Introduction

Preeclampsia is a pregnancy-related hypertensive disorder that mostly occurs after 20 weeks of gestation. If left untreated, it progresses to eclampsia, which is a complication of severe preeclampsia characterized by seizures (Medicine for Africa, 2008). The major manifestations of preeclampsia are blood pressure that exceeds 140/90 millimeters of mercury (mmHg), and excess protein in the urine (proteinuria). When convulsions occur in addition to these signs, it leads to eclampsia (Shah, 2009).

Other signs and symptoms of preeclampsia may include:

1, Severe headaches

2, Changes in vision, including temporary loss of vision, blurred vision, or light sensitivity

3, Upper abdominal pain, usually on the right side under the ribs

4, Decreased urine output

5, Nausea or vomiting

6, Shortness of breath caused by fluid in the lungs

7, Impaired liver function

8, Decreased level of platelets in the blood (thrombocytopenia)

9, Sudden weight gain and swelling (edema)

Figure 1: Symptoms of preeclampsia (European foundation for the care of newborn infants, 2021)

Incidence of Preeclampsia

The incidence of preeclampsia varies greatly all over the world. Globally, the incidence of preeclampsia ranges between 2% and 10% (Osungbade and Ige, 2011). The World Health Organisation (WHO) estimates the incidence of preeclampsia to be 7 times higher in developing countries, including some countries in Africa (2.8% of live births) than in developed countries (0.4%) (WHO, 2005).

Globally, it is estimated that the incidence of preeclampsia is 4.6% (Abalo et al., 2013). This is based on the secondary analysis of a WHO multi-country survey that included 875 cases of eclampsia, collected over a short duration from only secondary or tertiary hospitals (WHO, 2005). Women under 20 years of age, those with low levels of education, and those in their first pregnancy are all reported to be at higher risk of preeclampsia (WHO, 2005). Estimates from 16 datasets reported the case fatality rate to be 8.3% (Abalo et al., 2013). The WHO survey reported 32 maternal deaths, 3.7% of which were women with eclampsia (WHO, 2005). According to the results from a meta-analysis, the incidence of preeclampsia varies among different regions such as 1.0% in the Eastern Mediterranean and 5.6% in Africa (Abalos et al., 2013).

Figure 2 shows that only 4 African countries (Nigeria, Ghana, Morocco and South Africa) reported on both preeclampsia and eclampsia between 2002 and 2010. The other African countries were either reported not applicable or had no data available.

Figure 2: Different countries reporting on preeclampsia and eclampsia between 2002 and 2010 (WHO, 2012).

Risk Factors Associated with Preeclampsia

1, Maternal Age: According to several findings, women of early and late reproductive age were more at risk in comparison with the other age groups of women. A cross-sectional study conducted in Tanzania showed that mothers aged 35 years and over were 2.6 times more at risk of developing preeclampsia than younger mothers (Mrema et al., 2018). Another study conducted in Ethiopia also found pregnant women aged 35 years and over were twice as likely to develop preeclampsia and eclampsia compared to younger mothers (Endeshaw et al., 2016). Similar findings were observed in other studies conducted in Ethiopia and Sudan (Adam et al., 2013 and Tessema et al., 2015).

On the other hand, according to studies conducted in Mozambique and Sudan, it was found that mothers aged less than 18 and 20 years old were at greater risk of developing preeclampsia/eclampsia with odds of 3.61 and 7.6 as compared to mothers aged greater than 35 years old, respectively (Bugalgo et al., 2001 and Ali et al., 2011). In contrast, women aged less than 24 years were found to have a lower risk of preeclampsia when compared to women aged 35 years and over (Belay and Wudad, 2019). A retrospective cohort study conducted in Ethiopia to assess the association between prepartum and postpartum eclampsia showed that younger mothers were at significantly greater risk for prepartum eclampsia when compared to older mothers (Berhan and Endeshaw, 2015). Furthermore, a 5-year review of women with eclampsia conducted in Nigeria showed that teenagers (aged less than 19 years old) were at high risk for eclampsia (Okogbenin et al., 2010). However, one study conducted in Sudan reported that mothers at both extremes of age (age ≤ 20 and ≥ 35 years) were significantly at risk for preeclampsia with odds of 7.6 and 10.2 in comparison with their counterparts, respectively (Ali et al., 2011).

2, Anaemia during pregnancy: Anaemia during pregnancy increases the risk of having preeclampsia/eclampsia more than three times in comparison with mothers without anaemia. A case-control study conducted on 151 cases and 302 controls of pregnant women in Ethiopia, found that women who had anaemia during the first trimester were 2.47 times more likely to develop preeclampsia compared to women without anaemia (Endeshaw et al., 2015). Another study in Ethiopia also reported that pregnant women with anaemia were nearly twice as likely to develop overall preeclampsia and three times more likely to develop late-onset preeclampsia compared to women without anaemia during pregnancy (Endeshaw et al., 2016). Similarly, a study conducted in Sudan revealed that pregnant women with anaemia had about a 4-fold increased probability of developing preeclampsia as compared to women without anaemia (Ali et al., 2011). Another study conducted in Ethiopia on clinical and biomarker differences in prepartum and postpartum eclampsia found that a significantly high proportion of anaemia was observed among women with postpartum eclampsia (P<0.0001) (Berhan and Endeshaw, 2015).

3, Antenatal Care (ANC Visits): Mothers who have no ANC visits during pregnancy are about 3 times more at risk of having preeclampsia as compared to women who had ANC visits. Several studies conducted in Nigeria, Sudan and Uganda showed that pregnant mothers with no ANC visits had higher odds of having preeclampsia as compared to pregnant women who received ANC services (Guerrier et al., 2013, Ajah et al., 2016, Adam et al., 2013 and Wandabwa et al., 2010). In another study by Adam et al., (2013) it was discovered that women with no ANC visits had 4 times increased odds of preeclampsia/eclampsia as compared to women with ANC visits. Similarly, women without ANC visits in present pregnancy were 3.4 times higher when compared to those women having ANC visits (Wandabwa et al., 2010).

4, Previous Preeclampsia/Eclampsia: Women who have a history of preeclampsia or eclampsia are nearly 6 times at higher risk of developing preeclampsia or eclampsia when compared to women who had no history of preeclampsia or eclampsia in past pregnancies. A study conducted in Ethiopia found that a mother with a history of preeclampsia in her previous pregnancies was 4 times more likely to develop preeclampsia in subsequent pregnancies (Grum et al., 2017). Similarly, a study conducted in Cameroon reported that having preeclampsia previously increased the likelihood of having early-onset preeclampsia by 4 times as compared to late-onset preeclampsia (Nguefack, 2018). Same findings were also reported in studies conducted in Nigeria and Uganda (Guerrier et al., 2013, Anorlu et al., 2005 and Wandabwa et al., 2010).

5, Maternal Body Mass Index (BMI): Women that have a higher BMI were nearly twice as likely to develop preeclampsia than women with a healthy BMI. A study conducted among the 17,738 singleton births in Tanzania found that women who were overweight (i.e. BMI 25–29.9 kg/m2), and women who were obese (i.e. BMI >30 kg/m2) were 1.4 and 1.8 times more likely to have preeclampsia compared with women with a normal BMI, respectively (Mrema et al., 2018). The same study found that underweight women were 30% less likely to develop preeclampsia as compared to women with a normal BMI. A case-control study conducted in Ethiopia showed that for every 1cm increase in Mid Upper Arm Circumference (MUAC), there was an increase in the prevalence rate of preeclampsia by a factor of 1.4 (Endeshaw et al., 2015). Similarly, a result from a cohort study of 307 pregnant women in Nigeria found that a BMI > 25 kg/m2 estimated at ≤ 20 weeks of gestation reported a 4 times higher risk of developing preeclampsia during the gestational follow-up time (Musa et al., 2018).

6, Family history of Preeclampsia/Eclampsia: Women with a family history of preeclampsia or eclampsia are 1.68 times more likely to develop the same complications during pregnancy. 3 studies found that having a family history of preeclampsia or eclampsia was positively associated with the chance of developing preeclampsia or eclampsia in pregnant women (Musa et al., 2018, Tessema et al., 2015 and Kiondo et al., 2012). 

7, Parity: Parity is the number of times that a woman has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn. Primiparous women (Women who have been pregnant and given birth once) are 2.5 times more likely to develop preeclampsia/eclampsia as compared to multiparous women (women who have been pregnant and given birth more than once) (Grum et al., 2017). Several studies reported the likelihood of preeclampsia and eclampsia significantly higher in primiparous women as compared to multiparous women (Grum et al., 2018, Ajah et al., 2016, Anorlu et al., 2005 and Wandabwa et al., 2010).  In a study conducted in Tanzania, the risk of preeclampsia/eclampsia was found to be 30% less in the second pregnancy as compared to the first pregnancy (Mrema et al., 2018).

8, Chronic hypertension and diabetes mellitus: Women with chronic hypertension have an increased risk of preeclampsia compared to women without chronic hypertension. A study by Anorlu et al., (2005) found that the risk of preeclampsia increased more than 2 times among Nigerian pregnant women with a family history of hypertension. In another study, pregnant women with no history of diabetes mellitus were found to have a lower risk of developing preeclampsia compared to women with a diabetes mellitus history (Balay and Wudad, 2019). Likewise, having diabetes mellitus in a family member was found to significantly increase the risk of preeclampsia. A study conducted in Uganda showed that pregnant women who have a family history of hypertension were more than 2 times more likely to develop preeclampsia/eclampsia when compared to pregnant women who do not have a family history of hypertension (Wandabwa et al., 2010). Also, a cross-sectional study in Ethiopia found that a family history of hypertension during pregnancy increased the probability of recurrence in pregnant women by seven times (Tessema et al., 2015).

Public Health View

Globally, preeclampsia has remained a significant public health threat in both developed and developing countries contributing to maternal and perinatal morbidity and mortality (McClure et al., 2009). However, the impact of the disease is more severe in developing countries (Igberase and Egbeigbe, 2006), where, unlike other more prevalent causes of maternal mortality (such as haemorrhage and sepsis), medical interventions may be ineffective due to late diagnosis of cases (Onakewhor and Gharoro, 2008). The issue is confounded by the continued lack of adequate knowledge of the cause and the unpredictable nature of the disease (Osungbade and Ige, 2011).

The WHO-focused antenatal care strategy recommends screening for preeclampsia during the third antenatal visit at 32 weeks (WHO, 1994). In developing countries, strategies for risk assessment should still be based on obstetric and medical history and clinical examination of women. Pregnant women should be assessed at their first antenatal visit for risk factors of preeclampsia such as young age, nulliparity (a woman who has never given birth to a child), first pregnancy after the age of 35 years, obesity before the current pregnancy, prior history of preeclampsia, diabetes mellitus, and hypertension (Magnussen et al., 2007).

Routine screening for preeclampsia based on the measurement of blood pressure among all pregnant women should be practised as recommended by the WHO (WHO, 2003). Where resources are available, it is best to measure blood pressure using a mercury sphygmomanometer (WHO, 2002). Urinalysis for protein should also be routinely done at every antenatal visit for pregnant women in developing countries in addition to routine blood pressure measurement. The diagnostic criteria for preeclampsia developed by the National Blood Pressure Education Program Working Group are a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher. This would have been measured on at least 2 occasions, 4–6 hours apart and occurring after 20 weeks of gestation in a woman whose blood pressure had previously been normal. 

In addition to this, the presence of protein in the urine (proteinuria) with excretion of 0.3 g or more of protein in a 24-hour urine specimen or 1+ or greater on 2 random urine samples collected 4 or more hours apart is also a diagnosis for preeclampsia (Schroeder, 2002).

Once preeclampsia is confirmed, depending on the severity, options of care include continued evaluation of mother and fetus, antihypertensive therapy, and timely delivery (the only real cure). There is significant evidence that supports the use of magnesium sulphate to prevent seizures in women with severe preeclampsia and eclampsia (Duley, 2002 and Schroeder, 2002). Furthermore, there must be continued care for women to benefit from the existing cost-effective interventions. Women must have antenatal care during pregnancy; skilled care during delivery (to help in preventing seizures); and postnatal care to assess the recovery of women (Chigbu et al., 2009).

Social factors like poverty and level of education have also been discovered as influencing up to 27% of maternal deaths (Qui et al., 2010). So, raising awareness of the need for women to reach emergency care without delay, if complications arise during delivery, is very important. This is to ensure fast and effective medical intervention and to increase the chance of therapeutic success (Beum et al., 2004). Since many women deliver alone or with a relative (National Population Commission, 2009), community members must also be trained to recognize danger signs and develop plans for emergencies, including transport to hospitals or health centers. Prompt health-seeking behaviour is essential because it becomes more difficult to reduce the risk of death when complications have developed (Bugum et al., 2004).

The majority of maternal deaths have been shown to occur in poorly performing health systems (Lawn et al., 2009). Studies from some developing countries that have shown a remarkable reduction in maternal mortality (Lin et al., 2010, Qui et al., 2010 and Prata et al., 2010) opined that maternal safety must be made a priority health issue by the government and health workers. Improvements in service delivery can be achieved through the use of case management protocols for obstetric emergencies at each level of care and by monitoring standards of practice. To improve maternal health, barriers to accessing health services must be identified and addressed at all levels, with intensified efforts at community mobilization and engagement (Leen et al., 2009).

The use of data to improve the quality of care is also important, especially in improving reporting systems and record-keeping practices to estimate disease burden to aid service planning and delivery (Prata et al., 2010).

Recommendations

Since the major ways of control remain health care based strategies, Federal governments and other supporting agencies like the Non-Governmental Organisations should channel efforts at improving the public health systems and access to well-trained healthcare providers. National protocols on magnesium sulphate as the preferred treatment for preeclampsia and eclampsia should be reinforced. Further research is needed to understand the causes and the best preventive strategies for preeclampsia specific to geographic areas.

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