Critical care management of eclamptics: challenges in an African setting.

We conducted a retrospective study of the management and outcome for eclampsia patients in the intensive care unit (ICU) of National hospital, Abuja between November 2001 and April 2005 (42 months). The patients' case files and ICU records were used to extract the necessary data. During the study period, there were a total of 4857 deliveries, with 5051 total births (including multiple births) and 4854 live births. Forty eclamptics were admitted to the ICU, giving an ICU admission rate of 8.2/1000 live births. The records of two patients were incomplete. The average age of the patients was 28.4 years (range 17-4 years). Six patients (15.8%) were booked and 32 (84.2%) were not. The average duration of stay in ICU was 5 days. Twenty patients (52.6%) had antepartum eclampsia, 12 (31.6%) had postpartum eclampsia and six (15.8%) presented with intrapartum eclampsia. Twenty-nine (76.3%) gave birth via caesarean section and nine (23.7%) delivered per vagina augmented by oxytocin infusion. Seventeen (45%) received mechanical ventilation; 20 (53%) received oxygen via nasal prongs, nasal catheters or variable performance facemask. One patient (2%) did not receive oxygen therapy. All the patients were admitted postpartum. There were 11 maternal deaths, giving a case fatality rate of 29%. There were five (45.4%) deaths due to haemolysis, elevated liver enzymes and low platelet count syndrome and two (18.2%) due to disseminated intravascular coagulation. The remaining deaths were due to cerebrovascular accident (9.1%), lobar pneumonia (9.1%), acute renal failure (9.1%) and multiple organ failure (9.1%). All patients were admitted postpartum. This fatality rate is higher than that detailed in the reports reviewed in this study. Early referral of eclamptics or at risk patients to a tertiary care institution may help reduce morbidity and mortality. In addition, early referral to a facility providing basic essential obstetric care or comprehensive essential obstetric care is also important. Another important factor is the correct diagnosis of pre-eclampsia during antenatal and postpartum care by screening, noting blood pressure levels, performing urinalysis for protein and asking about warning signs such as headache, blurred vision, epigastric pain, etc.

Critical care management of gynaecological patients in Enugu, Nigeria.

A retrospective study of the management of gynaecological patients admitted to the general intensive care unit (ICU) of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, over a 6-year span was carried out. Out of a total of 816 patients admitted to the ICU during the study period, 21 (2.6%) were gynaecological patients with the following diagnoses: generalized sepsis, postoperative respiratory distress, hypovolaemic shock, preoperative anaemia and mennorhagia, and major surgery with potential for major complications. The mortality rate was 28.6% with six deaths, sepsis being the major cause of death (four fatalities).

Acute renal failure due to HELLP syndrome and acute renal failure in mid gestation.

A 34-year-old grand multipara (para 7, 4 alive) was managed at the National Hospital, Abuja, Nigeria for acute renal failure due to HELLP syndrome following referral from a peripheral hospital. She presented with a history of vomiting, headache, epigastric pain, loss of consciousness and tonic/clonic seizures. Though she was unsure of her exact dates, clinically the gestational age was estimated at 22 weeks. She was managed in the intensive care unit, following delivery of a macerated fetus within 15 h of hospital admission. The patient received mechanical ventilation and three sessions of haemodialysis as part of her successful management while in the intensive care unit. The uncommon presentation of eclampsia and HELLP syndrome before obvious preeclampsia is discussed, as well as the other signs and symptoms and patient management. The case also highlights the resource-poor environment of peripheral and tertiary hospitals in Nigeria.