[Fatal complications in pre-eclampsia and eclampsia].

OBJECTIVE: Analysis of preeclampsia and eclampsia--one of the major contributor to life-threatening maternal morbidity frequently leading to maternal mortality in the Czech Republic till late 70's. Our goal was to mention major causal links in clinical courses of individual maternal death and to highlight main mistakes and faults, and to provide frequencies and basic characteristics of risk groups.

DESIGN: Retrospective epidemiological study.

SETTING: Department of Obstetrics and Gynecology of the 1st Medical School of Charles University and General University Hospital, Prague. Institute for the Care of Mother and Child, Prague-Podoli; 1st Intern Department of the 1st Medical School of Charles University and General University Hospital, Prague.

METHODS: Analysis of 31 cases of maternal deaths associated with severe preeclampsia and eclampsia in the Czech Republic during 1978-2000, using a database of 470 maternal deaths during the observed period. We analyzed clinical course with special attention to obstetrical surgery and clinical management. We considered timelines of life-threatening events, age of mother, parity, and place of death.

RESULTS: There were 36 maternal deaths associated with severe preeclampsia and eclampsia in the Czech Republic in 1978-2000, contributing 7.7% to total maternal mortality. Group A1 was 5th most frequent cause of maternal death. We analyzed 31 cases closely related to severe preeclampsia and eclampsia. During 1978-1990 there was 1 death per 74,263 live-born babies in this category, while during 1991-2000 we observed only 1 death per 171,137 live-born babies. Clinical management was not adequate in 15 cases of death (48%) and content of care did not reflect possibilities of prevention, diagnosis and therapy. Severe preeclampsia and eclampsia was more frequent among older women and multiparae. First group (61%) is composed of women with manifest convulsions, 25% of them experienced convulsion after delivery, and only few cases had mild preeclampsia ante partum. Eclampsia with convulsions leading to coma were in 10 cases complicated with DIC, two cases in this group had premature separation of placenta. Besides classic symptoms of preeclampsia there were within this group 5 cases of multiple pregnancy, history of unstable hypertension, hepatopathy in previous pregnancy and chronic nephrosis. The second group (39%) were cases without convulsions. These cases were complicated with severe liver disorders and renal failure, and 5 cases of intra-cranial hemorrhage. Several cases had combination of symptoms. DIC was present in 6 cases. In both groups there were 5 cases with hemorrhagic skin symptoms, thrombopenia, symptoms of DIC and liver and renal failure, which would fall into HELLP syndrome according to current classification. The most of women died during the postpartum period (87%) mostly after emergency operative deliveries. The fact that no women died during pregnancy indicates the effort to perform life-saving operative delivery. Forty two percent of women were in term. Especially at the beginning of observed period we noticed tendency to prolong gestation in order to save the baby. The mortality of fetuses or newborns was 71%. Operative deliveries accounted for 71%, the majority of them were caesarean sections. More than 50% of cases were operated in coma. We indicate major mistakes and failures in organization of care, primary prevention, diagnosis, and consequent care.

CONCLUSION: Positive results in area of maternal deaths in association with severe preeclampsia and eclampsia during last 10 years are due to improved diagnostic and therapeutic measures in our field, especially in neonatology, because obstetricians currently terminate pregnancies early than before while symptoms of preeclampsia get worse. We focus on early recognition of symptoms of coagulopathy in combination with symptoms of preeclampsia, especially on early detection and treatment of HELLP syndrome.