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| OJHAS Vol. 14, Issue 1:
(Jan - Mar 2015) |
Original Article
Maternal Death Due to Eclampsia in Various Seasons in a Tertiary Centre in Eastern Part of India: A Three Year Retrospective Study.
Authors
Utpal Ghosh, Senior Resident, Bankura Sammilani Medical College, Bankura,
Debmalya Maity, Assistant Professor, Dept. of G&O, Bankura Sammilani Medical College, Bankura,
Debjyoti Santra, Associate Professor, Dept. of G&O, Bankura Sammilani Medical College, Bankura,
Arnab Koley, RMO, Dept of G &O, NRS Medical College, Kolkata,
Hoorbano Khan, Senior Resident, CSS, Kolkata,
Ananya Roy, Senior Resident, Gardenrich Central Railway Hospital,Kolkata.
Address for Correspondence
Dr.Utpal Ghosh,
Room No 26; First Floor,
Rabin Hall Hostel,
Bankura Sammilani Medical College,
Govind Nagar, Bankura,
West Bengal - 722102, India.
E-mail:
drghoshutpal@gmail.com
Citation
Ghosh U, Maity D, Santra D, Koley A, Khan H, Roy A. Maternal Death Due to Eclampsia in Various Seasons in a Tertiary Centre in Eastern Part of India: A Three Year Retrospective Study. Online J Health Allied Scs.
2015;14(1):2. Available at URL:
http://www.ojhas.org/issue53/2015-1-2.html
Open Access Archives
http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Jan 14,
2015; Accepted: Mar 26, 2015; Published: Apr 10, 2015 |
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Abstract: Background: Eclampsia is a complication of pregnancy induced hypertension and one of the leading contributor of maternal mortality and morbidity. It is more prevalent in developing countries. Literature suggests seasonal variation of incidence of eclampsia, being in winter and in monsoon in this part of this country. This study was conducted to assess the variation of mortality rate due to eclampsia during various seasons and to know the causes if any for higher mortality due to eclampsia in a particular season. Method: This study is a retrospective cohort study, spanning 3 years, from July 2011 to May 2014, in a tertiary centre in eastern India using hospital database and weather parameters available in print and electronic media. Result: Total deaths due to eclampsia was 26 in this study period. Highest fatality rate occurred in monsoon (July to October), followed by summer and then in winter (November to February), 11, 8 and 7 respectively. Conclusion: There is variation in mortality rate due to eclampsia in various seasons. Larger studies are needed to validate this finding.
Key Words:
Eclampsia, Mortality, Seasonal variations. |
Introduction:
Hypertensive disorder is the most common medical disorder in pregnancy, complicating 12-22% of all pregnancies.(1) Eclampsia is one of serious complications of hypertensive disorder in pregnancy and one of the leading contributors of maternal death. Preeclampsia and eclampsia contribute 24% of all maternal deaths in India.(2) The incidence of eclampsia in developed countries range from 1 in 2000 to 1 in 3448 pregnancies which is much lower than in developing countries like India.(3) Incidence of eclampsia in India has been quoted as 1.56%.(4) Though not all cases of eclampsia can be prevented, majority of them can be prevented by early detection and effective treatment of preeclampsia, for which good antenatal services are needed.(5) Complications of eclampsia are intra uterine fetal death, cerebrovascular accidents, pulmonary oedema, HELLP syndrome, renal failure etc.
Literature does support the concept of seasonal variation of incidence of eclampsia. It is not very clear whether there is any variation of death rate due to eclampsia in various seasons. To address this issue we undertook this scientific research. result of which will help in better planning and delivery of health care.
Materials and Methods:
It is a retrograde cohort study, spanning over three years from July 2011 to June 2014. For this study, hospital data base was used. All the patients of eclampsia, admitted in Bankura Sammilani Medical College during study period were recorded. For diagnosis of eclampsia, recommendation of National High Blood Pressure Education Program (NHBPEP 2000) was used. Data for various weather parameter (in mean) (monthly temperature, relative humidity, barometric pressure, amount of precipitation) was acquired from regional weather stations and has been cross checked with other data available in the literature (print and electronic). Each year has been divided into four seasons, winter (November to February), summer (March to June), monsoon and postmonsoon (July to October). The incidence of eclampsia and the different weather parameters among the four seasons were compared and analysed by SPSS, version 20(SPSS Inc., Chicago, IL, USA).
Results and Analysis:
We have analysed the data for the study period July 2011 to June 2014, a total span of 36 months.
Table 1: Number of deliveries, eclampsia & maternal deaths |
| Year |
Monyhs |
Number of Deliveries |
Number of Eclampsia |
Maternal Death |
2011 |
July-Dec |
11528 |
337 |
26 |
2012 |
Jan-Dec |
20678 |
400 |
44 |
2013 |
Jan-Dec |
20935 |
491 |
25 |
2014 |
Jan-June |
10149 |
195 |
10 |
TOTAL |
Jul '11-June '14 |
63290 |
1423 |
105 |
Maternal mortality due to eclampsia over the study period was 26. In 2011(July – Dec), it was 7 and it was10, 8 and 1 in 2012, 2013 &2014 (March-June) respectively.
Table 2: Deaths due to eclampsia in different season |
| Monsoon and postmonsoon |
Winter |
Summer |
6(2011) |
3(2011-12) |
4(2012) |
2(2012) |
2(2012-13) |
3(2013) |
3(2013) |
2(2013-14) |
1(2014) |
Total:11 |
7 |
8 |
Depending upon weather parameters, three seasons are prevalent in our study area and accordingly each year has been divided in three seasons, summer, Monsoon & postmonsoon, winter.
Table 3: Various weather parameters in study area.( SLIP= mean sea level pressure) |
| Season |
Temperature |
Humidity |
SLIP(HPA) |
Rainfall |
Summer |
30.21OC |
57.52% |
1003.73 |
104.33mm |
Winter |
20.21OC |
66.20% |
1013.64 |
13.34mm |
Monsoon and Post Monsoon |
27.91OC |
85.66% |
1002.45 |
271.92mm |
Table 4: P values of various seasonal comparisons. |
Parameters |
Win:Sum |
Sum:M&PM |
M&PM:Win |
Temperature |
P=.000 |
P=0.002 |
P=0.000 |
SLIP |
P=.000 |
P=0.504 |
P=0.000 |
Humidity |
P=0.056 |
P=0.000 |
P=0.000 |
Rainfall |
P=0.041 |
P=0.007 |
P=0.000 |
Eclampsia Deaths |
P=0.872 |
P=0.713 |
P=0.600 |
| (Win=winter, Sum=summer, M&PM=Monsoon & Postmonsoon.) |
Highest number of maternal deaths due to eclampsia occurred during monsoon and postmonsoon season (11), followed by summer (8) and winter (7). Total number of death due to eclampsia during this study period was 26.
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Chart 1: Comparison of eclamptic death in various seasons. |
Chart 2: Comparison of various weather parameters and eclamptic death rate in various seasons. |
Discussion:
Eclampsia continues to be an important cause of maternal and perinatal morbidity and mortality. Worldwide, it accounts for about 50,000 maternal deaths a year.(6) Eclampsia is more common in developing countries than the developed one. Obstetrical haemorrhage was the major contributor of maternal mortality in India in all kinds of set up in the past. But in recent past a paradigm shift in the pattern of maternal mortality has been observed inn India, and eclampsia contributes 40-50%(7) of all maternal deaths, whereas eclampsia causes 12% of all global maternal death. Various studies have shown seasonal variation in the incidence of eclampsia and different hypotheses have been put forward for such seasonal variation. This study was conducted to analyse any seasonal variations in deaths due to eclampsia. Total eclamptic deaths were 26 during the study period. Highest number of deaths occurred in monsoon and post monsoon season [11] followed by summer [8] and then in winter [7], though highest number of eclampsia occurred in winter, followed by monsoon and postmonsoon and then summer.(8) Thus disparity in incidence of eclampsia and case fatality due to eclampsia was observed.
Although these variations are subtle, some possible explanations can be provided. There are different hypotheses to explain seasonal variation; whether these contributory factors have any link with case fatality is a matter of further research. Humidity may be one such; and it is significantly (p<0.000) different between winter and monsoon–post monsoon seasons. Dietary factors such as vitamins, micro nutrients etc., have their influences on pathogenesis of eclampsia; deficiency of these in different seasons may have causal relation to seasonal variation of eclampsia. Even season in which conception took place may be an important factor.(9) Asa Reylander et al (10) in their study proposed that decreased availability of sunlight may be a probable cause of increased incidence of preeclampsia and eclampsia. Sunlight helps vitamin D synthesis which helps calcium metabolism. Activated vitamin D has inverse relationship with tissue plasminogen activator antigen (tPA-Ag) which is a marker of endothelial damage and eclampsia has generally been described as an endothelial disease. Dehydration has been cited as a protective factor for convulsion(11); insensible water loss is much higher in dry and warmer temperature. Westerterp et al demonstrated that physical activity-adjusted values of water loss were higher, in female in summer.(12) On the other hand, volume expansion and hyponatremia are thought to be triggering agents in eclampsia. Hyponatremia and over-hydration cause influx of fluid into the neurones causing swelling of the same and make it vulnerable for injury and seizure activity. In pregnant women, decrease in serum osmolality increases the seizure frequency. Monsoon has profound influence on human body fluid balance though the mechanism is ill understood.(13) Chakrapani and colleagues demonstrated that hyponatremia in hospital patients is significantly higher in monsoons with a significant correlation to increased rain fall.(14) In winter vasospasm may be a triggering agent for increased incidence of eclampsia which may have resemblance with increased incidence of myocardial infarction in winter. The answers for the observed disparity in the incidence of eclampsia and case fatality in various seasons may lie among these.
Conclusion:
Number of deaths due to eclampsia is found to be different in various seasons. In this study highest case fatality due to eclampsia occurred in monsoon and postmonsoon, followed by summer then in winter. Considering that eclampsia is an important cause of maternal mortality, association of various climatic factors and case fatality may need further research, so that we understand the pathophysiology and disease modifying factors of eclampsia better. This is a very small study, need of larger study to reach a definite conclusion in this regard need not be over emphasised.
References:
- Walker JJ. Preeclampsia. Lancet. 2000; 356: 1260-65.
- Begum MR, Begum A, Quadir E, Akhtar S, Shamsuddin L. Eclampsia: still a problem in Bangladesh. Med Gen Med 2004;6:52.
- Andersgaard AB, Herbst A, Johansen M et al. Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases. Acta Obstet Gynecol Scand 2006;85(8):929-36.
- Swain S, Ohha KN, Prakash A. Maternal and perinatal mortality due to eclampsia. Indian Pediatr 1993 Jun;30(6):771-73.
- Knight M. Eclampsia in the United Kingdom 2005. BJOG 2007 Sep;114(9):1072-78.
- Duley L. Maternal mortality associated with hypertensivedisorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J Obstet Gynecol. 2005;99:547-553.
- Sarkar M, Basak S, Mondal S, Das S, Roy D, Mandal J, Mondal SC, Das SK. Maternal mortality associated with eclampsia in an Indian medical college: a four year retrospective study. Journal of Medicine and Medical Sciences 2013;4(10):394-398. Available at http://www.interesjournals.org/full-articles/maternal-mortality-associated-with-eclampsia-in-an-indian-medical-college-a-four-year-retrospective-study.pdf?view=inline
- Ghosh U, Deb D, Mondal SK, Das AK. Seasonal Variation in the Occurrence of Eclampsia: A Three Year Retrospective Cohort Study in a Tertiary Centre in Eastern India. Journal of Evolution of Medical and Dental Sciences 2013;2(44):8629-8637.
- Nanbakhsh F, Broomand F, Mohaddesi H, Nefoozi S, Mazloomi P. Seasonal variation in the incidence of preeclampsia based on the time of conception. Life Science Journal 2012;9(4):1310-1314.
- Rylander A, Lindqvist PG. Eclampsia is more prevalent during the winter season in Sweden. Acta Obstet Gynecol Scand. 2011 Jan;90(1):114-7.
- Bitterman N, Skapa E, Gutterman A. Starvation and dehydration attenuate CNS oxygen toxicity in rats. Brain Res 1997;761(1):146-50.
- Westerterp KR, Plasqui G, Goris AH. Water loss as a function of energy intake, physical activity and season. Br J Nutr 2005;93(2):199-203.
- Kambal A. Evaporative water loss in adult surgical patients in the Sudan. Br J Surg 1978; 65(2):128-30.
- Chakrapani M, Shenoy D, Pillai A.Seasonal variation in the incidence of hyponatremia. J Assoc Physicians India. 2002 Apr;50:559-62.
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