A paroxysmal complication of pre-eclampsia, eclampsia is a serious obstetric situation responsible for significant maternal and perinatal mortality and morbidity (6% - 10%) according to FAYE A.  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?
Objective: To describe the epidemiological, therapeutic and prognostic aspects of eclampsia at the second reference hospital in the urban commune of Ségou in Mali.
3. 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 technical platform to carry out certain biological examinations, the incompleteness of certain files of the retrospective period were limiting factor. The data collected were processed and analyzed using the 2000 EPI info, EXCEL and WORD 2007 logitials. Quantitative variables were expressed on average and standard deviation, qualitative variables as a percentage.
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.
Table 1 summarizes the epidemiological characteristics of patients.
Table 1. Epidemiological characteristics of patients admitted for eclampsia at the second referral hospital in Ségou, Mali from 2010 to 2012.
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.
4.1. 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 (MgSO4) 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).
Table 2. Distribution of patients admitted for eclampsia at Fousseini Dao Hospital in Ségou, Mali from 2010 to 2012, depending on the method of admission.
Table 3. Breakdown of eclamptics based on voltage factors, fetal condition and timing of the seizure.
Table 4. Distribution of patients by delivery pathway, medical treatment received, transfer to resuscitation and length of hospital stay at the second-reference hospital in Ségou, Mali from 2010 to 2012.
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 hematoma in 13.3% of cases and delivery haemorrhage in 13.3%. We recorded 4 cases of maternal deaths (2.3%) 50% following a state of eclamptic disease, 25% following acute kidney failure and 25% following acute edema of the lung. Fetal complications were dominated by prematurity (29.5%) neonatal suffering (13.6%), hypotrophy (11.4%) and fetal death (14.7%).
Eclampsia is a pathology responsible for maternal and fetal complications that are sometimes serious. In our study, we recorded 8.5% of maternal complications. Referring to the distribution of cases by type of complications, we find that infectious complications (endometritis and parietal suppuration) are most often related to delivery conditions than to eclampsia itself. On the other hand acute kidney failure appears in 20%; retro-placental hematoma in 13.3% and hemorrhage of delivery in 13.3%. Eclampsia was lethal in 2.3% of cases. These deaths occurred in varying circumstances such as: 50% eclamptic condition; acute kidney failure in 25%; acute lung edema in 25% of cases.
Table 5. Patient distribution based on maternal-fetal complications.
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. Patient breakdown by the relationship between maternal Glasgow and Apgar score at the second reference hospital in Ségou, Mali from 2010 to 2012.
Khi2-9.0382; ddl-6 and p-0.1714.
Table 7. Distribution of patients by the relationship between the period of onset of the crisis and the fetal prognosis at the second reference hospital in Ségou, Mali from 2010 to 2012.
Khi2-17, 3217; ddl-6 and p-0.0082.
Table 8. Patient breakdown by the relationship between the birth route and the Glasgow score at the second reference hospital in Ségou, Mali from 2010 to 2012.
Khi2-25.60, ddl-2 and p-0.000.
5.1. 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 , CISSE CT. and Al with 0.8% of cases , PAMBOU O. and Al with 0.32% of cases , DEMBELE N F. with 1.13% of cases .
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 pregnancies  .
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.
5.2. 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 .
Our teenage girls’ rate was 60.2% of cases. Our result is higher than other studies carried out in Mali with 48% respectively; 48.60% and 50.8%   .
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 . We noted a predominance of primigeste (74.4%). This predominance of young primipares is reported by M. D. Beye et al.  (64.2%), Cissé CT et al.  (74.4%).
We have 77.3% housewives versus 22.7% singles. Our singles rate is lower than that of AHMADOU H.  and superior to that of HAMDA S.  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.  that young primigestes are most often exposed to this pathology. On the one hand, it appears that the ages corresponding to the peak of eclampsia are those of the optimum procreation period. On the other hand, through the age there are socio-cultural realities. In fact, this difference hides the same reality, which is the low purchasing and decision-making power of the women concerned. In our series 81.8% of them were out of school and 13.6% 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.  and DIARRA I.  who rated 72.56% and 74% respectively. They had not performed any antenatal consultations in 61.9%. However, 38.1% of them had done between 1 and 6 antenatal consultations during their pregnancy. The realities on the ground are many. It was noted that for those who had performed 1 to 6 antenatal consultations and who presented eclampsia, they reflected the community realities concerning the decision-making power of women to visit health training, including the lack of attendance at these facilities and the lack of qualified staff in most of our health facilities, sometimes of poor quality of pregnancy monitoring. Some patients had a pathological history (1.1% eclampsia; 2.9% high blood pressure). Only good quality antenatal consultations can be detected and adequately managed for severe forms of pre-eclampsia, and are one way to reduce the frequency of eclampsia and improve maternal-fetal prognosis.
The quality of the reference/evacuation in a country can influence the frequency of eclampsia. Thus, 66.4% of our patients came from health facilities within a 150 km radius compared to 33.6% of direct admissions. Our results are similar to those of DEMBELE N.F.  which yielded 69% medical evacuation for eclampsia and 31% of direct admissions.
In our series, illiterates were the most affected with 81.8%. Our frequency is higher than that of DIARRA I.  and lower than FOFANA B.  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.
5.3. 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.  which reported 82.6% systolic HTA between 130 and 160 mmHg and severe in 50.9% of cases. And these patients had in 85.6% diastolic HTA which was between 90 and 100 mmHg and severe in 41.8%. Changes in fetal heart rate are related to maternal hemodynamic disorders that result in either acute fetal suffering or fetal 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.  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.  (54%). This trend is also observed in CISSE CT.  which finds a high frequency of eclampsia on pregnancies—37 SA. Postpartum eclampsia accounted for only 26.1% in our series, while in 20th and per-partum, it accounted for 32.4% and 41.5% respectively. Trend observed in DEMBELE N F.  which pays (20.7%) postpartum eclampsia. In the Moroccan and Tunisian series, eclampsia in the preparationtum is the most common. Indeed at the Ibn Rochd University Hospital in Casablanca, Morocco, MIGUIL M. et al.  reported 79% of cases of eclampsia before work, 4% during work and 17% after work. In Tunisia Ferchiou M. et al.  found 56.9% in preparationtum; 32.5% in per-partum and 10.6% in postpartum. Indeed, the remoteness of our health facilities makes the delay longer between the admission of patients to our ward and the appearance of the first seizures that helped to trigger the work. This may explain this difference with the other authors.
5.4. 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).
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.  who had a caesarean section rate of 85.1%. In the MOMA survey conducted in West Africa cited by DUMONT A. and Col , 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 (MgSO4) 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.
Eclampsia is a pathology responsible for maternal and fetal complications that are sometimes serious. In our study, we recorded 8.5% of maternal complications. Referring to the distribution of cases by type of complications, we find that infectious complications (endometritis and parietal suppuration) are most often related to delivery conditions than to eclampsia itself. On the other hand acute kidney failure appears in 20%; retro-placental hematoma in 13.3% and hemorrhage of delivery in 13.3%. Eclampsia was lethal in 4 cases or 2.3%. These deaths occurred in varying circumstances such as: 50% eclamptic condition; acute kidney failure in 25%; acute lung edema in 25% of cases.
Lethality rates higher than ours are reported by the following authors: DIAKITE M.  had 6.2% maternal deaths; KONATE S.  had 4.26% maternal deaths; DIARRA I.  had 12% maternal deaths; TRAORE et al.  had 18.8% maternal deaths. By comparing our result with those of the above-mentioned authors, 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  which is 2.2% lower than ours.
Eclampsia is often associated with morbid fetal complications. These are dominated by prematurity (29.5%) hypotrophy (11.4%). Most African authors    in their series reported prematurity rates around 50% and SANOGO A.  recorded 11.7% prematurity.
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   in the same department. This improvement in fetal prognosis may be due to the significant changes that have been made in the organization of working conditions in recent years (free caesarean section, monitoring of labour by partogram and free magnesium sulphate).
The maternal-fetal prognosis remains reserved despite the progress made in the management of eclampsia in our services.
All the authors participated in the writing of the manuscript. They all approve the final version of the manuscript.
The ethics committee’s authorization was found prior to the start of the study.
I. Identification of the Patient
Q1. Entry date:
Q2. File number:
Q3. Name and first name:
Q5. Place of residence:
Q7. Marital status:
1) Bride; 2) Single; 3) Divorced; 4) Widow
1) Housewife; 2) Official; 3) Student; 4) Trader; 5) Others
Q9. Level of Education:
1) Illiterate; 2) Primary level; 3) secondary level; 4) Higher level
1) Home; 2) C S C O M; 3) Private firm; 4) Reference Centre.
Q11. Admission mode:
1) Addressed by the family; 2) Evacuated; 3) Referred
Q12. Reason for evacuation:
1) Convulsion; 2) Loss of consciousness; 3) H T A; 4) Others
Q13. Moment of crisis occurrence
1) Anté-Anté-partum; 2) Per-partum; 3) Postpartum.
III. Personal Antecedents
Q14. ATCD Medical:
1) HTA; 2) Heart disease; 3) Diabetes; 4) Eclampsia;
5) Sickerpanocytosis; 6) Others
Q15. ATCD surgical:
1) Caesarean; 2) Uterine rupture; 3) Salpingectomy; 4) Others
Q16. ATCD obstetrics:
1) Gestity; 2) Parity; 3) Live child; 4) False layer; 5) IIG
Q17. Family ATCD:
1) HTA; 2) Heart disease; 3) Diabetes; 4) Eclampsia; 5) Other
Q18. Pregnancy term:
Q19. Prenatal consultation:
1) Yes; 2) No
If so specify the number…………
Staff quality: 1) Matron; 2) Midwife; 3) Doctor; 4) Gynecologists; 5) Others.
IV. Exam at Admission
Q20. General state:
1) Preserved; 2) Passable; 3) Altered; 4) Glasgow
1) Lucid; 2) Obsessed; 3) Deep Coma
1) Present; 2) Absent; 3) Anasarque
Q26. Diuresis Schedule:
Q27. Uterine contractions:
1) Yes, I do; 2) No
Q28. Uterine height:
1) Presents; 2) Absent. If present specify heart rate………
Q30. State of the pass:
1) closed; 2) open
If open specify its dilation in cm
Q31. Ovular membranes:
1) Broken; 2) untouched
Q32. Amniotic fluid:
1) Claire; 2) Tinted
1) Cephalic; 2) Seat; 3) Cross/oblique
1) Engaged; 2) Unsigned
1) Normal; 2) Limit; 3) Shrink
Q36. Additional reviews:
4) Fasting Glycemia
5) 24-hour proteinuria
Q37. Treatment received before evacuation:
1) Anti-convulsive; 2) Anti-hypertensive; 3) 1/2; 4) Others
Q38. Medical treatment received at admission:
1) Anti-convulsive; 2) Anti-hypertensive; 3) 1/2; 4) Sulfate of Magnesium
Q39. The anti-hypertensive used……………………
Q40. The anti-convulsant used………………………
Q41. Delivery route:
1) Caesarean; 2) Low track
Q42. If low lane, specify type
1) Natural; 2) Forceps; 3) Ventous
Q43. Transfer to resuscitation:
1) Yes; 2) No
If so; length of stay
Q44. Maternal complications:
1) Yes, I do; 2) No
If so; Specify………………………
Q45. Maternal vital prognosis:
1) Alive; 2) Died (specify the cause…………)
Q46. Length of hospitalization………………
Q47. Obstetrical Prognosis
1) Favorable; 2) Unfavourable; 3) Others
V. Information on the New-Ne
Q48. Number of children:
1) 1st minutes; 2) 5th minutes.
Q51. State of newborn at birth:
1) Eutrophic; 2) Premature; 3) Hypotrophic; 4) Macrosome
1) Yes, I do. 2) Name
Q53. Referred to Paediatrics:
1) Yes; 2) No
If Yes motive…… Evolution time
Q54. Fetal Malformation
1) Yes; 2) No
If Yes specify the type:
Q55. Fetal vital prognosis:
1) Alive; 2) Deceased (precise cause:………………….)
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