ABSTRACT

Eclampsia is a pregnant induced hypertension and a severe complication of preeclampsia. It occurs from 32weeks of gestation and is the most common cause of maternal and fetal mortality and mobility. This complication arises mostly to pregnant women who lack knowledge on eclampsia. This study aimed at looking at the knowledge on Early identification of eclampsia among pregnant women at the Limbe Regional Hospital. This study was conducted among pregnant women at the Limbe Regional Hospital. A total of 80 participants were sampled with the use of a convenient sampling technique and data was collected with use of a well-structured questionnaire. At the end of this study, it was seen that women with eclampsia at the Limbe Regional Hospital, adequately did not have knowledge on eclampsia that is why they could not check their blood pressure and level of protein urea. This study also showed that a handful of these patients did not see the need to get blood pressure and protein urea measured during every ANC visit. Due to financial constrain, patients could not afford money to measure their blood pressure and protein uria even if they wanted to. Averagely, a few expressed family challenges and a handful did express dietary challenges with regard to intake of less balance diet and food rich in sodium. Stake holders are encouraged to get involved in the care of pregnant women with eclampsia and nurses are encouraged to create a relationship with the patients and carryout sensitization on eclampsia.

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Eclampsia is a severe complication of preeclampsia occurring usually after 32weeks of gestation and a major cause of maternal and fetal death and lead to premature birth worldwide. Hypertension in pregnancy is a major cause of maternal m­ortality, with a prevalence of 1.8 to 16.7 % in low and middle-income countries (LMIC) (Osungbade, 2011). The hypertensive disorders of pregnancy (HDP) include preeclampsia, gestational hypertension, chronic hypertension and superimposedeclampsia (Kwawukume EY, 2002). Eclampsia is particularly challenging to manage, as there is no reliable method of detection based on clinical assessment or biochemical markers (Kim YM et al., 2013).  In Northern Nigeria, where the maternal mortality ratio (MMR) is estimated at 1000/100,000 live births, 40 % of the deaths are due to eclampsia, a complication of preeclampsia (Okereke E et al., 2012) In Lagos, it was reported that maternal case fatality rate of 18.3 % and a perinatal mortality ratio of 279/1000 live births. In contrast, there has been a 90 % reduction in uncontrolled identificationpreeclampsia and eclampsia case fatality in high-income countries (HIC); this success was achieved through early detection and improved access to hospital-based care (Goldenberg RL et al., 2011) Therefore, overcoming the prevailing challenges in treating preeclampsia in LMIC hinges on the ability of the health care systems to identify and manage women at high-risk.

In pregnancies complicated by preeclampsia and eclampsia, improved outcomes are seen with early of symptoms, prompt presentation to healthcare facilities, and subsequent management with antihypertensive medications, magnesium sulphate, and delivery of the fetus and placenta. Development of preeclampsia or eclampsia is a significant risk factor for recurrence in subsequent pregnancies (American College of Obstetrics and Gynecology, 2013) Since preeclampsia and eclampsia are exclusively complications of pregnancy, antenatal care (ANC) visits and intrapartum admission are important opportunities for patient counselling. Prenatal education on symptoms of preeclampsia and eclampsia may result in improved outcomes (WHO, 2006) with studies linking understanding of counselling to higher rates of women taking action and reporting symptoms (Wallis et al., 2013) Despite the important connections between women’s knowledge of warning signs and seeking appropriate care, little research has addressed the patient perspective. Studies conducted in high-income countries demonstrate that only half of patients were counselled on signs and symptoms of preeclampsia (Wilkinson J et al., 2018), even though counselling by healthcare providers is associated with increased patient knowledge.

Studies on knowledge levels of preeclampsia and eclampsia have been carried out in different countries. In the United States of America (Whitney B, et al., 2012) 112 pregnant women were asked 25 questions on the symptoms, consequences, and proper patient actions associated with preeclampsia. The average score was 43%; higher scores correlated with higher literacy levels, multiparity, personal experience of preeclampsia, and having received information from a health worker or other source. An Australian postal survey of 68 women who had experienced preeclampsia found that 77% of them had no prior knowledge of the condition, and 51% did not initially realise how serious the condition could be. They reported feeling a loss of control, depression and anxiety. (East C et al., 2011)

In Sokoto, Nigeria (Adamu AN et al., 2014) 159 relations of 56 patients brought to a referral hospital with eclampsia were interviewed about their beliefs about the causation of eclampsia. Only six of these relations associated high blood pressure with eclampsia. Seventy five of the participants attributed the eclampsia to evil spirits, seven blamed God and 32 reported having no idea of the cause of eclampsia. Forty of the 56 patients had been given traditional treatment before being brought to hospital. Hypertensive diseases of pregnancy, notably preeclampsia and related conditions, are responsible for significant morbidity and for nearly one-tenth of maternal deaths in Africa. Preeclampsia only occurs in pregnancy. It is diagnosed when there is a new episode of hypertension (diastolic blood pressure consistently >90 mm Hg) and substantial proteinuria (>0.3 g/24 h). Preeclampsia may be mild at first, but can slowly or rapidly develop into severe preeclampsia, characterised by rising hypertension, increasing proteinuria or substantial maternal organ dysfunction. Symptoms of worsening preeclampsia occur in the majority of cases and include frontal headache, epigastric pain and visual disturbances. (World Health Organization, 2011) In the Tanzanian context, frontal headache and visual disturbances have been found to be particularly associated with imminent eclampsia. (France J et al., 2012) Severe preeclampsia can develop into eclampsia (with fits) or HELLP syndrome (haemolysis, elevated liver enzymes and low platelet count). (World Health Organization, 2011)

Early diagnosis and management can help to reduce the dangers of preeclampsia and its complications; the majority of deaths related to this condition are avoidable when care is given in good time. Avoiding delays and “bottlenecks” that are currently occurring in diagnosis and management are critical in this regard. (Baker U et al., 2015) Three phases of delay have been identified; “phase one delays” relate to the time taken to make a decision to seek care, “phase two delays” involve problems in reaching care and “phase three delays” encompass issues in provision of care. (Brighton. 2014) This study was concerned with identifying potential “phase one delays” relating to levels of knowledge. The overall objective was to assess the knowledge levels of women who are living in Makole Ward in respect to preeclampsia. Specific objectives were to assess knowledge levels in relation to risk factors, signs, symptoms, dangers, prevention and management of preeclampsia.

In Cameroon the diagnosis of hypertension is based on the criteria defined by the national high blood education programmed working group on the high blood pressure in pregnancy ,severe pregnancy was defined by one or more of the following criteria blood pressure greater than 160/110mmhg, proteinuria greater than 3.5g/24hrs, original (>600m/24hrs),UGR (> than 10%), oligoamnios symptoms suggesting end-organ failure such as headache , visual disturbance , epigastric pain ,medical complication including pulmonary edema acute renal failure hepatitis, hematoma’s occurrence of convulsion not attributed to other condition in a patient with preeclampsia was considered as eclampsia will record data regarding demographic parameter, gestational age ( determined by last menstrual period when known or first trimester  obstetrical ultrasound ) medical condition such as hypertension, diabetes mellitus, history of smoking , presenting sign and symptom, blood pressure on admission, laboratory evaluation on admission FBC, livre , eczema urea, uric acid , coagulation profile and 24hrs proteinuria. After  examination of 3 reference hospitals in Yaounde, maternal and perinatal outcome for severe pre eclampsia and eclampsia, it was found that the median gestational age at diagnoses was 37 weeks of gestation and caesarean section rate where 42.6% and 75% respectively for the general study population and for women had delivery within 24hrs followed the diagnosis of severe preeclampsia. All maternal death in 28 to 33-week gestational age group. Primiparous young women with low socio-economic status are the most typical preeclampsia cases (AHA, 2014).

For substandard healthcare systems like ours with lack of funding and poor infrastructure, observed seasonal variations and peaks of that complication can guide the channeling of limited resources appropriately, such that during high seasons, the necessary materials for optimal management of the disorder are prioritized, especially when drug availability is a limiting factor for adequate management.  In our context, eclampsia is a major cause of maternal death. Patients are often sent to referral hospitals for optimal care because of the scarcity of resources in peripheral health facilities. In a study to find out the characteristics of eclampsia in the Yaoundé GynaecoObstetric and Pediatric Hospital (YGOPH), the following findings were met.the frequency of eclampsia was 0.96% (151/25680). The mean age of patients was 23.95±6,02 years. Singles (73.5%), housewives (40.4%) and nulliparous patients (54.9%) were the most represented. The disease occurred more frequently during the major rainy season (43.7%). Patients were most often referred cases (70.2%). Eclampsia occurred mostly antepartally (70.3%). Hypertension was most often severe (83.45%). Nicardipine was the most used antihypertensive medication (76.8%) and magnesium sulphate was the anti-convulsant of choice (98.0%). The majority of women delivered by caesarean section (77.8%). HELLP syndrome was the most common maternal complication (9.9%), while prematurity was the most frequent feotal complication (58.9%) The maternal and neonatal mortality rates were 8.6% and 24.4%, respectively (Essiben et al, 2019). All this findings then led to the birth of this study in the Limbe regional hospital.

1.2 Problem Statement

Despite the fact that preeclampsia has been included in the early detection bundle of possibilities in ANC, some pregnant women still experience it at some point in time during the pregnancy and if left untreated can result to eclampsia as a complication. It was been noted in a pretesting survey at the Limbe regional hospital that these warning signs and symptoms ofeclampsia are not well known by pregnant women, thus leading to a disregard of these potential signs and symptoms during pregnancy, and possibly an episode of eclampsia during this period.

 New molecular insights offer new possibilities of early diagnosis of elevated maternal risk. Maternal risk factors, biophysical parameters like Doppler examination of the uterine arteries and biochemical parameters allow early risk calculation. Preventive and effective therapeutic agents like acetylsalicylacid can be started in the early second trimester. The existence of these risk determining factors of eclampsia are unknown to a majority of pregnant women in our society and setting. Therefore this study aims to assess knowledge on the early identification of eclampsia among pregnant women in the Limbe Regional Hospital.

1.3 Rationale

Eclampsia is a hypertensive disorder specific to pregnancy responsible for significant maternal morbidity and mortality in Africa. The majority of deaths related to eclampsia could be avoided with timely and effective care. “Phase one delays” arise because of lack of knowledge. Therefore, assessing pregnant women’s knowledge on early identification of eclampsia is relevant to creating awareness and education on the risk determinants of eclampsia during pregnancy and to mitigating the consequences and complications of this gestational hypertensive condition.

This study will help identify gaps in the knowledge of these pregnant women on Eclampsia and enable us to draw up strategies to bridge those gaps in order to improve on the knowledge of the hospital. This could be through the hospital staff, personnel attending to these women during ANC.

1.4 Research Questions

1. What are the causes and predisposing factors of eclampsia among pregnant women at the Limbe Regional Hospital?
2. What are the signs and symptoms identified by pregnant women on eclampsia at the Limbe Regional Hospital?
3. What are the preventive measures used by pregnant women in the prevention of eclampsia at the Limbe Regional Hospital?

1.5     Research objectives

1.5.1 General Objective

The main objective of this study is to investigate the knowledge on the early identification of eclampsia among pregnant women at the Limbe Regional Hospital.

1.5.2 Specific Objectives

1. To assess knowledge on the causes and predisposing factors of eclampsia among pregnant women in the Limbe Regional Hospital.
2. To identify the signs and symptoms ofeclampsia among pregnant women at the Limbe Regional Hospital.
3. To examine the preventive measures used by pregnant women in the prevention of eclampsia at the Limbe Regional Hospital.