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Saving Nigerian Mothers:Magnesium Sulphate for thetreatment of Severe Pre-eclampsia and Eclampsia
J Tukur*
B Ahonsi**A Karlyn**I Araoyinbo**
Presented at
Asia Regional Meeting onInterventions for Impact in
Essential Obstetric and Newborn Care
Presenting bySharif Mohammed Ismail Hossain
4-6 May, 2012
Dhaka, Bangladesh*Aminu Kano Teaching Hospital,Kano, Nigeria; **Population Council, Nigeria
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Introduction Eclampsia is a common cause of maternal deaths worldwideespecially in developing countries About 10% women have increased BP during pregnancy 2-8% pregnancies complicated by pre-eclampsia (PE) 10% pre-eclampsia carry on to eclampsia (E) 10-20% maternal deaths are associated with SPE/E (50,000) The Eclampsia Collaborative Trial and Magpie studies confirmed
the efficacy of MgSO4 in the treatment of severe preeclampsia(SPE) and eclampsia. It showed 52-67% lower recurrence of seizures/fits than those treated with diazepam
and phenytoin, respectively
58% prevents progression from SPE to E
Reduce maternal deathsWHO 2005, The lancet 1995, Khat et al 2006; Magpie trial 2002; ETCG 1995)
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Background: Nigeria and Kano StateCategory National Kano State (north-west
Nigeria)
State 37 -
Population 140m 9.4m (most populous)
MMR 545/100,000 live births 1,000/100,000 live births
TFR 5.7 7.3
CPR (modern) 10%
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Background: Maternal deaths due tosevere pre-eclampsia/eclampsia in Nigeria In north-west Nigeria
31.3-46.4 maternal deaths contributed by eclampsia
One study shows that 60% of the patients with eclampsia were78% of them were primigravida
In south and central Nigeria 34.4% maternal deaths contributed by eclampsia
In Nigeria, eclampsia is a common cause of maternal deaths Despite the evidences that Mgso4 prevents progression from SPEto eclampsia and reduce maternal deaths it was not universally
used in Nigeria
Adam et al 2003, Kullim et al 2009, Tukur et al 2007 and 2008, SGO 2004
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The study Population Council launched the study in Kano State (mostpopulous state) with support from MacArthur foundation Pre-post study in clinical setting without separate control group The study was approved by NIMR and Pop. Council IRB/ERRC
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InterventionsInterventions were provided to 10 secondary level hospitals: Training of service providers Developing Mgso4 clinical protocol Supplying and introducing Mgso4
Training 25 staff trained (a doctor and a midwife from each facility)
2-day training
1
st
day: lectures on evidence-based management of hypertensive disorders ofpregnancy, how to use Mgso4 and treatment of Mgso4 toxicity
2nd day: practical training at 25-bed eclamptic ward of MMSH, demonstration
of use of Sphygmomanometer and urinalysis for proteinuria, injection of Mgso4
and toxicity monitoring
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Intervention (cont) The trained staff returned to their hospital and conducted step-down training (trained 160 staff within 3 months) Developed Mgso4 clinical protocolKano State eclampsia protocol.docx Participants were supplied with:
Mgso4 patella hammer (to assess deep tendon reflexes) and
calcium gluconate (antidote of Mgso4 toxicity)
All 10 facilities (Kano, Bichi, Wudi, Gwarno, Rano, Minjibir,Tudun, Wada, Dogrewa, Rano and Rogo) commenced the use ofthe Mgso4 (Feb 2008- Jan 2009)
Kano is urban and all other facilities are rural
http://kano%20state%20eclampsia%20protocol.docx/http://kano%20state%20eclampsia%20protocol.docx/http://kano%20state%20eclampsia%20protocol.docx/http://kano%20state%20eclampsia%20protocol.docx/ -
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Data collection and analysis Baseline information collected retrospectively from 3 facilitiesfor1 year (Jan 1, 2007 -Dec 31, 2007) A form developed and used to collect information from each
hospital (covers maternal socio-demographic characteristics,pattern of SPE/E and feto-maternal outcomes)
12 months data were collected monthly Two data review meetingswere organized with hospital staff SPSS was used for data entry and analysis Multivariate analysis was performed to determine the factorsassociated with SPE/E and its case fatality rate (CFR) Relative standard error (RSE) was used as a measure of an
estimated CFRs reliability and
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Baseline findings Baseline findings from 3 general hospitalsshows:
1233 mothers/patients took SPE/E services in the previous year
258 mothers died due to SPE/E
Case fatality rate (CFR) was 20.9%
Information on peri-natal mortality was not available
Used diazepam to manage the SPE/E patients
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Post-intervention findings: Socio-demographiccharacteristics of SPE/E patientsBasiccharacteristics
Severe pre-eclampsia(%)
Eclampsia(%)
Total(%)
Age
24 20.4 14.9 15.1
Missing 2.0 1.7 1.7Parity
Primigravida 61.2 60.3 60.4
1-5 26.5 35.2 34.8
>5 12.2 3.3 3.7
Missing 0 1.1 1.1
EducationNo 73.5 74.1 74.1
Primary 14.3 17.8 17.6
Secondary+ 10.2 6.3 6.5
Missing 2.0 1.8 1.8
N 49 996 1045
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Behavior for ANC and time needed toreach the hospital after seizures/fits
Time needed toreach hospital
Number of seizures/fits Total(%)0
(%)1-2
(%)3-4
(%)>4
(%)
1 hours 73.1 66.2 55.4 47.3 60.2
>1-3 hours 20.2 21.9 28.4 12.2 23.7
>3 hours 6.7 11.9 16.2 31.5 16.1
N 104 370 303 165 942*
Health seeking behavior for ANC Percentage
Taken ANC 55.9
Not taken ANC 44.1
N 1045
* Information was missing for 103 cases
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Outcomes of pregnancy, fetal & maternaldeaths after administration of MgSO4Outcomes Severe pre-eclampsia(%) Eclampsia(%) Total(%)
Pregnancy outcomes
SVD 53.1 76.7 75.6
CS 30.6 16.2 16.8
AVD 2.0 2.3 2.3Missing 14.3 4.8 5.3
Maternal outcomes
Dead 2.0 2.3 2.3
Alive 87.8 94.4 94.1
Missing 10.2 3.3 3.6
Foetal outcomes
Dead 4.1 12.8 12.3
Alive 81.6 83.6 83.5
Missing 14.3 3.6 4.1N 49 996 1045
SVD-spontaneous vaginal delivery; CS-caesarian section; AVD-assisted vaginal delivery
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Factors associated with eclampsia casefatality rate (CFR)Variables CFR (95% CI) AOR (95% CI)
Age
15-19 (ref) 1.5 (0.5, 2.6) 1.00
20 3.4 (1.8, 5.1) 1.46 (0.40, 5.42)
Parity
Primigravida (ref) 1.6 (0.6, 2.6) 1.00
1-5 2.9 (1.1, 4.6) 1.14 (0.31, 4.17)6 8.6 (0.8, 18.0) 4.99 (0.77, 32.22)*
Education
None (ref) 2.4 (1.3, 3.5) 1.00
Primary 2.9 (0.1, 5.7) 1.18 (0.23, 6.23)
Secondary /Higher 3.0 (1.1, 7.2) 1.00 (0.12, 8.25)
Number of seizures/fits before presentation
2 (ref) 1.3 (0.3, 2.3) 1.00
3 2.9 (1.3, 4.4) 2.19 (0.63, 7.55)
Recurrent seizures/fits after administration of loading dose
No (ref) 1.8 (0.9, 2.6) 1.00
Yes 9.2 (2.1, 16.3) 7.65 (1.62, 36.03)*
* Significant at p
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Factors associated with eclampsia casefatality rate (CFR) contVariables CFR (95% CI) AOR (95% CI)Mode of delivery
CS (ref) 2.3 (0.1, 4.5) 1.00
SVD 1.8 (0.9, 2.7) 0.77 (0.19, 3.09)
AVD 4.2 (4.0, 12.3) 2.58 (0.16, 41.52)
Condition
Pre-eclampsia (ref) 2.3 (2.2, 6.7) 1.00
Eclampsia 2.4 (1.4, 3.4) 0.59 (0.04, 8.94)
Time needed to reach hospital
1 hours (ref) 1.5(0.5, 2.5) 1.00
>1 hour 3.1(1.4, 4.7) 0.26(0.05, 1.33)
ANC taken or not
Yes (ref) 1.8(0.7, 2.9) 1.00
No 3.3(1.6, 5.1) 0.57(0.15, 2.13)
* Significant at p
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Factors associated with perinatal deathsFactors Perinatal Mortality
% (95% CI)Adjusted OR
(95% CI)Recurrent seizures/fits after MgSO4 loading doseNo (ref) 11.4 (9.5, 13.6) 1.00Yes 27.7 (17.3, 40.2) 2.64 (1.25, 5.54)*
Mode of deliveryCS (ref) 8.5 (4.8, 13.7) 1.00
SVD 12.4 (10.2, 15.0) 1.24 (0.65, 2.36)AVD 29.2 (12.6, 51.1) 3.48 (1.12, 10.91)*
Number of seizures/fits before presentation to hospital0 (ref) 3.7 (1.0, 9.1) 1.001-2 10.4 (7.6, 14.1) 3.02 (0.90, 10.20)3-4 13.4 (9.9, 17.9) 3.69 (1.09, 12.48)5 17.9 (12.4, 24.5) 5.70 (1.63, 19.93)*
Time before presentation to hospital1hour (ref) 9.7 (7.5, 12.5) 1.001hour 16.3 (13.0, 20.2) 1.04 (0.65, 1.68)
*Significant at p
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Comparison of case-fatality rates atbaseline and during intervention periodPeriod All SPE/E
cases
(n)
Fatality dueto SPE/E
(n)
CFR(95% CI)
(%)
RSE(%)
Baseline 1233 258 20.9
(18.7, 23.2)
5.5
Intervention 1045 24 2.3
(1.5, 3.5)
20.2
CFR= Case-Fatality Rate
RSE= Relative standard error
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Overall post-intervention findings Post intervention findings from 10 hospitals shows:
1045 SPE/E patients treated in 12 months
996 eclamptic patients
49 severe pre-eclamptic patients
Mean time before presentation 8.4 hours
Mean no. of seizures/fits 3.2
Case fatality rate (CFR) was 2.3%
Perinatal deaths was 12.3%
Reduction of CFR by 42.4%
2.2% patients showed toxic effect of Mgso4 but had no fatality Intervention findings further confirm that teenage, primigravidity and low
educational attainment are risk factors for developing SPE/E
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Utilization of results By the 10th month of the project, the State Government took overthe purchase of the drug and continued thereafter State Government replicated the intervention in other 25 facilities A follow on projectis being continuing on injecting loading dose
of Mgso4 by field workers (CHOs and CHEWs) and then referralto higher level and focusing on averting eclampsia by ante-nataldetection of SPE and prompt treatment with MgSo4 and referral
The project demonstrated that: Evidence based interventions could be introduced into new areas
Engaging stakeholders can made a project sustainable
Introduction of evidence based interventions usually replicable
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Challenges Stock-outs in a setting of free maternity scheme (all the facilitiesreported periods of stock-out of magnesium sulphate at least once
during the 12 months of the project) Delays in reaching health facilities by the women
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Thank you