, 2007)
Hypertensive disease: These are diseases that women encounter during pregnancy
due to high blood pressure, and it causes morbidity to the fetus. This complication is
found in 2-3% of pregnancies and it can either be chronic or gestational hypertension
or Preeclampsia.
12
Gestational Diabetes: This is a condition that occurs in 4% of pregnancies due to
high levels of glucose in the blood. Gestational diabetes causes above normal blood
sugar but not enough to cause diabetes and it occurs in the last trimester due to
hormonal changes. Hormonal changes lead to the inability of the pancreas to
produce enough insulin in the body, which makes the blood sugar level to increase,
causing gestational diabetes. The complications of gestational hypertension will lead
to birth defects in the body organs, such as brain and heart, and can also lead to
miscarriage (Agboola, 2001). It also leads to increase in the baby’s weight and
increases risks during labour and delivery, and can lead to emergency caesarean
deliveries.
Anaemia: This is another test that is done during antenatal to the blood level in the
pregnant woman’s body, because when a pregnant woman is diagnosed with anemia
there will not be enough blood to support the baby. Anemia may occur due to low
vitamin or iron levels in the body. Pregnant women need essential hemoglobin that is
the protein in red blood cells that is used for carrying oxygen to other cells in the
body and to help the baby to grow properly in the placenta (El-Mowafi, 2002).
1.9 HYPERTENSION
Hypertension: This refers to the medical problem in which the arteries have
persistently increase blood pressure and is referred to as high blood pressure which is
the force of blood against the blood vessel walls. In pregnancy the systolic pressure
is greater than 140 mmHg over the diastolic pressure of 90mmHg and above (Brown,
2001).
13
High blood pressure can lead to the damage of several body organs and can also lead
to the cause of several illnesses such as kidney failure, heart failure, stroke and
aneurysm.
Blood Pressure readings
High Blood pressure 140/90 mmHg to 140/100 mmHg
Normal blood pressure 120/80 mmHg
Pre-hypertension The BP between 120/80 and 139/89
Systolic 120 peak pressure in arteries
Diastolic 80 minimum pressure in the arteries
Table 1.2 the different blood pressure readings
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